Here’s another excellent blog post by Dr. David McCartney on the Recovery Review blog.
In 2005, concerned at the lack of choice in addiction treatment in Scotland and hearing frustrations from patients and families around lack of access to residential treatment, I sought support and funding to set up a drug and alcohol rehab service based on the therapeutic community (TC) model. This would be unique in Scotland as, based in the NHS, it would be free at the point of delivery, eliminating difficult funding pathways.
I proposed the service should serve a local population to keep people close to their families and allow them to develop local recovery supports and access intensive aftercare. It should develop close working relationships with other treatment and support options – this should be an ‘as-well-as’ service rather than an ‘instead-of’ service. There should be direct family support and detox offered as part of the deal. We would actively connect people to recovery resources in the community, offer them peer support and open avenues into education, training and employability.
Outcomes from rehab in Scotland (and even the UK) at the time were hard to find – but so were any treatment outcomes from services already in operation, so I built in that we should commission a robust evaluation. If this wasn’t going to work, we needed to know that – and if it helped people achieve their goals we wanted to get that message (and any other learning) out there.
This proposal and the evaluation were funded for a two-year pilot and in 2007 LEAP was born. A lot of people then came on board to help transform an idea into a reality. A little delegation of addiction doctors approached me as soon as the funding announcement was made. They were worried that by encouraging people to seek an abstinent recovery, we would end up putting them in grave danger. I pointed to the mitigations we would build in, we would ensure that potential risks were discussed and that consent would be fully informed. I’m not sure that I convinced them all, but in time some of these colleagues began to refer patients to us.
A very scrutinised service
So what of the analysis of the service?
- Our initial evaluation was conducted rigorously by Figure 8 and the one-year 170+ page report shared with the commissioning ADPs and the Scottish Government shortly after a year of operation.
- The two year report followed in 2010.
- In 2014 we did a ‘Road Tour’, visiting Glasgow, Edinburgh and Dundee to disseminate the four year (as yet unpublished) outcomes.
- The one-year outcomes were published in a peer-reviewed journal in 2017.
- Our four-year outcomes have just been published in the British Journal of Psychiatry (Open) Journal this month.
After the initial baseline data collection, follow up was done by external researchers. Our family programme and recovery house have also undergone rigorous external evaluation.
So, in effect, quite a lot of scrutiny of what we’ve been doing – not to mention the data that has been reported regularly from the outset to the present day to the three Alcohol and Drug Partnerships that commission our service. What does all that data mean? Are there any key messages or things that are worth passing on?
The detail is in the published papers, but I think there are some valuable higher level lessons across the years that these reports and papers span. I want to share some of this because the learning has helped us, our patients and their families. It undoubtedly has wider implications.. What I’m sharing is based on research evidence, evaluation, plus a little bit of experiential learning too.
You can establish and run a rehab in an NHS setting
Not everyone thought that the NHS (in partnership) could run an effective rehab programme. The premise was simple: services to aid recovery from addiction should be available on the same basis as services for cancer, diabetes or broken bones – comprehensive and free at the point of delivery.
Until recently, to access rehab in Scotland you had to live in the right area, be wealthy or just lucky. Our initial evaluation gave us affirmation that an NHS service and its partners could deliver a service of high quality with good outcomes – joined up to other NHS services.
Lesson: there are advantages to embedding drug and alcohol rehab in the NHS as part of a recovery-oriented system of care.
Demand – if you build it, they will come
Lothian had few referrals to rehab per year prior to LEAP. It would have been easy to say ‘there’s no demand’, yet within a short space of time, a waiting list for rehab treatment developed which then doubled within a further year. Despite 16 new beds being available locally in Edinburgh for Lothian referrals, demand was quickly outstripping supply.
Lesson: when you value rehab and have straightforward pathways to it, referrals roll in.
Rehab associated with improvements in various life domains
We did find evidence that attending our programme was associated with improvements in a variety of outcome domains and that those who stayed longest/completed had the greatest gains. The two published papers capture this in detail.
Lesson: we can be optimistic that rehab is likely to help a significant number of people reach their goals.
Retention is important.
The best outcomes are for those who complete – our evaluations and our study have clearly demonstrated this. We adjusted our practice based on this finding to help the maximum number of people get to the end of the programme. Retention in the early days was around 55% (which was still better than the average for a 90 day programme in the UK), but we’ve increased this to around 65%.
