Developing targeted treatment responses to methamphetamine dependence

Transcription

1 Developing targeted treatment responses to methamphetamine dependence Briefing Paper by UnitingCare ReGen March 2015

2 Executive summary: UnitingCare ReGen s (ReGen) purpose is to reduce alcohol and other drug related harm, and promote health and wellbeing. ReGen is the leading alcohol and other drug (AOD) treatment and education agency of UnitingCare Victoria and Tasmania. Since it first observed an increase in demand for methamphetamine treatment in 2012, the agency has been working to identify the particular needs of people affected by methamphetamine use, develop targeted, evidence based responses and build sector capacity to engage and work with this highly stigmatised group. With support from the Victorian Department of Health and Human Services, ReGen adopted a series of changes to the structure and duration of its adult residential withdrawal program. These changes led to improvements in program retention, consumer satisfaction and staff confidence in managing methamphetamine withdrawal. In addition to the changes to ReGen s residential service (and in response to the longer duration of methamphetamine withdrawal) a new Step-up, Step-down model was established to provide a range of residential and non-residential supports. External evaluation of the Step-up, Step-down model and ReGen s Torque non-residential rehabilitation program (Torque) has helped demonstrate the potential effectiveness of each as a methamphetamine treatment option and highlight opportunities for future service development. Key outcomes from the Step-up, Step-down model include: Better preparation for residential withdrawal and lower levels of methamphetamine use prior to admission; More rapid reductions in withdrawal symptoms during residential treatment and less time required in the unit. Greater level Step-up, Step-down contact was associated with more positive quality of life outcomes (particularly for physical and mental health) at three-month follow-up. Torque outcomes include sustained reductions in methamphetamine use and offending at three-month follow-up. 1 ReGen s unique expertise in developing effective (and complimentary) methamphetamine treatment interventions means that the agency is ideally placed to develop a more comprehensive service model for methamphetamine treatment in Victoria. ReGen recommends that: supports the development, implementation (including appropriate staff training) and evaluation of a pilot Methamphetamine Treatment Model at ReGen. Training for clinical staff to include: Strategies for engaging this difficult-to-reach group and developing targeted pre and post-withdrawal support plans; & Delivery of targeted four-session methamphetamine counselling program for people not commencing Torque post-withdrawal. commit to the continuation (and potential expansion) of ReGen s Torque non-residential rehabilitation program as part of the Methamphetamine Treatment Model. ReGen continue to share program learnings with Government and the AOD treatment sector to inform future policy and service development. Evidence based, policy aligned: The evidence that the use of methamphetamines in the Victorian community is on the rise (along with the associated harms) is well established. The recent Parliamentary Inquiry into the supply and use of methamphetamines, particularly ice, in Victoria has documented a range of impacts for individuals, families and communities across the state. Public discussion of these impacts has been accompanied by the perception that there are limited treatment and support options available for and that there is little that can be done for those affected. There is a clear need for the development of targeted treatment responses and increase capacity of service sector to respond. ReGen has sought to inform public and policy debate with evidence gathered through its clinical services and through regular dissemination of its innovative practice in methamphetamine treatment. In response to the particular treatment needs of people who are methamphetamine dependent (and in recognition of the limitations of existing treatment models to adequately cater to these needs) ReGen has sought to develop new evidence-based treatment models to compliment established services and build sector capacity to engage and work with this highly stigmatised group. The agency s initial response has focussed on redeveloping its withdrawal services, to improve access and retention in the early stages of treatment. In the absence of significant research literature on managing methamphetamine withdrawal, ReGen has been guided by the ongoing review of consumers treatment experience and outcomes and the clinical judgement of senior staff. The development and implementation of ReGen s Step-up, Step-down model for methamphetamine withdrawal has been externally evaluated by LeeJenn Health Consultants. The findings of this evaluation are presented here and incorporated into ReGen s recommendations for future service development. 1 1 LeeJenn Health Consultants (2015) Evaluation of Torque a Catalyst non-residential program: Interim Report 2, Melbourne.

