Alcohol and Other Drug Treatment Reform

Victorian Alcohol and Drug Association

and Department of Health expert advisory groups

Summary paper – withdrawal treatment type

Please note: Information in the ‘context’ and ‘current treatment environment’ sections of this is taken from a range of key policy and programmatic documents. It is provided to give context to the group’s views but was not the subject of specific discussion at group meetings.

Context

In March 2011 the Victorian Auditor General’s Office (VAGO) published a review of alcohol and drug treatment services in Victoria (the VAGO report). One of the report’s key findings was that clients experience a high level of fragmentation and inconsistency in the service system and that this negatively affects its performance. In particular, the report noted that the location of allVictorian alcohol and drug community residential withdrawal services within 15 kilometres of Melbourne’s central business district limits access by people living in outer metropolitan Melbourne and rural and regional Victoria.

In June 2012, in response to the VAGO report and consecutive reviews of the alcohol and drug treatment system over the past decade, including aservice system review, the Victorian Government announced a framework for reforms to the alcohol and drug treatment system with the release of New directions for alcohol and drug treatment services – a roadmap. The roadmap details an ambitious agenda of redevelopment for the whole treatment sector. The redevelopment process is staged, with the first phase focused on non-residential adult services and the second stage on residential services including the youth sector. Preparing the ground for reform has involved commencing system-wide enhancements in 2012 including developing common screening and assessment tools, exploring the creation of a bed vacancy register and establishing new counselling services.

Reform of Victoria’s alcohol and drug withdrawal services is spilt into two phases. The first phase focuses on non-residential withdrawal services, including clinic-based, home-based and outreach withdrawal. The second phase focuses on residential withdrawal services. The Withdrawal Advisory Group was convened to identify any issues, opportunities, obstacles or factors to be considered in the implementation of key reforms acrossboth residential and non-residential withdrawal services

The purpose of this paper is to provide a summary of the issues and discussions from the Withdrawal Advisory Groupand to provide an outline of the outcomes and quality benchmarks the group considered relevant to a redeveloped alcohol and drug withdrawal response under a new treatment system.

Thisgroup met five times between July 2012 and March 2013.Whilst the purpose of the withdrawal advisory group was to consider all components of the withdrawal treatment type, there was a considerable focus on residential withdrawal. This discussion remains active. The group will reconvene post the recommissioning of community based alcohol and drug services to continue its deliberations in relation to the residential withdrawal services.

This paper is a reflection of the discussions and key points raised by the reference group at its meetings.It does not purport to be a comprehensive record of all issues raised and should not be taken to suggest that all participants agreed with all findings. For a full record of the group discussions please refer to the notes of the advisory groups (along with the papers that were prepared for the meetings), which are available on the Victorian Alcohol and Drug Association (VAADA) website at

Please note that while the views of the advisory group will be taken into consideration in designing system reviews, this paper should not be taken as a guide to the specific services that may be sought by government through the recommissioning process for alcohol and other drug services.

Current treatment environment

In Victoria, withdrawal services are provided in both residential and non-residential settings and can includethe use of medications to help manage the side effects of withdrawal. Residentialsettings are more frequently used for people experiencing severewithdrawal side effects or complex behaviours. A non-residential setting, such ashome-based or outpatient withdrawal, typically involves clients experiencing less severe withdrawal side-effects and who have a level of stability in their lives, includingsupportive friends or family and stable housing.Withdrawal includes the following funded service types:

• residential withdrawal

• outpatient withdrawal

• home-based withdrawal

• rural withdrawal

These services are designed to cater for a range of client complexity and geographic demand.

Residential withdrawal

Residential withdrawal services provide alcohol and drug withdrawal to young people and adults through a dedicated community-based residential facility or throughhospital-based treatment. Community residential drug withdrawal is provided to clientsin a suburban setting located close to a public hospital. The treatment emphasis is on a short length of stay.

Outpatient withdrawal

Outpatient withdrawal services are provided to clients who are experiencing mild withdrawal symptoms which can be appropriately managed without admission to aresidential withdrawal service. The service provides a series of intensive individualoutpatient consultations over a short period, followed by ongoing counselling andsupport to complete the withdrawal.

Home-based withdrawal

Home-based withdrawal services are provided in cases where the withdrawal syndrome is of mild to moderate severity and the client is able to be supported by afamily member or friend at home. This service may be provided as part of the ruralwithdrawal support service following a short hospital admission, or as the completetreatment if no hospital admission is required. The service is provided by anexperienced nurse in conjunction with a medical practitioner, preferably the client’sgeneral practitioner.

