Our DAAT has apparently the lowest throughput in the country, and so feels it has to do something about it. Our Clinical Director turned up at the CDT to discuss the way forwards with this in mind. The proposal is for limited duration of treatment episodes. The impression he gave is that this is seen as the way forwards by the NTA. One suggestion was for 6 month treatment epsiodes, but fortunately he accepted this was a bit short! I don't know how far the discussion has gone, but he is proposing a draft guideline regarding this in the New Year.

This approach would mean detoxing patients who are not ready to be detoxed, an approach I am not prepared to be involved with. (Any jobs out there?) Can any one help? What I need is something to refute the suggestion that the NTA sees this as appropriate. The new CG doesn't support this.
Rob

Rob,
It may be an idea to discuss this with your local NTA lead as it sounds a bit strange to me.
It really does sound a backward step.
I too would not want to be involved with what sounds like enforced detox - it won't work anyway.

One Word.......UNBELIEVABLE!!!!!!!!!

I agree completely with Simon. I would get in touch with your NTA lead imediately and tell them you understand this to be clinically unsupportable and likely to lead to increased deaths as well as multitudinous community harms and undo all your good work.
Very dangerous. I don't have time to look out suitable quotes form the CGs and other sources, but this is certainly WRONG, and as Simon says it won't work.

Hi all and Merry Christmas. I am sure the NTA have stated that they won't be limiting treatment times in a briefing recently (haven't looked it up but will try as just seen this thread)However, I do think it is a possible agends item for the not too distant.. an example being that of Subutex (courses of treatment as apposed to maintenance)and in the current climate of 'how many cured' it would make sense if they could collect (even more) data showing 'treatment effectiveness' as being worth the money spent. I too echo the concerns of the other posters about the risks/impracticalities but any Gov that politicises the treatment of clients runs the risks of catching their arses in the door on the way out.. watch this space i guess.

Merry New Year (nearly).

Similar schemes have been suggested in our area. I believe the NTA needs to take some criticism in enforcing target driven services over quality. DAATs and local services are forced to meet these targets or risk budget cuts.

The best evidence I've found for length of treatment is in the NTA's own publication http://www.nta.nhs.uk/publications/documents/nta_treat_...iveness_2006_rb5.pdf

Page 7 states "Where Methadone Reduction Treatment MRT was delivered as intended, it was associated with poor outcomes. For the patients who received MRT, the more reducing doses they received, the worse their outcomes. In particular, the more rapidly the methadone was reduced, the worse the heroin
use outcomes. Studies in other countries have also found worse outcomes for patients receiving abstinence-oriented rather than
indefinite maintenance (Capelhorn et al, 1994)."

Page 23 states "A comprehensive review of the literature concluded that patients who remained in methadone treatment for at least two to three
years of continuous maintenance were more likely to benefit than patients who received briefer periods of maintenance, and that this was unlikely to be due merely to processes of selective attrition (Ward et al, (1998b)."

An of course you have the NTORS study to fall back on and the DoH are now stating every £1 spent in treatment saves £9.50 in health and social costs http://drugs.homeoffice.gov.uk/treatment/strategy/

All I can say is good luck!!!

Looks like the NTA and others may be adopting the refrain heard from young children on lengthy car journeys
" Are we there yet"
Unfortunaely it is a chorus which is likely to get louder as the months unfold.
Best Wishes for 2008

" More with less

That brings us to the final problem – money. Per patient, resources for addiction treatment have been cut and will probably continue to be cut. Getting more patients more quickly out the back door of treatment is how the NTA hopes to square the circle of getting more in the front with proportionately fewer resources...

...To meet new expectations about ‘successful’ treatment completion, people may be led to exit treatment only to come back sooner rather than later because their lives have not fundamentally altered for the better, or exit
more finally via overdose and disease. Already some services have assumed that their mission now is to keep people for 12 weeks then get them out as soon as possible as a treatment completion or referral on, the criteria for success they think is being set from the centre."

The above lengthy quote is from Mike Ashton's recent DrugScope article 'The New Abstentionists', available at http://www.drugscope.org.uk/NR/rdonlyres/32255850-766C-...EF/0/Ashton_M_30.pdf

I think he has probably got to the heart of what may be going on in your neck of the woods Rob.

Happy New Year everyone.
Simon

Simon, I think you have got it spot on. The new NTA "matrices" are going to affect pay etc & hence must have "compleated episodes" of treatment. Perhaps the most worrying aspect is that not only is the Clinical Lead proposing this, but that apparently the 3 Drugworker team leads also seem to support it.
The NTA, RCGP & National guidelines all make it clear, that detox is the patient's choice, not the CDT's. Therefore, as Drs we need to work to "Best Practice". I feel that if we go along with this, we will be up there with the Clinical Lead when the corporate manslaughter charge goes to court. As Shared Care Lead, I probably need to advise the GPs of this. should make for a lively SCMG meeting!

Isn't this always the problem with stats and league tables?

Someone will inevitably be at the top of any given list and someone else at the bottom.

If you remove yourself from the bottom of the list, someone else will be there instead. For there to be a winner, there also has to be a loser!

In any race, someone has to come in last place.
Whatever happened to it being 'the taking part' not the winning that was important? And why has it become a race anyway?