3 Program development/regen s approach: From 2010/11 to 2013/14, ReGen experienced a significant increase in the number of people seeking treatment for problematic methamphetamine use. In 2014, 45% of people presenting for treatment nominated methamphetamines as either their first or second drug of choice. A subsequent review of service outcomes for people undertaking methamphetamine withdrawal at the Curran Place residential withdrawal unit highlighted poor rates of retention (early, unplanned exits) and participation in the structured education program. Most significantly, it was also found that many people experienced no decrease (and, in some cases, experienced an increase) in methamphetamine withdrawal symptoms after completing a seven-day residential stay. With support from the Victorian Department of Health and Human Services, a series of changes were made to the structure and duration of the residential program to better meet the needs of this group. These changes led to improvements in program retention, consumer satisfaction and staff confidence in managing methamphetamine withdrawal. In addition to the changes to ReGen s residential service (and in response to the longer duration of methamphetamine withdrawal) a new Step-up, Step-down model was established to provide a range of residential and non-residential supports. Providing a stepped care approach, the Step-up, Step-down model included: Assessment, clinical review and care planning including the identification of people suitable to receive nonresidential withdrawal (NRW) support from nursing staff; NRW support offered to eligible consumers with the provision of outreach (home-based) withdrawal support while on the waiting list for residential withdrawal services. NRW treatment was to primarily focus on pre-admission planning including: Education on harm reduction strategies and self-care; Motivational interviewing and counselling support; Advice on expectations of the withdrawal experience and the residential service; Liaising with GPs and linking consumers with support services as required; & Support for families of consumers during home-based withdrawal; Outcomes: Key findings from the external evaluation 2 of the Step-up, Step-down model include: Compared to people with no Step-up contact, those engaged in Step-up care were better prepared for residential withdrawal and were less likely to have used methamphetamines within 24 hours of their admission to the unit (see Table 1); Those engaged in Step-up care required less time in the unit (6.3 days average length of stay) and experienced more rapid reductions in withdrawal symptoms during their residential treatment (see Figure 1). A greater number of Step-up, Step-down contacts was associated with more positive quality of life outcomes (particularly for physical and mental health) at three-month follow-up. Withdrawal Table 1: Patterns of methamphetamine use prior to residential withdrawal admission Proportion who used methamphetamine on day of, or day before, admission to unit Proportion who used methamphetamine three or fewer days prior to admission No-contact group (n=39) Step-up group (n=22) 46.2% (n=18) 22.7% (n=5) 66.6% (n=26) 54% (n=12) Figure 1: Changes in withdrawal severity (ACSA scores) during residential withdrawal Methamphetamine withdrawal symptom severity (ACSA scores) 2 Admission into residential withdrawal for up to 10 days with the expectation that a consumer s participation in the program during first few days of withdrawal would be relaxed if required to accommodate a methamphetamine crash period; Day 1 Day 5 Day 7 Non-residential withdrawal support on completion of the residential component of the treatment and support plan. Such support could include: No-contact (n=9) Step-up (n=7) Continued withdrawal information and management; & Counselling and case management support including facilitating links with other services where required. 2 LeeJenn Health Consultants (2014) Methamphetamine step-up step-down withdrawal model evaluation: Final Report, Melbourne.

