17th International EWODOR Symposium “Pathways and challenges to addiction recovery: The role of treatment, self-help and other mechanisms of change” WELCOME SESSION On the need for recovery-oriented research, practices and policies Wouter Vanderplasschen, prof. dr. VAKGROEP ORTHOPEDAGOGIEK ONDERZOEKSGROEP HERSTEL EN VERSLAVING
ON THE NEED FOR RECOVERY- ORIENTED RESEARCH, PRACTICES AND POLICIES Wouter Vanderplasschen, prof. dr. 1. WELCOME TO GHENT FOR THE
XVIITH EWODOR SYMPOSIUM
5 ERIC BROEKAERT (1951-2016), EWODOR’S FOUNDER AND DRIVING FORCE EWODOR
̶ Founded in 1983 ̶ European Working Group on Drugs Oriented Research ̶ One of the oldest networks of drug researchers and practitioners in Europe ̶ Scientific branch of the EFTC ̶ Close collaboration between research and practice ̶ Treatment organisation supporting persons with drug problems and a university ̶ Vehicle to promote research-practice interactions and to exchange ideas regarding recovery-oriented practices in the field of substance abuse treatment 2. WHY RECOVERY?
8 BETTY FORD INSTITUTE CONSENSUS PANEL, 2007
“Recovery from substance dependence is a voluntarily maintained lifestyle, characterized by sobriety, personal health, and citizenship.” UK DRUG POLICY COMMISSION RECOVERY CONSENSUS GROUP, 2008
“The process of recovery from problematic substance use is characterised by voluntarily- sustained control over substance use, which maximises health and wellbeing and participation in the rights, roles and responsibilities of society.” MENTAL HEALTH RECOVERY
Anthony (1993) defined recovery as "a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness." AT LEAST TWO TYPES OF RECOVERY (SLADE ET AL., 2010)
̶ The first involves clinical recovery – when someone 'recovers' from the illness and no longer experiences its symptoms
̶ The second involves personal recovery – recovering a life worth living (without necessarily having a clinical recovery). It is about building a life that is satisfying, fulfilling and enjoyable. 3. WHY DO WE NEED A RECOVERY-ORIENTED APPROACHES?
13 ̶ Limitations of available substance use services: ̶ <3% of all persons entering MMT abstinent after 5 years (DORIS- study) ̶ High costs of (residential) treatment, poor and unsure outcomes ̶ Intergenerational dependence ̶ Often “treated as a junkie” ̶ Fragmented services + need for wrap-around support ̶ Involvement of service users + experts by experience generally limited ̶ Underutilisation of strengths and personal and social recovery capital ̶ Personal vs. societal treatment objectives (“parked on methadone”) ̶ Alternative to the chronic, relapsing brain disease model ̶ Support needed that is characterized by connectedness, hope, identity, meaning and empowerment (Leamy et al., 2012)
15 SOME RECENT DEVELOPMENTS TOWARDS RECOVERY-ORIENTED SUPPORT
̶ Emerging recovery movement in the US, Australia, Scotland, England, … ̶ Development of recovery-oriented drug and treatment policies in the UK, the Netherlands, Flanders, etc.. ̶ Renewed interest in AA, NA, and other types of self-help ̶ Private companies/ngo’s that focus on continuity of care rather tahn on primary treatment ̶ Recovery management check-ups ̶ Increased use of technology-based interventions ̶ Community-based support and activating the social network ̶ Growing research base on recovery ̶ Recovery-oriented systems of care RECOVERY PATHWAYS IN THE UK, THE NETHERLANDS AND BELGIUM WWW.REC-PATH.CO.UK FOCUS ON 5 POTENTIAL PATHWAYS TO RECOVERY 1. ‘natural recovery’ 2. 12-step self-help 3. Other self-supported recovery 4. Outpatient 5. Residential NEED FOR: ̶ Recovery-oriented policies ̶ Recovery-oriented practices ̶ Recovery-oriented research
̶ For supporting better, contributing lives and more inclusive societies, despite the limitations caused by addictions Prof. dr. Wouter Vanderplasschen Hoofddocent
VAKGROEP ORTHOPEDAGOGIEK Ghent University @ugent E [email protected] Ghent University T +32 9 331 03 13 www.ugent.be Treatment and recovery and the reform of the mental health and addiction field in Belgium Dirk Vandevelde, Director of De Kiem (Belgium) No presentation available EWODOR: The oldest drug research Network in Europe Rowdy Yates, em. prof. EWODOR: The Oldest Drugs Research Network in Europe
P. R. Yates, Honorary Senior Research Fellow, Scottish Addiction Studies, Faculty of Applied Social Science, University of Stirling, Scotland.
