Thinking outside the box 21st Century Rehabilitation

Thinking outside the box 21st Century Rehabilitation

Dr. Mike McPhillips

Consultant Psychiatrist

Addictions Specialist

Dr. Mike McPhillips

Consultant Psychiatrist

Addictions Specialist

What did that NICE young man say?

What did that NICE young man say?

Drug misuse, Psychosocial interventions National Clinical Practice Guideline Number 51

National Collaborating Centre for Mental Health

Commissioned by the National Institute for

Health and Clinical Excellence, 2007

Nice findingsNice findings“There is consistent evidence that 12-step attendancemediates better substance misuse outcomes” (p181).

“A large-scale prospective cohort study (n = 3,018)conducted by Moos and colleagues (1999) revealed thatpeople receiving 12-step-based treatment for drugand/or alcohol misuse had superior abstinenceoutcomes compared with those in CBT or eclectic (based

ona combination of 12-step and CBT principles) treatmentgroups”.

“There is consistent evidence that 12-step attendancemediates better substance misuse outcomes” (p181).

“A large-scale prospective cohort study (n = 3,018)conducted by Moos and colleagues (1999) revealed thatpeople receiving 12-step-based treatment for drugand/or alcohol misuse had superior abstinenceoutcomes compared with those in CBT or eclectic (based

ona combination of 12-step and CBT principles) treatmentgroups”.

NICE recommendationsNICE recommendations

“Staff should routinely provide people who misuse

Drugs with information about self-help groups...based

on 12-step principles”

“If a person who misuses drugs has expressed an interest in attending a 12-step self-help group,

staffshould consider facilitating the person’s initial

contactwith the group, for example by making theappointment, arranging transport, accompanying

himor her to the first session…”

“Staff should routinely provide people who misuse

Drugs with information about self-help groups...based

on 12-step principles”

“If a person who misuses drugs has expressed an interest in attending a 12-step self-help group,

staffshould consider facilitating the person’s initial

contactwith the group, for example by making theappointment, arranging transport, accompanying

himor her to the first session…”

“Rehab.” “Rehab.” Modern era

• Began at Hazelden, Minnesota, 1949• Now worldwide• In UK since 1974

Elements• Medical Care, including detoxification• Group Therapy-based• Education• Spiritual Renewal• Overwhelmingly, 12-Step model

Modern era• Began at Hazelden, Minnesota, 1949• Now worldwide• In UK since 1974

Elements• Medical Care, including detoxification• Group Therapy-based• Education• Spiritual Renewal• Overwhelmingly, 12-Step model

Traditional rehab: problemsTraditional rehab: problems

• Frequent use of addicts in recovery as counsellors

• Mandatory attendance in all programme elements (including daily AA meetings)

• Prohibitions”on “luxuries • ,Single rooms ,Mobile phones• ,Internet, books ,TV • ,Cosmetics, Immodest clothing• .Some foodstuffs

• Frequent use of addicts in recovery as counsellors

• Mandatory attendance in all programme elements (including daily AA meetings)

• Prohibitions on “luxuries”• Single rooms, Mobile phones,• Internet, books, TV,• Cosmetics, Immodest clothing,• Some foodstuffs.

Traditional Rehab: problems

Traditional Rehab: problems

• Time consuming (28 days minimum).

• .Stigmatising, shame-based tactics

• .Expensive (₤2,000 – 10,000 per week)

• Lack of privacy (treatment involves open groups and public meetings, frequent.(newspaper interest

• Time consuming (28 days minimum).

• Stigmatising, shame-based tactics.

• Expensive (₤2,000 – 10,000 per week).

• Lack of privacy (treatment involves open groups and public meetings, frequent newspaper interest).

“If the only tool you have is a hammer...”

“If the only tool you have is a hammer...”

“....then every problem will come to look like a nail”

“....then every problem will come to look like a nail”

“I Don't Wanna Go To Rehab”“I Don't Wanna Go To Rehab”

Clients likely to refuse structured, group-based Programmes:

• Unhappy refugees from previous 12 step programmes

“never again”

• Reserved or shy people

“too much soul-baring with strangers”

• People with reputations to lose

Aristocracy, Royalty, Businessmen, Doctors, Lawyers, Clerics.

