Drug Treatment Matrix cell E2: Treatment systems; Generic and cross-cutting issues

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Effectiveness Bank Drug Treatment Matrix

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Treatment systems; Generic and cross-cutting issues

Seminal and key studies on local, regional and national systems for effectively and cost-effectively providing drug addiction treatment. Commentary focuses on payment-by-results funding mechanisms, crime-reduction as a justification for treatment, and ways to improve treatment systems, especially the core care planning process.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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S Chronic care for chronic conditions (2002). Alternative source at time of writing. Implications of truly treating addiction of the kind seen by public treatment services as analogous to a chronic disease include organising long-term monitoring and care (on which see guidance and associated reviews below) and judging services on how the patient fares during treatment, not after they leave. Discussion of the need for continuing care in cell D2. For related discussion in this cell click and scroll down to highlighted heading.

K £3 for £1 claim offers treatment investment rationale for commissioners (1999). NTORS recruited its national English treatment sample in 1995 when all the modalities it studied were under threat. It estimated that within one year they had reaped benefits which greatly outweighed their costs, an estimate analysed by the Effectiveness Bank in the listed report and in a presentation. An NTORS analysis (2004) for the two years after treatment entry came up with an even greater ratio of savings to costs. The later DTORS study (2009) of a similar sample calculated an almost identical savings:costs ratio for the year after treatment entry, but on shakier grounds. For related discussion click and scroll down to highlighted heading.

K Challenge to Scottish treatment system (2006). Recruiting its sample in 2001, DORIS was the Scottish equivalent to the English NTORS. It challenged the Scottish treatment system to forefront abstinence as an aim because this is what the patients want (see analysis in cell A2’s bite) and because it promotes social integration. Both may be true, but neither was proved by DORIS. See also these reports on employment (2008) and crime (2007) outcomes, and an omnibus report (2008) on the project’s findings.

K Successful completion indicator of lasting remission in England ([UK] National Treatment Agency for Substance Misuse, 2010). Support for the contention built in to national policy and funding criteria that leaving treatment after having ‘successfully completed’ is an indicator of lasting remission. However, the same analysis (and another published in 2012) suggests staying in treatment for at least a few years is even better. For related discussion in this cell click and scroll down to highlighted heading.

K Disappointing results from English payment-by-results schemes (2017) Study funded by the UK Department of Health found the schemes reduced rates of successful completion of treatment, seen as (above) a critical indicator of successful treatment. See also research report from the same study including data from interviews with people involved in the schemes, and an official evaluation ([UK] Department of Health, 2013) and study (2015) of the pilots during their first year. These also found that the proportion of patients exiting treatment free of dependence was worse than in other areas and in the pilot areas before the schemes. Related study and review below. For discussion click and scroll down to highlighted heading.

K Foundations of high-quality care planning in English commissioning areas ([English] National Treatment Agency for Substance Misuse, 2007). In 2005/06 every treatment-providing area in England was assessed for the quality of its care planning, and an attempt made to identify the distinctive characteristics of high-performing areas. The result was a menu of potentially performance-improving features of local treatment systems. For discussion click and scroll down to highlighted heading.

K Systems change helped improve access to and retention in treatment (2008). US NIATx programme halved waiting times and extended retention partly by fostering a self-sustaining inter-service improvement network and a performance analysis system linked to funding. See also this later extension (2012) to the programme and a similar study (2010) (free source at time of writing) of the NIATx method in Los Angeles treatment services which recorded substantial improvements in waiting times, retention, and ‘no-shows’. Related NIATx study and web site below.

K Expert coaching helps services improve patient access and retention (2013; free source at time of writing). Randomised trial tested the improvement collaborative model developed by the US NIATx quality improvement resource. Arrangements for services to learn from each other were less effective and less cost-effective at improving patient access and retention than assigning each clinic an NIATx-trained quality improvement expert to individually ‘coach’ them through the process. Related NIATx study above and web site below.

K Pay for results, not for trying (2008). Rather than specifying treatment inputs like numbers of counselling sessions, the US state of Delaware incentivised patient recruitment, engagement, and drug- and alcohol-free treatment completions; the result was more patients, more engaging treatment, and a rapid increase in satisfactory treatment completions. But there were signs too that services focused on doing enough to earn the rewards without seeking to excel in these or in other ways. Related UK study above and review below. For discussion click and scroll down to highlighted heading.

K How much should treatment systems rely on residential rehabilitation? (2007). Rare randomised trial confirmed that unless there are pressing contraindications, intensive day options deliver outcomes equivalent to residential care. Often of course, there are pressing contraindications. See also this informal Effectiveness Bank review.