President, European Federation of Therapeutic Communities Executive Director, European Working Group on Drugs Oriented Research
e-mail: [email protected] url: https://eftc.ngo/ Founded in 1983, Rotterdam, The Netherlands
Charles Kaplan, Eric Broekaert & Martien Kooyman saw a need to improve the scientific outputs from European therapeutic communities. Sustained & Developed for 35 years
Eric Broekaert & Vera Segraeus extended the scope of EWODOR to encourage greater interest amongst academics and build bridges between the research and practitioner communities EWODOR - Early Symposia
• 1983 – Erasmus UniversityRotterdam, The Netherlands • 1984 – Erasmus UniversityRotterdam, The Netherlands • 1985 – Erasmus UniversityRotterdam, The Netherlands • 1986 – Erasmus UniversityRotterdam, The Netherlands • 1988 – Erasmus UniversityRotterdam, The Netherlands • 1989 – Universiteit Gent, Belgium EWODOR Symposia in the 90s
• 1990 – Universiteit Gent, Belgium • 1991 – La Sapienza Universita di Roma, Italy • 1993 – Universidad de Deusto (Bilbao), Spain • 1994 – Universidad de Deusto (Bilbao), Spain • 1996 – University of Stirling, Scotland • 1998 – Universidade do Porto, Portugal • 1999 – Universiteit Gent, Belgium EWODOR Symposia in the 00s • 2000 – Universiteit Gent, Belgium • 2001 – Universiteit Gent, Belgium • 2002 – CeIS Modena, Italy • 2003 – University of Stirling/Phoenix Futures, Scotland • 2004 – Aarhus Universitet, Denmark • 2005 – Universteit Gent (Blankenberge), Belgium • 2006 – STAKES (Helsinki), Finland • 2007 – Institutt fur Klinisk Medisin (Oslo), Norway • 2008 – Linnaeus University (Vaxjo), Sweden • 2009 – University of Stirling/Phoenix Futures, Scotland EWODOR Symposia in the 10s
• 2011 – Universidad de Barcelona/Proyecto Hombre, Spain (Catalonia) • 2012 – Aristotle University/KETHEA(Thessaloniki) Greece • 2014 – Trinity College Dublin/Coolmine TC, Ireland • 2016 – Lumsa Universita/Dianova (Rome) Italy • 2018 – Universiteit Gent/ De Kiem TC, Belgium EWODOR Symposia: Changes and Trends • A total of 28 symposia/meetings (not 17!!!!) • An increasing emphasis on co-organising with TCs • An increasing emphasis on publishing proceedings in peer-reviewed journals • Proceedings published in various monographs and in International Journal of Social Welfare, European Addiction Research, International Journal of Therapeutic Communities, Journal of Substance Abuse, (+ edited book published by Universidad de Barcelona Medical School). EWODOR: Milestones • IPTRP – 1994. A major international comparative study of parallel disorders amongst TC residents • Involved academics from 9 European universities and utilised 28 separate field sites • 1996 – EWODOR establishes an online discussion forum for addiction researchers • 2003 – EWODOR pilots a multinational online course using lecturers from 5 European universities • Original Goals – improve scientific understanding amongst TC staff; encourage addiction interest amongst academics; and create a bridge between the research and practitioner communities EWODOR 2018
Eric Broekaert 1951–2016: The Lord of the Dance Drug treatment demand and drug- related problems in Belgium Lies Gremeaux, dr. Drug Treatment demand and drug-related problems in Belgium
17th International EWODOR Symposium - 2018
dr Lies Gremeaux Belgian Reitox national focal point Epidemiology and public health SCIENSANO Mission of EMCDDA & the Reitox Network
National Focal Points in 28 Member States (+ Norway and Turkey)
Collect objective and reliable information on the drug situation
Support an evidence-based drug policy
Information system for national and international policy makers & professionals The drug problem in Belgium at a glance
Overview:
1. Treatment entries in Belgium: Key data and trends
2. Current situation and developments for the main substances of (ab)use
3. Conclusions TREATMENT OF SUBSTANCE USE IN BELGIUM: WHAT WE KNOW (AND WHAT WE DON’T KNOW) Drug treatment in Belgium: setting and number treated
A. Treatment demand indicator (TDI) register
• Key Indicator EMCDDA
• New entries for problematic use of alcohol or illicit substances = incidence!
