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December 7, 2015
Only around 2% of people in active addiction treatment will get access to residential rehabilitation services. In some areas that figure will be even less. Over the last decade there has been a definite policy of restricting access to residential rehab by the health and social services in the United Kingdom. In cases where residential rehab is offered, it tends to be seen as a “last resort” treatment. This policy is seen to be endorsed by Britain’s National Institute for Health and Clinical Excellence (NICE).
Following on from Mike Ashton's article last week, this week we hear from Castle Craig's Development Director, Dominic McCann:
NICE’s guidelines (1) on inpatient and residential treatment cannot be summarised into a simple rule, and the 'last resort rule' has surely done a great disservice to a lot of people.
First of all, we need to establish what is inpatient and residential care? It can be anything from a one week hospital detox, to a one or two year spell in a therapeutic community. Within that spectrum you have 12 step rehabs, and Castle Craig-type units involving detox and an intensive six week programme and extended care options (2).
There is a lack of reliable evidence comparing inpatient and outpatient treatment. One reason for this is that patients with severe drug and alcohol problems cannot safely be included in trials. This makes it very hard to draw conclusions about whether one type of treatment works better for those who are considered "most severe." In fact, NICE Guideline 51 even suggests that rehab might be less effective for such cases, and a better option for people who are "less well established in their drug using careers," (3). In NICE Guideline 115 we also learn that the “more severe and less socially stable fare better in inpatient” (4). The use of the term “more severe” rather than “most severe” is telling; we are not talking about a last resort treatment.
If we really want to understand why some people see rehab as a treatment option for only the most severely affected, then we can see it as an admission that local outpatient services just can't cope with patients who are very dysfunctional and very sick. Often a long-term residential programme in a therapeutic community (traditional or 12-step) is seen as the common sense option, and not necessarily an evidence-based treatment.
In unravelling NICE's train of thought, and its clinical recommendations, it is worth remembering that this statutory body is not making purely clinical judgements, they also have a political role insofar as they must keep a close eye on the purse strings of the NHS. At the moment 50% of the residential treatment sector in the UK is made up of therapeutic communities, and many others are expressly religious, or offer a very basic service. NICE’s experts would have been wary about opening a flood of expensive referrals into some of these treatment services, many of which have low success rates and high dropout rates. (Having said that, many of the UK’s outpatient services will not be faring any better.)
Mike Ashton’s article makes an interesting point about the randomised comparison (Greenwood 1990) influential in the devising of the NICE drug-dependency guidelines. He notes that three-quarters of the candidates (the most relevant ones) could not be safely randomised at the start of this trial. But apart from this built-in flaw, I also find this study unhelpful because the outpatient programme being compared was described as “very intensive”, and therefore not reflective of most UK outpatient services.
In any case one study is never influential, and NICE could not find enough studies in order to draw firm conclusions. 15 studies were excluded from the same analysis because they were not considered robust enough. Meanwhile the evidence from the large cohort studies (NTORS, DATOS etc.) was found to be broadly favourable towards residential treatment, but was then politely rebuffed for the same reasons. A lot more reliable evidence is needed, (NICE even says "urgently needed") and it is impossible to come to firm conclusions about the clinical effectiveness of inpatient vs outpatient.
Nor are there any firm conclusions about cost-effectiveness. Treatment drop-outs are a big waste of the drug and alcohol treatment budget, and outpatient detox and therapeutic communities (on either side of the spectrum) have poor retention rates. Looking at our own record at Castle Craig, I would imagine that shorter (1 to 3 months) and intensive inpatient treatment spells have the best retention rates. In any case, both the influential Rychtarik study as well as DATOS and NTORS point to the longer term savings of residential treatment.
I don’t know if Mike Ashton’s reference to William White is relevant in the context of the NICE guidelines. To my mind the “transfer of learning challenge” is White’s critique of the old therapeutic communities, with their highly artificial cultures and lengthy treatment programmes. But in modern/medical models of residential treatment, the patient is away from home for shorter periods, and treatment centres go to great lengths nowadays to prepare patients for reintegration and relapse prevention. I think that William White would look at a modern 12-step treatment centre like Castle Craig and see them as a much better model of care.
On the surface, NICE seem to have taken a tough line against all residential treatment centres, however, a detailed reading of the NICE Guidelines (CG 51, 52 and 115) as well as other supporting documents from NICE and the National Treatment Agency for Substance Misuse (NTA) - does not lead me to that conclusion.
If I were a doctor, planning the best treatment journey for one of my patients, then I would find plenty of scope within the guidance to refer to inpatient detox and rehab.
Based on indicators found in the NICE guidance, firstly I would be looking at the available local services - and considering whether detox and treatment services were readily available. I would also be considering the quality and intensity of those outpatient services. Were those local services abstinence based, and was there a culture supportive of abstinence based or 12 step treatment? Were there links to mutual aid? Was there a seamless integration or transition of withdrawal management and intensive psycho-social support?
Next I would be looking at my patient - how severe was their dependency - was it more severe than what could be termed “moderate”? Had they tried and failed previous community treatments or demonstrated poor adherence? Had they been drinking or using for long enough to be cognitively or functionally impaired? Were they older than the average alcohol / drug dependent patients? Were they a lot younger? Was their social situation at home unconducive to recovery? Were they at risk of being made homeless if their drinking or drug misuse continued? Were they pregnant or considering pregnancy? Could their detox needs be termed either lengthy or complex? Did they have psychiatric or physical co-morbidities? Had they suffered significant weight loss? Was there an intertwined drink and drug and / or prescription drug problem? Were they early in their drug using careers, and motivated by residential or 12 step treatment? Did they have good recovery capital - highly motivated? Was my patient in need of greater anonymity in view of their position or career in the community?
Then I would be looking at the available residential services: I would want to know that detoxification and assisted withdrawal was integrated with an intensive psycho-social programme. I would want to know about the quality of the service such as retention and outcome rates. I would want to know how intensive and how long the treatment programme was.
Again, all of these are relevant indicators and factors relevant to an inpatient referral, found in the NICE guidelines.
NICE's guidelines have correctly prioritised community treatment as the front line service, and in an ideal world with excellent quality and universally accessible outpatient care, there might be hardly any need for inpatient treatment. But every front line needs a second line, and inpatient treatment is much more than just a 'last resort'."
(1). The relevant guidelines for drug and alcohol dependency are numbers 51, 52 and 115. There is also a NICE quality standard - number 23 - and a supporting document referred to in the quality standards called drug dependency clinical management guidelines (2007), also known as the NTA’s Orange Book.
(2). NICE’s guidelines sometimes make an effort to identify and distinguish these models and sometimes they don’t go far enough, and make generalisations.
(3). Clinical Guidelines 51, 9.3.8-9
(4). Clinical Guidelines 115, 5.32.1.
Only around 2% of people in active addiction treatment will get access to residential rehabilitation services. Mike Ashton shares his take on the residential v. non-residential question.
Castle Craig's Head of Development