R Recovery-oriented systems of care (2008). Creating a recovery-friendly environment is the best way to sustain resolution of substance use problems argues this (as we described it) “sweeping, learned but practice-oriented tour-de-force”. For discussion click and scroll down to highlighted heading.

R Evidence for key features of a recovery system ([US] Substance Abuse and Mental Health Services Administration, 2009). Evidence for key elements of recovery-oriented systems of care such as continuity of care anchored in the community and delivered by integrated services on the basis of system-wide education and training. See also associated implementation case studies. For related discussion click and scroll down to highlighted heading.

R Policy strategies for improving outcomes (2011). Two of the world’s most respected addiction researchers also with top-level policymaking experience set out the options for improving treatment systems. For discussion click and scroll down to highlighted heading.

R Funding mechanisms for substance use treatment (Report for the Australian Department of Health, 2014). Chapter 6 comprehensively reviews funding mechanisms including payment by results, for which it finds no peer-reviewed evidence that it has improved post-treatment alcohol or drug client outcomes. Part 2 of the report makes recommendations for Australian service planning and commissioning which may in parts be applicable to the UK. Related UK and US studies above. For discussion click and scroll down to highlighted heading.

G Commissioning for recovery ([UK] National Treatment Agency for Substance Misuse, 2010).

G Commissioning integrated drug treatment systems in England (Public Health England, 2018). Key principles and associated action-prompts for developing an integrated local system to reduce drug-related harm, including treatment. One of a suite of commissioning guidance and resources. Supported by ‘return on investment’ resources (Public Health England, 2016) enabling commissioners to estimate social benefits and effects on performance indicators of various interventions.

G Scotland’s vision of a high quality treatment system (Scottish Government and Convention of Scottish Local Authorities, 2014). What for the Scottish Government ‘quality’ consists of in substance use services. Intended to ensure commissioning of services of sufficient quality to meet the needs and aspirations of a local population. An evaluation ([Scottish] Care Inspectorate, 2017) reported that “Overall, the Quality Principles are being embedded and beginning to show some impact in more person-centred treatment, care and support”. The report seems no longer available but there are summaries (1 2). See also more provider-oriented English guidance for NHS and independent substance use services.

G Commissioners in England face challenge of funding cuts ([UK] Advisory Council on the Misuse of Drugs, 2017). Based on research, financial data and stakeholder surveys and testimonies, the UK government’s official drug policy advisers warn that without significant efforts to protect investment and quality, in England “loss of funding will result in the dismantling of a drug misuse treatment system that has brought huge improvement to the lives of people with drug and alcohol problems”. Supported by sector-led survey of treatment services in England in December 2016 to March 2017 which “uncovered worrying signs that damage has already been done and the capacity of the sector to respond to future cuts has been eroded”.

G Elements and procedures of an effective local treatment system (2016). The Obama administration’s extension of health care and in particular substance use treatment to more of the US population generated a need for guidance on how local areas should set up addiction treatment systems. This clear US guidance covers the types of services to be provided, the links between them, and how to assess need and maintain quality.

G Integrated care for drug or alcohol users (produced for the Scottish Advisory Committee on Drug Misuse, 2008). Guidance for Scotland on implementing a treatment system which combines and coordinates all the services required to meet the assessed needs of patients.

G Strategies to promote continuing care (2009; free source at time of writing). Expert US consensus on practical strategies to promote continuing care based on a review (2009) which was later updated (2014; free source at the time of writing) and the data reanalysed, with results still supportive of continuing care/aftercare but less strongly. Related seminal paper above. More on continuing care in cell D2.

G US NIATx system change resources ([US] NIATx, accessed 2018). Web-based service provided by the University of Wisconsin and supported by US government, offering practical strategies for commissioners and planners to promote change across a treatment system including engaging services in mutual leaning and support, tested in a study listed above. Specific aims include reducing waiting times and improving retention (see this example listed above), and increasing admissions and reducing no-shows (see this example). For discussion click and scroll down to highlighted heading.

G Planning and implementing treatment and rehabilitation (United Nations, 2003). Strategic framework, integrating services, and evaluation.

more Search for all relevant Effectiveness Bank analyses or search more specifically at the subject search page. Also see hot topics on evidence-based commissioning and recovery as a treatment objective and William White’s on-line library of papers related to recovery-oriented systems of care.

Matrix Bite Open Matrix Bite guide to this cell Open Matrix Bite guide and commentary. First ‘bites’ funded by Society for the Study of Addiction web site. Opens new window