• Registration since 2011
• Use of the national identification number Drug treatment in Belgium: setting and number treated (2017)
A. Treatment demands (Outpatient & Inpatient) : 12,037
Illicit Substances Drug treatment in Belgium: setting and number treated (2017)
A. Treatment demands (Outpatient & Inpatient) : 12,037
B. Opioid Substitution Treatment (OST) : 16,453
4% 15%
Methadon Buprenorphine both
81%
Source: OST register, Sciensano Drug treatment in Belgium: setting and number treated (2017)
A. Treatment demands (Outpatient & Inpatient) : 12,037
B. Opioid Substitution Treatment (OST) : 16,453
C. Census Prison OST : 706
TOTAL 2017 ~29,289
D. Alcohol (TDI) ~9,200 – 12,000 Treatment demands by substance type 2017
50% !
Source: TDI register, Sciensano Treatment demands by substance type
2017 No Other 8% Opioids 1% 21%
Cannabis 32% Cocaine 22% Hypnotics 7% Other
stimulants 9% Source: TDI register, Sciensano Treatment demands by substance type 2017 Regional Flanders differences 6% 1%
7% Wallonia 0%
8% 14% 19% 2% 34% Brussels 36% 23%
22% Opioids 33%
8% Cocaine
7%
1% 14% Stimulants other than 3% 7% cocaine 26% Hypnotics
29% Cannabis Source: TDI register, Sciensano Trends in numbers of all entries, 2011-2017
Source: TDI register, Sciensano Trends in numbers of 1st entries, 2011-2017
Cannabis 57.3%
Cocaine 38.6%
Opioids 13.4%
Source: TDI register, Sciensano SUBSTANCE (AB)USE IN BELGIUM
CURRENT SITUATION & DEVELOPMENTS On the Belgian drug market… 2016
Source: NFP, Sciensano Cannabis in Belgium
EDR18: « Cannabis: availability and use remain high and changing international policies may bring challenges to Europe » (2016) .
(2013) LYP Adults: 4.6% Stimulants in Belgium: Cocaine
EDR18: « Cocaine: increased availability and highest purity in a decade »
(2013) LYP Adults: 0.5%
Source: NFP, Sciensano Stimulants in Belgium: Cocaine
! Wastewater-based epidemiology Stimulants in Belgium: Cocaine
! Wastewater-based epidemiology
! Crack / free-base cocaine / smoking cocaine • Phenomenon spread all over the country • Prevalence high among treatment entries • Prevalence high among people who inject drugs • Difficulties in terminology!! Other stimulants in Belgium
• MDMA / Ecstasy . Party drug . Ignorance of products . Not only youngsters . Wastewater: high + weekend
• Amphetamines . No Meth . More specific subpop. . Wastewater: medium Source: NFP, Sciensano Opioids in Belgium
EDR18: « High-risk opioid use: heroin still dominates»
• Ageing cohort of high-risk opioid users, who are likely to have been in contact with substitution treatment services
• Injecting drug use: continues to decline among new treatment entrants
A range of synthetic opioids such as methadone, buprenorphine and fentanyl are also misused.
Prescribed medicines & New synthetic products?! Source: NFP, Sciensano New psychoactive substances in Belgium
EDR18: « Fewer NPS detected but more evidence of harms » New psychoactive substances in Belgium
120
! Online100 aspect ! Poly drug use 80 Others ! Link to treatment?? Tryptamines Piperazines 60 Phenethylamines Cannabinoïds 40 Cathinones
20
0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Source: EWS, Sciensano Trending Synthetic Opioids in Belgium?
. Since 2015: several deaths linked to fentanyl use
Misuse & abuse of medication Fentanyl derivatives « new substances »
. Specific subpopulations . Risk of synthetic opioid epidemic ~ USA? Some conclusions:
Alcohol remains the most important substance for treatment demands; cannabis proportion is growing.
Rising concern on the cocaine situation
Availability and quality of more conventional drugs at the basis for rare use of NPS
Fentanyl derivatives present on the BE market Thank you very much for your attention
[email protected] Head of Belgian Reitox national focal point
Epidemiology and public health SCIENSANO
More info?
Belgian National Focal Point: https://drugs.wiv-isp.be Belgian Country Drug Report 2018: www.emcdda.europa.eu/countries select Belgium
European Monitoring Centre for Drugs and Drug Addiction: www.emcdda.europa.eu European Drug Report 2018: http://www.emcdda.europa.eu/edr2018 Interventions pour réduire le risque de mort pour overdose aux opiacés
61 PLENARY SESSION: “Recent insights to building recovery” Chair: Wouter Vanderplasschen, prof. dr. Recovery pathways from addiction: the client perspective Dike van de Mheen, prof. dr.
