Summary

There is highly processed and review-level evidence as well as policy directives that support the effectiveness of a person-centred sustained and holistic approach for improving health and treatment outcomes of people who use drugs.

Review-level evidence demonstrates the benefit of psychosocial interventions and suggests case management is effective as a strategy for linking community and treatment services for persons with substance use disorders in need of a variety of support.

Rationale

NICE Clinical Guideline 51 Drugs Misuse: Psychosocial Interventions [1] general considerations state:

• Best practice for the treatment and care of people who misuse drugs should have the opportunity to make informed decisions about their care and treatment, in partnership with healthcare professionals. Good communication between staff and service users is essential. Treatment and care, and the information service users are given about it, should be culturally appropriate. It should also be accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English.
• If the service user agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. Families and carers should also be given the information and support they need.
•  Assessment should have a holistic approach to care planning with the service user, with consideration given to specific needs, history of drug use and previous experience of treatment, goals and preferences.
• Staff should support service users in fulfilling their care plan with a supportive relationship, developing coping strategies, access to wider range of services and maintaining engagement as well as ensuring successful collaboration with other care providers.
• Residential treatment may be considered for people who are seeking abstinence and who have significant comorbid physical, mental health or social (for example housing) problems. Urgent assessment should be offered to people who have relapsed.

Housing support

There is review-level evidence from a rapid systematic review that support with housing, particularly for people with mental health or substance misuse problems benefits health. Evidence suggests housing provision should optimally be combined with other support services. [2]

Evidence of effectiveness of psychosocial interventions to improve drug-related outcomes

There is highly processed evidence of effectiveness from a Cochrane Review of standard psychosocial support (routine counselling) delivered with methadone maintenance treatment (MMT), when compared to any other structured psychosocial intervention delivered with agonist maintenance treatments.[3]

Case management for people with drug use problems

There is highly processed evidence from a Cochrane Review that suggests case management is effective as a strategy for linking community and treatment services for persons with substance use disorders in need of a variety of support. However, effects differ depending on availability, access and model of case management (with the most promising effect found for strengths-based approaches and the use of a manual to guide and standardise delivery).

Findings related to drug use outcomes varied but overall did not provide convincing support that case management is effective to reduce illicit drug use, although a small effect was found when compared with other specific treatment such as motivational interviewing or drug counselling. A small number of studies found evidence of a moderate significant effect for improvements in housing and small (yet non-significant) but consistent effect on legal outcomes (e.g. number of days incarcerated, charges for drug-related offences). This evidence is drawn from studies that concerned patients who were out of treatment when assigned to case management or control. [4]

Scottish policy and practice note

Scottish Government's Developing Recovery-Orientated Systems of Care (ROSC) through Service Redesign: Driver Diagram [5] is a tool to assist local areas with service planning and redesign to work towards the implementation of a recovery-orientated system of care (ROSC). The tool includes links to guidance and advice when undertaking system redesign work locally.

Quality Principles: Standard Expectations of Care and Support in Alcohol and Drug Services 2014 [6]
The underlying philosophy of a ROSC is that treatment and aftercare are integrated, and priority is given within the system to sustaining individuals in their recovery journey. The distinguishing features of a ROSC include being person-centred, inclusive of family and significant others; provision of individualised and comprehensive services across the lifespan with systems anchored in the community. At its core it has strength-based assessments and interventions that are responsive to personal belief systems, a commitment to peer recovery support services, is inclusive of the voices and experiences of people and their families in recovery and provides integrated services. It also provides for system-wide education and training, ongoing monitoring and outreach, is outcomes-driven and evidence-based.

References:

1. National Institute for Health Care Excellence (NICE, 2011) Clinical Guidelines 51: Drugs Misuse: Psychosocial Interventions. London: NICE.

2. Fitzpatrick-Lewis, D. Gannan, R. Krishnatatne, S. Ciliska, D. Kouyoumdjian, F. Hwang, S. W. (2011) Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review. BMC Public Health. 2011;11(683):1–14. .

3. Amato, L. Minozzi,S. Davoli, M. Vecchi, S. (2011) Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database of Systematic Reviews; (10).

4. Hesse, M. Vanderplasschen, W. Rapp, R. Broekaert, E. Fridell, M. (2007) Case Management for persons with substance use disorders. Cochrane Database of Systematic Reviews.

5. Developing Recovery-Orientated Systems of Care (ROSC) through Service Redesign: Driver Diagram:

• Interactive version (external link): www.ssks.org.uk/topics/drugs-and-alcohol/developing-recovery-orientated-systems-of-care-driver-diagram.aspx

• PDF version ( external link, 110.15 KB): www.ssks.org.uk/media/88060/driver_diagram_feb_2013.pdf

6. Scottish Government and COSLA. (2014) The Quality Principles: Standard Expectations of Care and Support in Alcohol and Drug Services. Edinburgh:Scottish Government and COSLA. Available from (external link) : www.scotland.gov.uk/Publications/2014/08/1726/downloads