• People in the public eye

Sportsmen/TV personalities/Models/Pop stars/Actors/Politicians

Clients likely to refuse structured, group-based Programmes:

• Unhappy refugees from previous 12 step programmes

“never again”

• Reserved or shy people

“too much soul-baring with strangers”

• People with reputations to lose

Aristocracy, Royalty, Businessmen, Doctors, Lawyers, Clerics.

• People in the public eye

Sportsmen/TV personalities/Models/Pop stars/Actors/Politicians

Rehab: 2000 - Rehab: 2000 - Newest trends in addiction

treatment:

• Individually-tailored programmes

• No compulsory elements

• More use of 1:1 therapy

• No mandatory attendance at AA/NA

• More physical comfort

• Holistic therapy (CBT/complementary therapies, nutrition, fitness, weight control)

Newest trends in addiction treatment:

• Individually-tailored programmes

• No compulsory elements

• More use of 1:1 therapy

• No mandatory attendance at AA/NA

• More physical comfort

• Holistic therapy (CBT/complementary therapies, nutrition, fitness, weight control)

Alternatives to Residential CareAlternatives to Residential Care

• “Sweating it out”

• Hospital-based inpatient detoxification

• Outpatient detoxification

• Home Detoxification

• “Sweating it out”

• Hospital-based inpatient detoxification

• Outpatient detoxification

• Home Detoxification

Post- detox. interventionsPost- detox. interventions

• Motivational Interviewing

• Cognitive Behavioural Therapy

• Twelve Step Fellowship meetings

• Day Programmes

• Individual counselling

• Religious organisations

• Aversion/anti-craving medications

• Motivational Interviewing

• Cognitive Behavioural Therapy

• Twelve Step Fellowship meetings

• Day Programmes

• Individual counselling

• Religious organisations

• Aversion/anti-craving medications

Preparing for Home Detox. Preparing for Home Detox.

Detailed initial assessment– Drink and drug history– Comorbid physical problems– History of severe withdrawals (DT's,

epilepsy)

Plan B– GP– Psychiatrist– Inpatient medical ward

Detailed initial assessment– Drink and drug history– Comorbid physical problems– History of severe withdrawals (DT's,

epilepsy)

Plan B– GP– Psychiatrist– Inpatient medical ward

Detox: Published outcomesDetox: Published outcomes

• Specialist inpatient unit, 24/7 trained staff: 80%+ complete

• General Hospital Ward, general staff: 50%+ complete

• Domiciliary detox, nurse visits Mon-Fri, 9-5:

50-75% complete

• Outpatient, doctor-supervised, daily attendance Mon-Fri +/- family support:

20-50% complete

• Specialist inpatient unit, 24/7 trained staff: 80%+ complete

• General Hospital Ward, general staff: 50%+ complete

• Domiciliary detox, nurse visits Mon-Fri, 9-5:

50-75% complete

• Outpatient, doctor-supervised, daily attendance Mon-Fri +/- family support:

20-50% complete

1:1 Home detox: >300 cases, 1999-

1:1 Home detox: >300 cases, 1999-

24/7 Home CNS, medically supervised:• 95% complete

Advantages• Discretion • Excellent safety record, (client and nurse)• High client satisfaction• 1:1 therapy & support throughout detox.• Client accompanied to medical OPA, AA

meetings, assessments for aftercare, etc.

24/7 Home CNS, medically supervised:• 95% complete

Advantages• Discretion • Excellent safety record, (client and nurse)• High client satisfaction• 1:1 therapy & support throughout detox.• Client accompanied to medical OPA, AA

meetings, assessments for aftercare, etc.

Detox. mythsDetox. myths

'they always relapse, so there's no point....'

• Of those who relapse, 40-50% show significantly reduced use/improved health over the next six months

'there's no point in forcing people....'• Outcomes for coerced patients are almost as

good as those of voluntary patients

'they have to hit rock-bottom first....'• Some will die. Many will be damaged irreversibly.

Early intervention works best.

'they always relapse, so there's no point....'

• Of those who relapse, 40-50% show significantly reduced use/improved health over the next six months

'there's no point in forcing people....'• Outcomes for coerced patients are almost as

good as those of voluntary patients

'they have to hit rock-bottom first....'• Some will die. Many will be damaged irreversibly.

Early intervention works best.

Home detox: the rock starHome detox: the rock star

Home detox: the Home detox: the businessmanbusinessman

Home detox: the GP's visitHome detox: the GP's visit

Home detox: medication Home detox: medication deliverydelivery

Home detox: the Home detox: the Consultant arrivesConsultant arrives