Drug Treatment Matrix cell E3: Treatment systems; Medical treatment

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Treatment systems; Medical treatment

Seminal and key studies relating to local, regional and national systems for effectively and cost-effectively providing medical interventions and treatment in medical settings. Highlights a simple innovation which transformed detoxification recyclers into typical patients, asks if you agree with an expert group’s vision of what a good quality service looks like, and questions whether Britain is making progress on organising care for mentally ill problem drug users.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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K Advancing recovery in US states (2012). In the US homeland of competition and private health care, it was cooperation and coordination which led to the introduction of new medications and innovations to promote continuing care – plus the exercise of regulatory and financial muscle and the salutary experience of senior staff who placed themselves in the patient’s shoes.

K No use-reduction effect after detoxification from stimulants (2014). Free source at the time of writing. Australian study finds a typically five-day inpatient detoxification no more effective than no treatment at all at reducing methamphetamine use among dependent users, most of whom injected the drug.

K Case management links detoxification to treatment (2006). Siting case managers there transformed detoxification services into gateways to longer term treatment and reduced repeat detoxifications. The initiative was part of a broader ‘recovery revolution’ in Philadelphia. Transitioning detoxification patients to follow-on treatment is associated (2014; free source at time of writing) with fewer readmissions and may be dependent on the links clinics have to follow-on services. For discussion click and scroll down to highlighted heading. Related discussion also in cell A3.

K No need to start methadone in specialist clinic before transfer to primary care (2014). From France the first study to randomly allocate patients to start methadone maintenance either in primary care or at a specialist centre found primary care more attractive to patients, and no less effective at reducing street-opioid use and promoting engagement and retention.

K Commission to enhance adherence to clinical guidelines (2008). Two sets of US methadone clinics selected for high versus low adherence to clinical guidelines provided evidence that in everyday practice, the recommended high doses and intensive psychosocial services really do make the intended difference to substance use and perhaps also to other outcomes. Findings suggest that commissioning to strengthen adherence to guidelines will improve outcomes. More on dose and psychosocial services in cell C3.

K ‘Dual diagnosis‘ provision in England ([UK] Care Services Improvement Partnership, 2008). First national assessment for England of progress towards implementing the good practice guidelines set out by government in 2002. Regional reports also available. For discussion click and scroll down to highlighted heading.

Reduction in psychiatric admissions from before to the year after allocation to integrated versus parallel care; shows reduction was much greater when substance use and mental health care were integrated

Psychiatric admissions in the years before and after allocation to integrated versus parallel care

K Integrated dual diagnosis teams help prevent crises (2006). Rare (largely) randomised trial of truly integrated substance use and mental health care for severely mentally ill problem substance users found these arrangements reduced the frequency of psychiatric and legal crises chart. Related review below. For related discussion click and scroll down to highlighted heading.

R Build opioid treatment system on buprenorphine to minimise medication-related deaths (2015). In England and Wales from 2007 to 2012, per prescription the overdose death rate involving buprenorphine was one sixth that of methadone. Implication is that a treatment system built on buprenorphine will be safer – as long as it attracts and retains enough patients.

R Evidence weak for integrating addiction and mental health treatment (2013; free summary and commentary from the US Centre for Reviews and Dissemination). Synthesis of research finds some evidence that integrating substance use and mental health treatment improves psychiatric symptoms and (in residential settings) drinking, but none of the slight advantages approached statistical significance, and only one of the studies assessed whether treatment truly was integrated. Study not included in review above. For discussion click and scroll down to highlighted heading. See also Effectiveness Bank hot topic on ‘dual diagnosis’.

R Pay-for-performance systems an evidential leap in the dark (Cochrane review, 2011). Overview of reviews on financial incentives for healthcare professionals in general could find no evaluations which reported on patient outcomes. Also conducted under rigorous Cochrane procedures, a similar review (2011) but of individual studies found “insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care”. A review (2014) specific to drug and alcohol treatment could find “no peer-reviewed evidence that [pay-for-performance] … improves client outcomes post-treatment”. Discussion in cell E2 and related discussion below – click and scroll down to highlighted heading.