I'm all for direction in treatment, equality of opportunity, and an end to postcode lotteries, but why does this need to translate into targets and competitiveness? We're not a sales-team!

Surely quality of care, good therapeutic interactions, and improvement in quality of life (preferably as judged by the client) is what's important here, not whether you have 45% successful discharges as compared to 55% in the neighbouring county?

Please, doesn't the story of the Hare and the Tortoise have some real life comparisons here?

I think we are missing the point here somewhat. I don't think its all about money or about league tables. Its about a misinterpretation of 'completed treatment episodes' combined with a misinterpretation of the 12 week retantion target as meaning that after that the duty to retain lapses. There has rightly been an emphasis on giving people more access to abstinence options and tier 4 services, however as the NICE detox guideline says this has to be with informed patient consent.

I believe the NTA are going to publish something on treatment completion which will hopefully clarify the matter.

I do think that this sort of policy does leave the door open for litigation, however I think its more likely to be of the sort brought against the prison service a couple of years ago than corporate manslaughter. The NICE technology appraisal on methadone and buprenorphine maintenance effectively gives people the right to expect this, should they need it.

quote:

Originally posted by robc:
Our DAAT has apparently the lowest throughput in the country, and so feels it has to do something about it...Rob

QED. For the head of robc's DAAT, it IS about league tables.

Now if their throughput is 2% when everyone else's is 90%+, that's one thing, but is such radical action warranted where the difference is not so great?

I guess without knowing the throughput in this case and how it compares, I don't know where robc's DAAT fits in.

I do hear on the grapevine that some DATs (who I will not name) are reputedly claiming 100% successful closures.

Is this realistic? Did not one single client in a year stop responding to attempts to contact/move away and not tell anyone?

This puts unnecessary pressure on those of us who are doing good work and recording closures accurately to either change what we're doing or massage the figures. Neither of which is particularly attractive.

In robc's case it sounds like the DAAT are considering radically altering their treatment to satify statistical rather than client need, contrary to a wide body of evidence and guidance. And that greatly concerns me.

But to achieve greater throughput it didn't need such a radical approach which goes outside of good practice. Its come about through misinterpretation. I didn't say there was no element of 'money and league tables' though - it would be niaive to assume that.

The 12 week target would seem to have a number of flaws one of which is that DAAT areas with fragmented services where an individual can be moved from one element to another with a “successful discharge” from each service before moving on, whereas DAAT areas with more integrated services would have fewer opportunities to reflect what in my view is better practice.

Thjis has been noted by the NTA and i understand there may be changes soon in the way data collected to reflect this better

hello. i thought that this might help your debate.

The NTA currently have a Clinical Governance in Drug Treatment ( a draft good practice guide for providers and commissioners) document up for consultation.

A section on pg 34 states that services have:

'systems in place to minimise client did not attend/drop out rates and support clients being retained in treatment.'

http://www.nta.nhs.uk/areas/clinical_guidance/clinical_...ance_consult_doc.pdf


Doesn't really fit with time limited treatment!

Thanks Campbell. Since you have mentioned the Clinical Governance guidance I would like to take this opportunity to remind the field at large that this is now out for public consultatiion, and the deadline for responses is 14th may - I urge you all to read it and address the questions posed within it, which are directed at everyone, in every service at all tiers whether statutory or non-statutory, and whether service users, providers or commissioners. The final document will affect us all, this is our chance to ensure policy is in line with best practice for us all.

In the meantime, there is clearly a fair amount of debate in the field regarding the best approach to ensuring the speedy patient journeys through treatment we all wish to see. The debate centres around the best way to achieve this, either by supportiing patients through enhanced treatment packages to make the journey as quickly as they are able to do, or by limiting the treatment package time in order to ensure completion within a predeterrmined period, which can be seen as a bottom up vs a top down approach. Whilst time-limiting treatment from the top may at first sight appear a neat solution, which provides certainty for all, the evidence does not support ending treatment before the client has genuinely completed their own journey, indeed, overwhelmingly it suggests that patients whose treatment is ended before completion are most likely to revert to pre-treatment levels of drug use and risk-taking behaviour. Hence, whilst the NTA supports all evidence-based inteventions which have been shown to increase the likelihood of treatment completion as early as possible, this must be seen in the context of individualising treatment packages to suit individual patients in individual circumstances, rather than a one-size-fits-all approach. I hope that this clarifies the position.

With all due respect, I think some confusion has entered somewhere along the line. The North West NTA team have been busy working up the Twin Track approach in the engineering of treatment systems. I suspect that this has been interpreted as time limiting treatment. It is not. Rather, we are working with DATs to create a system with genuine choice. Moreover, the choices need to be clear. This doesnt mean putting time limits on treatment. Rather, its about making it clear how the system works and where patients/clients go to get what. I apologise if this work has been misinterpreted. Mark Gilman (aka Regenerate - I had to set up a separate ID for home)

Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) frequently co-occur, and this comorbidity results in a more severe clinical presentation and treatment outcome. Consensus is lacking regarding best practices; however, a number of integrated psychosocial treatments (e.g., Seeking Safety, Substance-Dependence PTSD Therapy, Concurrent Treatment of PTSD and Cocaine Dependence) have shown empirically supported promise in reducing symptoms of both disorders
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