Presentation not available Strengths-based approaches to building recovery David Best, prof. dr. STRENGTHS-BASED APPROACHES TO BUILDING RECOVERY
Professor David Best Sheffield Hallam University Australian National University Definitions
Betty Ford; UKDPC (et al): Sobriety, participation, global health Deegan (1998) Leamy et al (2011): CHIME Connectedness Hope Identity Meaning Empowerment Hedonism and eudaimonia Recovery studies in Birmingham and Glasgow (Best et al, 2011a; Best et al, 2011b)
More time spent with other people in recovery More time in the last week spent:
Childcare
Engaging in community groups
Volunteering
Education or training
Employment RNS Objectives & Orientation
CHIME
C Hope I Meaning E
Connectedness H Identity M Empowerment RNS Objectives & Orientation
The Engine of Change
Measure
Plan
Empowerment M⁴ Engage | Connect Hope Meaning, Mentor, Monitor, Measure
Identity Recovery enablers - Humphreys and Lembke (2013)
Three key areas of clear evidence-based models for recovery: RECOVERY HOUSING MUTUAL AID PEER DELIVERED INTERVENTIONS Peer models are successful because they provide the personal direction, encouragement and role modelling necessary to initiate engagement and then to support ongoing participation Time in residence + meaningful activities to positive outcomes (FARR)
Changes in work and study over the course of recovery
90
80
70
60
50 Early recovery 40 Sustained recovery Stable recovery 30
20
10
0 Restored Dropped out Got fired or Frequently Furthered Got good job Lost Steadily Started own professional of school or suspended missed work education or evaluations occupational employed business license college or school training license Best and Laudet (2010)
Personal Social Recovery Recovery Capital Capital
Collective Recovery Capital Therapeutic landscapes
Williams (1999): “changing places, settings, situations, locales and milieus that encompass the physical, psychological and social environments associated with treatment or healing” (Williams, 1999, p.2) Wilton and DeVerteuil (2006) describe a cluster of alcohol and drug treatment services in San Pedro, California as a ‘recovery landscape’ as a foundation of spaces and activities that promote recovery Therapeutic landscapes (2)
Wilton and DeVerteuil: a social project that extends beyond the boundaries of addiction services into the community through the emergence of an enduring recovery community, in which a sense of fellowship is developed in the wider community Challenge stigma Change community recovery capital Ice Cream Cone Model
There is a strong and dynamic relationship between the three component parts of RC.
The techniques in the model are intended to support the growth of RC by maximising the resources available to each individual, and based on the assumption that recovery is an intrinsically social process and one that needs not only personal commitment and determination but also the support and engagement of the social network and support system.
(Best, Irving, Collinson, Andersson & Edwards, 2016)
Innovating for Improvement Round 3 Project
Funding by: What to link to Asset Based Community Development domains
MUTUAL AID GROUPS RECREATION AND (MA) SPORT (R&S)
VOLUNTEERING, PEER AND RECOVERY EDUCATION AND COMMUNITY GROUPS EMPLOYMENT (VEE) (PRCG) Assets: recreation and sport Assets: mutual aid groups Assets: peer and recovery community groups Assets: volunteering, education and employment “We do that already”: Normal referral processes are ineffective
Alcoholic outpatients (n=20)
Standard 12-step referral Intensive referral (list of meetings & clinician (in-session phone call to active encouragement to attend) 12-step group member)
0% attendance rate
Sisson & Mallams (1981) 100% attendance rate Manning et al (2012)
Acute Assessment Unit at the Maudsley Hospital Low rates of meeting attendance while on ward RCT with three conditions: Information only Doctor referral Peer support Those in the assertive linkage condition: More meeting attendance (AA, NA, CA) on ward More meeting attendance in the 3 months after departure Reduced substance use in the three months after departure The KFC Programme
The Family Connectors programme utilises the existing social capital of friends/family of the prisoners on the outside. These relationships then provide the basis for the restoration of bonding capital (resources within existing networks of the target individual) and the formation of bridging capital (resources outside the immediate network) and so decrease the gap between the prisoner and the community. An innovative model: Jobs, Friends and Houses
A social enterprise developed by Lancashire Police Blackpool is an area of significant deprivation and dislocation Standard treatment pathways but with increased emphasis on prison release (Gateways) The aim is to build a recovery community Jobs, Friends and Houses
Transforming the building stock in the town Physically building a recovery community Providing a recovery housing pathway Providing meaningful employment and training (8-week Build It Up course then 2-year apprenticeship) Increasing the visibility of recovery Create a sense of collective pride Offending changes
Before joining JFH, the clients had a total of 1142 recorded offences on the Police National Computer (an average of 32 per person), over criminal careers lasting 13 years. Twenty-eight JFH staff had experienced a total of 176 imprisonments before the start of JFH. Since joining JFH, a total of five offences had been recorded resulting in charge (by three individuals). The average annual offence rate was 2.46 pre JFH and 0.15 since joining JFH. This represents a 94.1% reduction in the annual recorded offence rate. Year 1 savings to the public purse
REDUCTIONS IN HEALTH AND SOCIAL CARE: IMPRISONMENT: £15,319 £471, 081
JFH
REDUCTIONS IN RE BENEFIT CLAIMS : £55,728 OFFENDING: £245,402 Mapping the associations between social network factors and treatment outcomes: Melbourne Youth Cohort Study (Best et al, 2016) Time in residence + meaningful activities to positive outcomes (FARR) Current innovations
SONAR: Social Networks and Recovery: Based on five TCs across Eastern Australia REC-PATH: Recovery Pathways in 4 European Countries: Policy, Survey, Cohort, Qualitative - focus on recovery and gender LiR Euro survey HMP Holme House - Drug Recovery Programme Samaritan Daytop, McShin PLENARY SESSION: “Quality control and evidence-based research in substance abuse treatment” Chair: Rowdy Yates, prof. em. Quality of care, training and supervision in substance abuse treatment Michal Miovský, prof. dr. Proč je důležitá kvalitní rešerše?