R G Methadone maintenance as spine of a recovery-oriented treatment system (2012). From authoritative US recovery advocate William White, a humanistic interpretation of what makes an opioid maintenance treatment system recovery-oriented, including features of the treatment and its links with the community and other services. Based on freely available monograph (2010). For discussion see cell D3.

G Commissioning for recovery ([UK] National Treatment Agency for Substance Misuse, 2010). From what was England’s special health authority tasked to improve the availability, capacity and effectiveness of drug misuse treatment, guidance for funding authorities on how to construct a local pattern of services.

G UK consensus on medications as a route to recovery ([UK] National Treatment Agency for Substance Misuse, 2012). How medications fit into a treatment system oriented to long-term recovery. While protecting the gains of the harm-reduction era, attempts to show that methadone maintenance and allied treatments can be part of the recovery agenda, despite that agenda’s associations with abstinence from all drugs (no methadone) and with leaving treatment (no or curtailed maintenance).

G Opioid substitute prescribing and recovery-oriented treatment in Scotland (Scottish Drug Strategy Delivery Commission, 2013). Expert group’s vision of what a recovery-oriented treatment system should look like, progress towards it in Scotland, and the role of methadone maintenance and allied treatments within such a system.

G Integrated care for substance users in Scotland (Report produced for the Scottish Advisory Committee on Drug Misuse, 2008). Guidance on how to construct a treatment system that combines and coordinates all the services required to meet the assessed needs of the individual. Includes care pathways and responding to patients with mental illnesses. For related discussion click and scroll down to highlighted heading.

G Expert advice on commissioning drug and alcohol treatment ([UK] Joint Commissioning Panel for Mental Health, 2013). Co-chaired by the Royal College of General Practitioners and the Royal College of Psychiatrists, a collaboration of leading organisations and individuals with an interest in commissioning mental health services explains the rationale for and offers practical advice on commissioning effective addiction services. For discussions click here and here and scroll down to highlighted headings.

G Build opioid treatment system on maintenance (World Health Organization, 2009). Unequivocal backing from UN agencies for methadone and other long-term maintenance treatments as the prime modalities treating dependence on heroin and allied drugs. In contrast, says the report, detoxification results in poor long-term outcomes. Related discussion in cell A3.

G Pharmacy-based services for drug users ([UK] National Treatment Agency for Substance Misuse, 2006). Commissioning pharmacy services to contribute to treating and reducing harm from problem drug use.

G What UK specialist addiction doctors should do and be able to do ([UK] Public Health England, Royal College of Psychiatrists, Royal College of General Practitioners, 2014). Guidance for commissioners and others from body overseeing addiction treatment in England and from UK professional bodies on the part addiction specialists are expected to play in promoting recovery, and the importance of retaining their expertise in the sector.

G How to assess the performance of specialist doctors ([US] American Society of Addiction Medicine, 2014). Criteria designed to be used as the basis for local reimbursement and quality-control systems which evaluate performance against the standards ([US] American Society of Addiction Medicine, 2014) expected of specialist addiction physicians. For discussion click and scroll down to highlighted heading.

G NICE advises against specialist ‘dual diagnosis’ services ([UK] National Institute for Health and Care Excellence, 2016). The UK’s gatekeeper to the public provision of health interventions says that rather than creating specialist ‘dual diagnosis’ services, health and social care (including substance misuse) services should adapt to mentally ill substance users, and their care should be led by mental health services. Another NICE guideline (2011) has dealt specifically with psychosis and substance use. Guidance is reflected in NICE quality standards (2019). See also earlier dual diagnosis good practice guide ([UK] Department of Health, 2002). Related review and study above. For discussion click and scroll down to highlighted heading.

G “No wrong door” (Public Health England, 2017). From the authority responsible for supporting substance use treatment in England, a strong statement that commissioners should ensure that co-occurring substance use and mental health problems are addressed as an integral part of all relevant local care pathways, and that this care is initiated no matter which service the patient first approaches. For discussion click and scroll down to highlighted heading.

more Search for all relevant analyses or for sub-topics go to the subject search page or hot topics on commissioning and dual diagnosis.

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