We have a really high threshold for discharging people and we have instituted measures associated with treatment completion. We’ve found that tailoring the programme, varying the length of it, using contingency management, peer support and a variety of procedures to manage challenging behaviour short of discharging people work well.
Lesson: we need to pull out all the stops to get people over the finish line (and the finish line is not the finish line in any case…)
Deaths
Deaths in this rehab population were not related in time to detox and were more likely to occur from respiratory disease (a quarter) and complications of alcohol dependence (a third) than be drug-related. That doesn’t mean we are complacent. We instituted measures like raising our methadone threshold (to avoid people detoxing too much in the community prior to admission), inpatient partial detox, naloxone distribution, overdose prevention training, rapid referral back into MAT where return to use occurs, offering inhouse re-titration onto OST to those leaving early etc.
Lessons: the risks associated with opioid detox can be mitigated in this setting. It’s important to look after general health.
The severity of dependence does not predict outcomes
The LEAP study cohort at intake was older than the average treatment seeking population (34 vs 27), had higher drug and alcohol use and more severe alcohol and drug problems as measured by the severity of dependence scale than in the Scottish DORIS cohort. However the severity of dependence did not seem to predict treatment outcomes.
Lesson: don’t deny a rehab place based on how severe someone’s dependence or problems are – you may be surprised.
Rehab can impact on injecting behaviour
In our study we divided our patient group into those who completed vs those who did not complete and compared the two groups. In those who completed there were significant reductions in injecting behaviour (though we need to be cautious as numbers were small).
Lesson: rehab is effective harm reduction
Rehab can generate significant cost savings
Although health economics is a notoriously difficult subject, our evaluators noted:
“This report suggests that the costs incurred in achieving recovery outcomes for LEAP graduates are more than offset by the savings across health and criminal justice domains by a factor of as much as 3.”
Lesson: rehab can make significant cost savings downstream and may be more cost effective than other treatment options in the long term.
Abstinence is associated with better outcomes.
Abstinence is not everybody’s goal, but in our patient group, those who achieved abstinence did best overall – something in keeping from research elsewhere. It’s been my experience as a professional that abstinence as a goal is not well received or supported in some circles, yet undoubtedly it is something some people coming for help want and something that significant numbers of people can achieve (More than 60% of those who completed treatment at LEAP reported abstinence at 4 years in our study).
Lesson: abstinence is a legitimate and achievable goal, associated with good outcomes.
Other lessons
There are other lessons we’ve learned: the recovery journey can be long and non-linear, so rehab makes best when it’s joined up to a robust system of care. The therapeutic community is a powerful force for change. There’s no need for a battle between harm reduction and abstinent recovery when the larger system you operate within offers both and referrals happen in each direction depending on need.
Hope matters – lived experience in the staff team and from peer volunteers really helps here.Harm reduction measures are simple to adopt into rehab settings. Effective and fast referral back into community treatment is important when people return to use. Intensive preparation and long-term aftercare are vital.
A multi-disciplinary team allows us to accept those with greater needs. Addressing mental health is critical to success. People have multiple co-morbidities. Polypharmacy can be effectively addressed in rehab. People are often able to go on to do longer term therapies for PTSD. People may need more than one rehab treatment episode, so ‘one shot and you’re out’ makes no sense. When patients benefit from rehab so do families, but families also have the right and opportunity to find their own recovery and support can be provided in-house by the service to achieve this.
Summary
Residential rehab should be part of a comprehensive care system – the time for saying ‘there’s no evidence that it works’ is over. Yes, it’s only a part of the recovery journey for some, not all, and yes, it’s not something everyone wants. But some people do want rehab and they ought to have a choice about it. It is possible to deliver rehab in an effective manner with good outcomes, including harm reduction outcomes for the people who go through it. Furthermore, as the evidence accumulates, it’s possible to improve the quality of the services we offer.
Rehab is effective and can be a powerful tool to help those with addictions reach their goals.
I’d like to thank all of those who gathered and examined evidence for our service – Figure 8, McMillan Rome and the authors of our two peer-reviewed papers, but particularly Dr Nina Mackenzie for her part in our four-year outcome paper. Thanks are also due to the amazing LEAP team and volunteers, NHS Lothian, our colleagues across statutory and third sector services, our partners (City of Edinburgh Council, Access to Industry, the Cyrenians, The Ritson Clinic, the Lothian Alcohol and Drug Partnerships and the Residential Referral Team) and, most of all, to our patients who have achieved remarkable outcomes through their determination to recover and via the hard work they put in.