• Základní orientace v tématu – zda a v jakém rozsahu se na dané téma publikuje, kdo a v rámci kterých oborů se jim zabývá a k jakým poznatkům dospěl. • CílemDeveloping je získat co nejvíce of Education prací, které and se daným Training tématem University zabývají. • VýsledkemInfrastructure je tzv. „mapa in poznání“ Addictions: • SoučástCan ideového we expect a technického a Real Impactplánu výzkumu • Významnáon Treatment část designu Services? výzkumné studie – originální práce, ale i přehledového článku - systematické review • Je to tedyMichal systematický Miovsky postup, zahrnující základní principy a současně určitý potenciál variability a kreativity dle konkrétního tématu a typu studie. The 17th International EWODOR Symposium (Pathways and challenges to addiction recovery: The role of treatment, self-help and other mechanisms of change). September 20th & 21st, Ghent, Belgium. A Major Challenge in addiction field
• Scientific research is not being translated to the workforce and we have a poor dialog between science, practice and employers.
• Addiction remains misunderstood, resulting in non-evidence based practices for treatment and prevention
• Failure of non-scientific interventions results in loss of public confidence in the field
Conclusion: We need to do a better job of preparing the addictions workforce and improve dialog between academic sphere, professional societies, workforce and employers. The Global Context
• Addiction Prevention and Treatment is not recognized as a unique field; incorporated within other disciplines: - Treatment: psychology, public health, medicine, social work, nursing - Prevention: psychology, public health, communications, education, communication • Tangential and fragmented focus; multidisciplinary specialization is lacking • University consortium needed to shape the discipline and advocate for formal academic training programs in addiction studies I. The building an addiction specialized institutional infrastructure in treatment, rehabilitation, prevention and harm/risk reduction has started almost 150 ago and accelerated within the second half of 20th century.
…but addiction specialized institutional infrastructure is quite wider concept and real frame than just treatment and prevention services…. Infrastructure in Addiction Science: The Emergence of an Interdisciplinary Field (Babor et al., 2017) - A First Wave: Organizational and Communication Structures • 1870 – American Association for the Study and Cure of Inebriety • 1884 – Society for the Study and Cure of Inebriety (United Kingdom) • 1907 – International Bureau Against Alcoholism Second Wave: Institutional Support for Research • Early 1940s – Yale Center of Alcohol Studies, New Haven, Connecticut, United States • 1949 – Addiction Research Foundation, Toronto, Canada • 1950 – Finnish Foundation for Alcohol Studies, Helsinki, Finland • 1960 – National Institute for Alcohol Research, Oslo, Norway • 1967 – Addiction Research Unit, London, United Kingdom • 1971 – U.S. National Institute on Alcohol Abuse and Alcoholism • 1973 – U.S. National Institute on Drug Abuse Infrastructure in Addiction Science: The Emergence of an Interdisciplinary Field (Babor et al., 2017) - B
Third Wave: The Modern Era • Addiction research centers • Addiction specialty journals • Addiction-focused professional societies • Addiction-focused libraries and • Addiction-focused education and training programs Growth of addiction specialty journals and Research centers (Babor et al., 2017) - C Growth of addiction specialty societies and Addiction Specific Libraries (Babor et al., 2017) - D First National and International Associations and Societies for Adicction Specialits • There are First Associations or working groups under the umbrella of some societies with education and training programmes and networking. II. The university academic degree programs with special focus on addictions are just a logical consequence of the infrastructure building process. The process has started almost 40 years ago.