Rural withdrawal

Rural withdrawal services combine a short hospital stay (where required) with a period of home-based withdrawal for clients located in rural Victoria. Rural withdrawal currently has a range of different functionalities.It is often delivered by an experienced nurse in conjunction with a medical practitioner.

Goal of withdrawal

The primary goal of alcohol or drug withdrawal is to safely achieve neuroadaptation.

Residential withdrawal is suitable for those with severe withdrawal syndrome or complex behaviours.

Cost of withdrawal services

Community residential withdrawal is one of the most expensive service types in the Victorian service system. Unit cost per separation in 2010-11 was $7,274 for a four bed service, $3,562 for a six bed withdrawal service, and $2,395 for a 12 bed service. Twelve bed withdrawal services comprise the bulk of community residential withdrawal services in Victoria.

Other models of adult withdrawal are costed per Episode of Care (EOC). Home-based and rural withdrawal cost $1,377 per EOC in 2010-11, while outpatient withdrawal cost $448 per EOC in 2010-11.

Reviewsand evaluations

There have been a number of reviews and evaluations in the past decade relating to withdrawal services. These include:

  • TheDefining AOD Treatment and Workforce project (2010)
  • The Adult Community Residential Drug Withdrawal Services Review (2006)
  • The Pathways Report (2003) (also known as the Service System Review 2003)
  • The Evaluation of Community Drug Withdrawal Services (2000)

Many of the issues raised in the Withdrawal Advisory Group meetings reflected the themes identified in previous reviews. A summary of the key themes from the advisory group is provided below.

Key themes from the withdrawal group

The Advisory Group noted that withdrawal itself cannot be viewed as a stand alone treatment. The group agreed that if viewed in isolation withdrawal is unlikely to produce long-term behaviour change and as such needs to be provided in the context of a wider range of treatment and support services.

Broadly speaking, the group agreed that withdrawal should be viewed as one step towards commencing behaviour change. Most of the group felt that the changes to drug use behaviour are achieved through post-withdrawal treatments such as counselling and therapeutic communities or through maintenance pharmacotherapy.

Withdrawal investment

The group discussed the relative effectiveness and cost of residential versus non-residential withdrawal services. Some members of the group noted that whilst non-residential treatment is often considered less effective than residential withdrawal it is demonstrably cheaper to provide.

Continuity of care

The group discussed the importance of continuity of care associated with withdrawal. Some members of the group suggested that withdrawal services should be co-located with other therapeutic treatment services. Several members of the group suggested that co-locating counselling and residential rehabilitation services with withdrawal services would improvecontinuity of care and mitigate the risk of post-withdrawal relapse and overdose.

Accessibilityto withdrawal services

The group considered the accessibility of withdrawal services in Victoria. Much of this discussion focused on the measurement of accessibility through waiting lists, bed availability and service capacity. Some members of the group suggested that whilst these are critical measures, accessibility could also be measured through hours of operation, affordability, distance to service, intake and assessment processes, client awareness of service, and accessibility to diverse populations.

Many members of the group noted that some residential withdrawal services have differingintake, prioritisation and assessment practices, which was considered concerning. The trial of the centralised bed vacancy register was supported by the group.

Some members of the group also noted that the availability of in-region residential withdrawal services was considered important to rural clients, families and communities. The development of strong links with supportive community and service providers was considered a valuable element of rural withdrawal providers. Some members of the group considered the rural withdrawal treatment type as critical to ensuring accessibility to withdrawal in rural and remote areas, and recommended brokerage funding be incorporated into the model to pay for client transport to treatment services as they felt this impedes access to treatment.

The group noted the requirement for clearer and better defined pathways through the treatment system. The group suggested that accessibility should be a key issue for the reform of withdrawal services and recommended that it be closely monitored through the recommissioning process.

Co-occurring conditions and complexity

The Withdrawal Advisory Group discussed many of the current difficulties in meeting the needs of clients with an Acquired Brain Injury (ABI) or mental illness.

The group suggested that ABI clients represent a significant proportion of clients presenting for withdrawal and the presence of ABI is common among heavy drinkers and older people. Some members of the group suggested thatwhile some good work is occurring around the treatment of ABI clients, many services struggle to accommodate the needs of clients with an ABI.

Many group members agreed that access to specialist neuropsychological assessments for ABI clients seeking withdrawal is a key challenge for services. The group noted that are significant costs and delays in accessing qualified assessment.

