competences of the recovery orientated workforce

Report of the Recovery Orientated Drug
Treatment Expert Group
NTA, 20/11/2012
The problem
2010 drug strategy:
“Substitute prescribing continues to
have a role to play in the treatment of
heroin dependence, both in stabilising
drug use and supporting
detoxification. Medically-assisted
recovery can, and does, happen. ...
However, for too many people
currently on a substitute prescription,
what should be the first step on the
journey to recovery risks ending
there. This must change.”
Towards a solution
 NTA asked Professor John Strang
to chair a group to provide
guidance on the proper use of
medications to aid recovery
 Expert group comprised clinicians,
managers, service user
representatives, commissioners,
researchers and others
 Chair’s interim report published
July 2011
The interim report - outline
 Common ground in the group: strong body of evidence for
the effectiveness of opioid substitution treatment (OST) but
people in treatment could be better supported in their
 Existing guidance (NICE and orange book), and the
evidence on which it is based, already describes much of
what is best practice
 12 immediate steps that can be taken to improve the
recovery orientation of treatments that include prescribing
 But will also need a renewed emphasis on improving
people’s recovery
 Areas of work for the group’s final report
RODT - 12 immediate steps overview
Increase recovery-oriented ambition and progress by:
examining current practice to make sure there is balance between
overcoming dependence and reducing harm, and that recovery care
planning is good
checking clients are working towards abstinence and, as more people are
ready to come off, make sure they are properly supported
making sure clients are still getting real benefit from prescribing and, if
necessary, optimising treatment: adding psychosocials and/or getting dose
doing more to support people to recover: visible exits from treatment,
social networks, employment, housing
making sure staff are competent in all these interventions.
Strang J (2011) Recovery-orientated drug treatment an interim report by Professor John Strang,
chair of the expert group. NTA
12 immediate steps – the short version
Audit the balance between overcoming dependence and reducing harm.
Review patients to ensure they have achieved, or are working towards, abstinence –
particularly from their problem drugs.
Encourage more patients to take opportunities for achieving greater recovery.
Ensure the eventual exits from treatment are visible from the outset.
Review the continuing benefit of ongoing prescribing to patients.
Ensure extra support is available to patients coming off medications, along with
rapid re-entry if they relapse.
Social capital
Review, and where necessary improve, the quality of recovery care planning.
Work with housing and employment services to maximise local access to both.
Check treatment is optimised, with appropriate range and intensity of interventions.
Support services to improve patients’ access to social networks, including families,
mutual aid and peer support.
Support individuals to improve their social capital through work, volunteering and
training opportunities.
Ensure keyworkers are competent to deliver a full range of psychosocial
The group’s final report – July 2012
 High-quality treatment system
that substantially improves health
 Heroin is sticky
 Leaving treatment is important
but it isn’t recovery
 Lots of people haven’t recovered
 Done right, OST is effective but a
platform for recovery
 Don’t end it too early
 Some people recover fast, some
don’t – all need recovery support
Key to success
 Vision and leadership
 Organisations & staff able to support and sustain change
 Staff who believe in the treatment they are delivering
 A structured programme with clear treatment goals
 Availability and range of OST medications
 Range and quality of psychosocial interventions
 Active referral to self help and mutual aid
 Links to recovery orientated community organisations
McLellan and White commentary
Opioid maintenance and recovery-oriented systems of
care: it is time to integrate
“Recovery status is best defined by factors other than
medication status. Neither medication assisted treatment of
opioid addiction nor the cessation of such treatment by itself
constitute recovery. Recovery status instead hinges on
broader achievements in health and social functioning - with
or without medication support.”
A Thomas McLellan & William White
The evidence ...
 ... is good that OST:
 Retains people in treatment
 Suppresses illicit use of heroin
 Reduces crime
 Reduces the risk of BBV
 Reduces risk of death.
 ... is less persuasive that OST:
 Suppresses other drug use
 Improves physical and mental health
 Improves social reintegration of marginalised heroin users
 Promotes abstinence from all drugs.
Principles and prompts – for commissioners
Integrated recovery-orientated
systems of care are needed to
build and maintain recovery
Is a full range of treatment options commissioned, including residential
rehabilitation, so that there is the necessary flexibility to build a range of
treatment and recovery pathways for different needs: from brief
interventions for those not needing structured treatment to full packages of
care-managed pharmacological, psychosocial and recovery interventions for
those with complex needs?
Arbitrarily curtailing or limiting
the use of OST does not achieve
sustainable recovery and is not
in the interests of people in
treatment or the wider
Do contracts avoid imposing arbitrary time limits on treatment or elements
of it, such as prescribing?
Drug treatment is not expected
to deliver recovery on its own
but can integrate with and
benefit from other support
Is an integrated recovery-orientated system of care being created that
involved other health and social care services with drug treatment to
provide recovery support, including mental health, employment, housing,
mutual aid, recovery communities, etc?
Are services expected to set clear and ambitious goals for each individual’s
treatment, with planned timescales for action, and expect targets for
general improvements in treatment and recovery, such as:
• increased psychosocial interventions
• hosting of 12-step meetings
• development of aftercare functions and peer support?
Methadone helps… and holds people…
Do it quick for those new to treatment
 Greatest improvement seen during first three months
 Getting treatment right during this period vital to the
recovery process
Kakko J, Grönbladh L, Svanborg KD et al. (2007) Am J Psychiatry 2007; 164:797–803
Avoid unintended consequences
Let’s be clear:
 This is about increasing recovery-oriented
ambition and progress for individuals and in
systems where there is not currently enough of it
 It is not about destabilising - to the point of
unacceptable risk - individuals who are deriving
benefit from OST.

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