This phenomenon meets needs given by the field (treatment and prevention practice and services) as well as needs given by academic field (e.g. public health, specific interdisciplinary based addiction research etc.). The oldest European academic education programs e.g. on Trinity College in Dublin (est. 1983) First Associations and Societies with training and education programmes – 2 Google university survey in EU
• AIMS: The aim of the study was to map addiction (-specific) study programmes in Europe. • METHODS: An international internet search of university study programmes in the world was conducted during the period January-July 2015, with the main focus on Europe and North America. • FINDINGS: A total of 34 university study programmes in Europe were found in the tracking period. They were located at 24 different universities, and operated at all levels (bachelor’s, master’s, and PHD). • Keywords: drug and alcohol studies, addiction studies, addiction counselling University survey in Europe - B University survey in Europe - C
• 17 programmes provide no information on their websites about clinical internships as a part of the study. • 17 programmes at all levels have placements or clinical practice as an integral part of the programme. • 13 programmes include clearly defined placements or internships in practice/service settings. • Four programmes specify how many hours in a clinical setting students have to undergo (from 100 to 400 direct hours). • One has a practical way of teaching standard modules and one has a six-month-long clinical placement. • Five programmes encourage students to work in a relevant job or volunteer activity in the field of addictions, or they are supposed to accomplish this before starting the study programme. EU Survey: for more details Google university survey in US
• AIMS: The aim of the study was to map (specific) addiction study programmes in the US and Canada. • METHODS: An international internet search of university study programmes in the world was conducted during the period July 2015-March 2016, with the main focus on North America. • FINDINGS: A total of 393 university study programmes in US and Canada were found in the tracking period. They were located at 393 different universities, and operated at all levels (bachelor’s, master’s, and PHD). • Keywords: drug and alcohol studies, addiction studies, addiction counselling University survey: preliminary results EU Survey: for more details
ICUDDR: founding meeting in Honolulu (USA) in March 2016 Goals of ICUDDR - A
• Network Development: Establish a network of universities with academic programs in addiction studies
• Education: Engage students in addiction studies programs and continuing education
• Research: Advance research in addiction prevention and treatment Goals of ICUDDR – B
• Community Outreach: Enhance university partnerships with addiction professionals, and research and practice communities • Advocacy - Within universities to develop academic programs in addiction studies - Policy change to support academic programs and enhancement of addiction services - Guidelines and standards for academic programs in addiction studies First international curricula UTC/UPC/URC 2017 Program implemented UTC/UPC The first implementation UPC/UTC study in Europe in Prague (2017-2018)
• Charles University was established in this context as a co-ordinating institution for European partners and universities. • Prague team has decided to implement full basic level of UPC and UTC into the on-going Master degree program and create an international program in parallel with the Czech study program. • On-going evaluation will be fully available as a example of real European implementation of UPC/UTC. • Prague team follows an original idea don’t split a complex program but create a complex education and training program generate/produce “generic addiction professional” with full insight into prevention, treatment and harm reduction. Description of the Prague Model (est. 2004)
(1) Bachelor’s (BC) study programme in Addictology (Addiction Professional) 3-year programme with approx. 150-170 students (Czech language)
(2) Master’s (MA) study programme in Addictology (Addiction Science) 2-year programme with approx. 70-90 students (Czech language)
(3) Doctoral (PHD) study programme in Addictology (Addiction Science) 4-year programme with approx. 20-30 students (Czech and English language)
26.9.2018 Programme description: for more details
Miovsky, M., Kalina, K., Libra, J. (2014). Education in Addictology in the Czech Republic: the Scope and Role of the Proposed System. Adiktologie 14(3), 310-328. Miovsky, M., Gabrhelík, R., Libra, J., Popov, P., Pavlovska, A., Kalina, K., Miller, P. M., Grund, J.-P. C. (2016). The Prague Comprehensive Model of Academic Addictology (Addiction Science) Education. Adiktologie, 16(1), 36-49.
Both papers available on ResearchGate profile: https://www.researchgate.net/profile/Michal_Miovsky 4th Annual ICUDDR Conference
• 3rd Annual ICUDDR conference (June, 2018, San Diego, California) • Invitation on 4th July 22-23, 2019, Cusco, Peru: Cayetano Heredia University
• Wide range of international panels and presentations on university-based academic programs in addiction studies - Update on the current science of substance use disorders, treatment, and prevention - Workforce development - Implementation of evidence-based academic programs in addiction studies ICUDDR Membership
• http://www.icuddr.com/
• http://www.icuddr.com/members hip/join-us-electronic-form/ Websites on www.icuddr.com Who is ICUDDR member?