4 Three-month follow-up From a small sample followed up after three months (n=16), differences between the step-up consumers and consumers with no NRW contact did indicate the step-up group had on average, greater quality of life, less psychological distress and less methamphetamine use at the time of follow-up (see Table 2). These data suggest that a greater quantity of stepped-care contacts may be associated with more positive consumer outcomes at three-month follow-up, with higher consumer health satisfaction ratings in particular. Table 2: Consumer outcomes at three-month follow-up Health and Wellbeing measures-mean scores No-contact group Steppedcare group K10 psychological distress 29.3 (n=6) 23.8 (n=9) WHOQOL Quality of life rating 3.0 (n=6) 3.9 (n=8) WHOQOL-Satisfaction with health 2.33 (n=6) 3.3 (n=7) WHOQOL -Physical 60.0 (n=5) 65.9 (n=9) WHOQOL Psychological 41.7 (n=4) 50.9 (n=9) WHOQOL Social relations 55.0 (n=5) 45.4 (n=9) WHOQOL -Environment 57.5 (n=5) 64.1 (n=8) Substance use measures SDS-severity of methamphetamine dependence -mean score Average number of days used methamphetamine past 4 weeks 5.4 (n=7) 4.9 (n=9) 7.5 (0-23) (n=6) 4.0 (0-28) (n=8) * Note: the number of clients (and missing data) varies for each outcome measure; results are presented for all clients with relevant available data shown for each measure. Implications for future service development: While the sample size for Step-up, Step-down evaluation data is small, in combination with ReGen service data, consumer and staff feedback, and the outcomes of ongoing quality improvement processes, some key themes emerge: People actively engaged in methamphetamine use pose particular challenges for service providers in ensuring treatment retention; The combination of stepped-care withdrawal plus nonresidential rehabilitation (Torque program) is emerging as an effective treatment pathway for this group, both in terms of duration and intensity; While people seeking admission into the Torque program 3 are receiving good continuity of care, there are still service gaps for those only seeking methamphetamine withdrawal; People who have completed residential methamphetamine withdrawal are still experiencing withdrawal symptoms after three months; & The need for further professional development of ReGen clinical staff in delivering methamphetaminespecific treatment interventions, including postwithdrawal counselling and aftercare groups. Subsequent options for future service development at ReGen include: Establishment of a comprehensive Methamphetamine treatment model that incorporates a range of potential stepped-care interventions (dependent on consumer need), such as: Intake/Assessment Counselling (typically as a complex intervention) Care and Recovery Co-ordination 3 3 LeeJenn Health Consultants (2015) Evaluation of Torque a Catalyst non-residential program: Interim Report 2, Melbourne.

5 Non-residential withdrawal and counselling Step-up support & withdrawal preparation Residential withdrawal Step-down support (NRW, counselling, C&RC, aftercare group, web-based resources.) Non-residential rehabilitation (Torque) Self-directed, web-based resources for individuals and family members Referral to other ReGen services e.g. Family services Referral to other external services e.g housing and employment Delivery of targeted methamphetamine counselling intervention (adaptation of Baker, Kay-Lambkin, Lee & Claire s four-session model 4 ) Establishment of a targeted aftercare group, co-facilitated by consumer participants and ReGen staff Expanded delivery of brief education programs for people considering treatment (Methamphetamine Personal Education Program) and affected family members (Methamphetamine Family First Aid Program) Continued external evaluation of service outcomes Recommendations: supports the development, implementation (including appropriate staff training) and evaluation of a pilot Methamphetamine Treatment Model at ReGen. Training for clinical staff to include: Strategies for engaging this difficult-to-reach group and developing targeted pre and post-withdrawal support plans; & Delivery of targeted four-session methamphetamine counselling program for people not commencing Torque post-withdrawal. commit to the continuation (and potential expansion) of ReGen s Torque non-residential rehabilitation program as part of the Methamphetamine Treatment Model. ReGen continue to share program learnings with Government and the AOD treatment sector to inform future policy and service development. 4 For discussion of the content of this briefing paper, please contact Laurence Alvis, Chief Executive Officer ( ; lalvis@regen.org.au). Additional information about ReGen s development of targeted methamphetamine treatment responses (including the full evaluation report on the Step-up, Stepdown model) can be found on the agency s website: 4 University of Newcastle (2003) A brief behavioural intervention for regular amphetamine users: A treatment guide.