The Stimulant Treatment Program: A stepped care approach'

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The Stimulant Treatment ProgramA stepped- care
approach.
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STP Background

• In 2006, the NSW Government committed 2.45
  million over four years as part of the Co-
  Morbidity Package (COMP) to establish and develop
  Stimulant Treatment Programs.
• The pilot involves 2 services, located at St.
  Vincents Hospital in Darlinghurst Sydney and the
  other in Newcastle as part of Hunter New England
  Area Health Service
• This newly established program is the first
  integrated and collaborative treatment program to
  deal systematically with stimulant related
  problems.
• The project is evaluated independently.

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Aims of the STP

• Increase access to treatment for (heavy)
  stimulant users
• Reduce health, social and legal problems
  associated with stimulant use
• Assist people using stimulants who want to reduce
  or cease use
• Support people who are abstinent from relapsing
  to problematic stimulant use

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Aims of the STP

• Provide a combination of brief interventions,
  individual counselling programs and education for
  parents and significant others
• Provide substitution pharmacotherapy treatment
  for severely dependent stimulant users
  currently only conducted at St Vincents STP.

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Key tasks of the STP

• Promote services that are attractive to stimulant
  users,
• Retain them long enough to achieve lasting
  change and
• To creatively engineer access points which
  proactively engage potential clients in
  partnership with other local service providers

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Engaging stimulant users

• UK evidence suggests that targeted programs for
  users of stimulant drugs are effective
• Stimulant users report seeking services that are
  specialised, separate and distinct from
  hospital/health campuses
• Stimulant users that we see report that there had
  been an unmet need in the form of a specific
  stimulant service
• It was important for us to also foster links with
  other support services and user organisations,
  already supporting those with stimulant issues

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Components of effective treatment

• Competent staff and service
• Immediate access
• Rapid response
• Client-counselor relationship
• Effective referral and induction processes
• Flexibility and a tailored response to the
  individual

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Stepped care approach

• According to Sobell Sobell (1999), a stepped
  care approach involves three fundamental
  principles of health care
• Treatment should be individualized
• The treatments selected should be consistent with
  the contemporary research literature.
• Clinical judgment by experienced clinicians
  lacks strong empirical validation but is critical
  for determining when to choose particular
  treatment options.
• The treatment should be least restrictive but
  still likely to work.

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Process of treatment at the STP

• Triage and referral
• Intake
• Assessment
• Treatment offered
• Counselling interventions
• Counselling plus pharmacotherapy

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Triage and Referral

• Stimulant users often seek help in a crisis.
• Easy and immediate access to support, advice and
  referral via 24-hour telephone helplines are
  recommended by users and have been found to be
  effective in practice. This service is provided
  through the STP helpline, available 24/7
• Preliminary findings from the evaluation report,
  indicates the majority of new clients
  self-referred.

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Intake

• After contact is made, a rapid response is widely
  thought to be the key to engaging stimulant users
  in treatment.
• Treatment service is open weekdays from 8.30am to
  5pm.
• Intake asks about
• what the person has been using
• the impact stimulants have had on their life
• what support the person seeks
• Brief intervention is offered

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Assessment

• Aims to gain a broad picture of the ways
  stimulants have affected the persons life
  including health, welfare and relationships.
• Initial assessment is protracted due to
  suspiciousness and paranoia.
• Engagement and developing the therapeutic
  alliance early in treatment is therefore critical.

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STP Counselling

• Is the core work undertaken with all people
  admitted
• Stepped care approach is applied, with increasing
  intensity of treatment depending on the persons
  needs.
• Support is provided primarily through individual
  sessions while involvement group work is also
  encouraged.
• Motivational interviewing and a CBT approach is
  taken by half the counselling team following the
  work of Baker, Lee et.al. (2005). The other half
  of the team use Narrative therapy.
• Assertive follow-up is standard practice across
  the teams

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Dexamphetamine Pharmacotherapy

• Patients who continue to experience serious and
  multiple harms associated with their stimulant
  use despite active involvement in counselling may
  be referred for assessment for pharmacological
  treatment.
• There are very strict entry criteria for
  pharmacotherapy treatment
• Pharmacotherapy is best implemented on a
  case-by-case basis rather than as routine
  treatments.