Some members of the group noted that as most ABI clients have impaired executive functioning, counselling services may not be suitable. It was noted that withdrawal services should focus on environment and supports for people with ABI. It was suggested that lack of access to ABI-related workforce development, particularly in rural areas, might hinder the growth of sector expertise.

The group also noted that many withdrawal services also find it difficult to accommodate the needs of clients with serious mental illness. Some group members noted that the management of psychotic episodes and the interaction with withdrawal symptoms pose a significant challenge for residential and non-residential services.

Most members of the group agreed that the capacity to appropriately screen, assess and manage clients with an ABI or mental illness should be critical issue for reform. Many group members felt thatalcohol and drug services should be provided clear direction about their responsibility to work in an integrated manner with other health and human services regarding these clients.

Rural withdrawal

The differences between metropolitan and rural withdrawal services were discussed by the Advisory Group. Most of the group members felt that rural services in general have greater difficulty accessing post-withdrawal support from GPs but also report much stronger relationships with local hospitals. Most of the group felt that these relationships are built on integration efforts among local health providers in response to client need. It was recommended that reform consider and build on the existing strengths of the rural withdrawal model.

Waitlists

The Advisory Group’s discussion on waitlist management highlighted a diversity of practice across the sector. Group members noted that some residential withdrawal services maintain active engagement with their clients (e.g. regular telephone contact) and provide access to support groups, whilst waiting for residential withdrawal, whereas other services require clients to make regular contact to demonstrate their continued commitment to withdrawal. Most group members agreed that building collaborative relationships with the care and recovery coordination service type would be critical to supporting clients prior to entry into a residential withdrawal service.

Post-withdrawal care

Post-withdrawal care was identified by the Advisory Group as critical to the success of withdrawal. The group agreed thatpost-withdrawal care covers a wide range of services related to the ongoing management of clients following completion of a withdrawal stay or non-residential withdrawal episode. The advisory group recommended that this be considered as part of the model of care for withdrawal.

The role of hospitals and health services

The role of hospitals in the alcohol and drug system was discussed at length by the Advisory Group.The demand on hospitals was acknowledged as one of the factors influencing inconsistent responses to people with alcohol and drug issues. Some members of the group suggested that emergency departments were reportedly interested in ‘fast solutions’ and that many hospital staff lacked the skills and capabilities required to deal adequately with alcohol and drug presentations.

Some members of the group noted that inpatient withdrawal admissionscriteria variedacross hospitals, and that client co-morbidity is usually required for a hospital withdrawal admission. Some members of the group also suggested that this may related to inflexible admission criteria of community residential withdrawal services which often screen out clients with co-morbidity.

Some members of the group noted that a more thorough understanding of how the hospital inpatient system currently works would inform future discussions in relation to residential withdrawal services. It was also noted amongst the group that current barriers to inpatient withdrawal requires further consideration. Further exploration of this issue will occur when the group reconvenes.

The role of Addiction Medicine Specialists

Some members of the group suggested that Addiction Medicine Specialists (AMS) could be better utilised across the system. The importance of hospital links and step-down arrangements was a key point of discussion. Many members of the groupagreed that the expert role of AMS is critical to good outcomes for patients accessingstep-down withdrawal beds from a hospital stay. The role of addiction medicine specialists in providing secondary consultation and the relationship between general practitioners and non-residential withdrawal services was also considered important by the group.

Some group members recommended the following issues for further consideration:

  • Identification of dedicated addiction medicine beds across the state to support seamless step-up and step-down arrangements
  • AMS as responsible for the clinical governance of the medically supervised withdrawal service type.
  • Addiction medicine nursing specialists to undertake client risk assessments that facilitate access to hospital withdrawal beds. Where this is not possible, hospital staff could be up-skilled to undertake this task and make appropriate links with local alcohol and drug services.
  • Nurses with alcohol and drug expertise to be present on hospital wards as well as in emergency departments.
  • Clearly defined step-up and step-down pathways between hospital and community based services.

The role of GPsand Alcohol and DrugNurses

The group considered the role of General Practitioners in the alcohol and drug system as an important element of reform. Many of the group felt that GPs lack knowledge about the alcohol and drug withdrawal process and sometime fail to seek expert advice through DACAS. The critical role of GPs in delivering non-residential withdrawal, residential withdrawal, post-withdrawal support or step-down care was discussed at length and many of the group felt that GPs were not currently well integrated in the alcohol and drug treatment system.