• First addiction specific particular courses for existing professions (traditionally in curriculums of medicine, psychology, social work etc.). • There is possible to recognize 3 visible streams with more and more converging directions: • (a) universities using addiction curricula for particular courses (integrated into the program in psychology, medicine etc.), • (b) universities with addiction specialty life-long clinical and theoretical trainings, summer schools etc. (no-degree programs), • (c) university/academic degree addiction specific programs
• For more details visit www.icuddr.com (Membership area). ICUDDR Membership
Global Membership
121 Current members (academic institutions)
from 42 Countries Summary…many sensitive issues on the grassroots level
• What is meant by accreditation/licensing/certification, etc. and ownership (ideas, curricula, methods…?): sharing models, structures, subjects, standards? • Accreditation of education and training institutions/universities? Which level? By whom and how? Reason? • Licensing of graduates? Saving markets? Legislative background? Definition of job description and profile of the profession – and logically emerging questions such as what is this profession? (integrity, homogeneity/consistency, self-definition, professional identity)….. • What about employers/service providers? Societies/associations? Impact on quality and safety of our services? Impact on costs? • What are we speaking about if we are speaking about an addiction professional (“generic” or just particular methods)? Social worker or health worker? Interdisciplinary? Are we speaking about a completely new profession or just a specialization? Thank you for your attention www.icuddr.com On the place of experiments in therapeutic community treatments Steve Pearce, dr. “On the place of experiments in therapeutic community treatments”,
dr. Steve Pearce, Oxford Health NHS Foundation Trust, UK
133
Hierarchy of evidence
• Type I evidence – at least one good systematic review, including at least one randomized controlled trial • Type II evidence – at least one good randomised controlled trial • Type III evidence – at least one well designed intervention study without randomisation • Type IV evidence – at least one well designed observational study • Type V evidence – expert opinion, including the opinion of service users and carers Barriers to experimental research
• Insufficient preparatory work to define the nature of the intervention, including necessary components • Uncertainty over necessity of RCT • Practitioner/community conviction/ethical concerns • Complexities around clients selecting each other • Concern over the effect of randomisation on the culture and treatment programme Conceptual objections
• Is an RCT necessary in view of TC praxis comprising ‘Evidence based treatment’ (i.e. treatment utilising evidence based principles) • We have no evidence from an RCT as to the effectiveness of University or of the ‘good family’ – do we really need RCT evidence as to the effectiveness of the TC? Difficulties in implementing an RCT of TC treatment
• Forensic settings provide • Generalisability particular challenges to – Day/residential randomisation – Addiction/PD/other • Day settings possibly easier than – Secure/non residential settings • High attrition rates – from treatment – from research Difficulties in implementing an RCT of TC treatment
• Ensuring treatment fidelity – Community of communities accreditation? • How to measure effect of RCT on the culture? – Qualitative methods • Ethical problems – Is it OK to randomise when harm can result from non-treatment? • Maintaining equipoise among the researchers if they are TC practitioners • Dismantling studies or black box? Difficulties in implementing an RCT of TC treatment
• What is a reasonable and credible control condition? – Not too active, minimal TC elements, but still attractive • ‘Self-selection factor’ – Once committed to the idea of joining a TC, why would subjects agree to be randomised? General RCT problems
• Need long-term outcome – So not a waiting list control • Need large n (many TCs are small)
• Need more than one RCT from more than one centre Other practical difficulties
• Can TCs afford to ‘lose’ (ie not treat) 50% of their referrals? • In TCs that include democratic selection, how would this affect a trial? The feasibility of conducting an RCT at HMP Grendon 2003 • Possible • Prison service support • Advantages to service • Numbers applying • Roadshows • Disruption to culture • Early randomisation – at application • Maximise n • Dropout rate – up to 33% – part of therapy
• http://www.homeoffice.go v.uk/rds/pdfs2/rdsolr0303. pdf Studies of TCs to date
• NHS Centre for Reviews and Dissemination - Systematic Literature Review & meta-analysis, Lees, J, Manning, N, Rawlings, B, 1999 • Secure and non secure, democratic and addictions TCs • Carried out a Meta Analysis with an overall summary log odds ratio is -0.567; 95% confidence interval -0.524 to -0.614; indicates a strong positive effect for TC treatment. • 29 studies: 8 RCTs, of which 4 addictions (secure and non-secure), 2 non-secure democratic, 2 secure democratic
• http://www.york.ac.uk/inst/crd/pdf/crdreport17.pdf RCTs of Drug free TCs
– Cochrane review: Smith et al 2008. Therapeutic communities for substance related disorder • 7 RCTs • 2 Prison RCTs, reductions in recidivism and drug and alcohol offences • 4 TC v TC RCTs • 1 TC v mental health treatment trial – Vanderplassen 2013 • 16 trials
145 UK National Lottery board research 1999-2003
• ATC sponsored • “A comparative evaluation of therapeutic community effectiveness for people with personality disorders” • Started with 313 people (60 TCs). • Data quality poor. • By 9 months down to 15% of original numbers. • Much better response where TC had in-house researcher. Problems of not implementing an RCT of TC treatment
• Alternative treatment approaches produce higher quality evidence
• Uncertainty over effectiveness persists – Selection bias
• Future funding risk National Institute for Health and Care Excellence (NICE)
• None of the TC research had a significant influence on outcomes for BPD or ASPD guidelines (2014) • Drug misuse in over 16s: psychosocial interventions (2016) – [psychosocial residential treatment] should normally include contingency management, behavioural couples therapy and cognitive behavioural therapy. Services should encourage and facilitate participation in self-help groups. – “People in prison who have significant drug misuse problems may be considered for a therapeutic community developed for the specific purpose of treating drug misuse within the prison environment.” – http://www.nice.org.uk/Guidance/CG51/NiceGuidance/pdf/English TaCIT • Design: Two-arm, parallel, randomised controlled trial • Population: people aged 16 to 65 who are registered with a GP and have a personality disorder (assessed by SCID-II). • Recruitment: From people in contact with mental health services and living in Oxfordshire. • Exclusion criteria: i) A primary diagnosis of a psychotic disorder, alcohol or drug dependence ii) A degree of learning disability, or intellectual impairment which prevents use of DTC services; iii) Unwilling or unable to provide written informed consent to participate in the trial. Active treatment
• Active treatment: Day-DTC Groups provided in Oxfordshire - weekly options group and individual sessions visitors slot at the TC - 4.5 day TC (for up to18 months) or 1.5 day TC creative group, psychodrama, small groups, objectives groups and large groups. Cooking, shopping, eating, working and playing together PLUS ‘out of hours’ telephone support - access to weekly peer support group - 6 months post therapy support Interventions and follow-up
• Control group: Treatment as usual (TAU) plus crisis plan (SUN) and follow-up review • Follow-up interviews: at 12 and 24 months and 5 years Randomisation
Independent telephone randomisation. Randomisation ratio of 1:1 with a minimisation scheme in order to balance potential confounding variables (age, sex and baseline service utilisation) across intervention groups. Outcome measures
As used in an ongoing cohort study among 5 day TCs
• Primary outcome: healthcare utilisation (inpatient, outpatient, A&E) • Health: GHQ-12 • Social function: SFQ-12 • Self harm: modified Davidson measure (2000) • Quality of Life: EQ-5HD • Medication use, aggression, CSQ, use of benefits How have we addressed the problems?
Adherence to model Community of communities High enough n 150 pa taken into first stage Self selection Early randomisation RCT effect on culture Early randomisation Losing proportion of referrals 350 referrals pa Adequate TAU … Black box or dismantling Black box Equipoise Researcher blinding Ethical objections Most of country has no provision Generalisability … TaCIT CONSORT18 October 2013 Considered 126
Randomised Not randomised 70 56
Refused consent DTC Crisis planning 34 35 35 No PD 15 Receiving full intervention Crossed over Deceased 9 (26%) 2 1 Substance dependence Receiving partial intervention 5 13 (37%)
Primary diagnosis Not receiving intervention of psychosis 13 (37%) 1
Followed up: 436at 1 year (66%) Lives out of area 1 Deceased 1 155 Comparison of experimental and control TCs on COPES domains
156 Results Psychiatric inpatient days at 1 year
Total Mean 250 7 6 200 5 150 4 DTC DTC 100 3 TAU TAU 2 50 1 0 0 Pre Post Pre treatment Post treatment treatment treatment
157 Results for study participants at baseline, 12 and 24 month follow- up
Modified and overt aggression Client satisfaction* (MOAS)* 30 5 25 4 20 3 15 TAU TAU
2 score CSQ DTC
DTC 10 MOAS MOAS score 1 5 0 0 1 2 3 1 2 3 General health Social function† questionnaire† 18
10 16 8 6 14 TAU TAU 4 Astitel DTC DTC GHQ GHQ score 2 12 0 10 1 2 3 1 2 3
*t<0.05 †t=NS Timepoints: 1=Baseline, 2=12 months, 3=24 months 158
Thank you
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