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Eligibility criteria

• Over 21 years of age.
• SDS score greater than 4, indicating severe
  amphetamine dependence
• Currently experiencing major adverse consequences
  from use impacting on physical health and/ or
  mental health
• History of problematic stimulant abuse for at
  least 2 years
• History of at least 2 previous episodes of
  substance use treatment for amphetamine
  dependence
• Stable accommodation within the local
  geographical area (such that daily attendance for
  dosing is feasible)
• Opinion by a doctor who is independent of the STP
  indicting that dexamphetamine substitution is
  warranted

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Exclusion criteria

• A currently active psychosis or recent (within
  the last 6 months) confirmed diagnosis of
  schizophrenia, schizoaffective disorder, bi-polar
  disorder, or Tourettes syndrome.
• A major medical contraindication
• Substance dependence diagnosis of the following
  substances opioids, benzodiazepines,
  barbiturates, alcohol.
• Concurrent methadone or buprenorphine
  substitution maintenance treatment
• Use within the last month of mono-amine oxidize
  inhibitors (MAOIs).

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Preliminary Evaluation

• Preliminary 6 month evaluation 2006-2007
• Promote services that attractive to stimulant
  users
• Retain people long enough to effect change
• To creatively engineer access points to
  proactively engage potential clients

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Evaluation Promote services that are attractive
to stimulant users

• The STPs were effective in their capacity to
  attract primary methamphetamine users into
  treatment, with 49 (n115) of service users
  report being treatment naive.
• At St Vincents Hospital
• 104 patients have presented to the SVH STP with
  all patients receiving brief interventions.
• 63 of these people referred on to more in depth
  counseling interventions.
• 3 patients received pharmacological treatment of
  dexamphetamine.
• In the Hunter,
• 112 people presented to treatment, with 52 going
  on to assessment phase and 35 into treatment.
• Total of 216 people accessed the 2 services in
  the 7 months to June 07.

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Evaluation Retain people long enough to achieve
change

• Dependence
• Higher levels of dependence occur by the use of
  higher concentration forms of methamphetamine
  such as crystal and base with more efficient
  means of use such as smoking and injecting.
• Overall 66 inject while 27 smoke.
• All patients of the STP were stimulant dependent
  as measured by the SDS.
• At 3 month follow up, only a third remained
  dependent on stimulants.
• Physical health
• SF12 at baseline 84 of patients reported poor
  health
• At follow up 8 of patients scored in the same
  range

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Evaluation Retain people long enough to achieve
change

• Mental health
• History of mental illness
• 21 nil, 25 1 diagnosis, 31 2 diagnoses,
  15 3 diagnoses.
• Reported diagnoses include
• 35 drug induced psychosis, 70 depression,
  39 anxiety.
• K10 at baseline, 75 of patients were severely
  distressed
• At 3 month follow up, 8 of patients were
  severely distressed.
• On the Brief Psychiatric Rating Scale
• 83 rated on hostility, 83 suspiciousness,
  58 hallucinations, 38 reported unusual thoughts.

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Evaluation To creatively engineer access points
to proactively

engage potential clients

• Patients seen on the hospital wards, the PECC
  unit, Emergency Department or Psychiatric
  Hospital all receive brief interventions
• Increased awareness of service availability
• Referral by key agencies
• Effective referral and induction processes can
  help clients feel more motivated to enter
  treatment.
• Referral and coordinated care plans developed
  with patients and key agencies is often necessary
  and best practice
• Word of mouth from service users has been
  critical
• STP has demonstrated its acceptability to the
  target population.

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Implications for service delivery

• High levels of paranoia and suspiciousness can
  provide a significant barrier to treatment entry.
• Engagement and developing the therapeutic
  alliance early in treatment is therefore
  critical.
• Routine screening is crucial including assessment
  of psychotic symptoms and suicidal thoughts.
• Almost half of clients had no previous treatment.
• Therefore, identifying their hopes and
  expectations of service is critical.
• Primary reason for presenting
• Hopes for change
• How we can support this change
• Important to develop creative ways of working.

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Challenges

• Infrastructure costs setting up within a non area
  health service environment
• Relocation of Newcastle clinic
• Communication between sites
• Models of service delivery
• Follow-up rates for evaluation
• Initial client expectations around
  pharmacotherapy

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Case Studies

• Rick 20 year old male who had only recently
  moved from the country to Sydney to be amongst
  the gay party scene, started smoking, then
  injecting ice, cocaine and using GHB.
• Became every weekend and then into the week, used
  GHB in a suicide attempt and was referred via the
  PECC unit
• Meth use a strong feature of his sexual practice,
  recent HIV diagnosis
• Marie 28 year old female smoking ice since
  2005, became problematic a year later smoking
  around 3 ½ grams per week from the moment she
  woke and throughout her working day.
• Prescribed Zoloft for depression, reported
  frequent suicidal thoughts
• Used ice to maintain weight, significant issues
  around body image
• Felix 30 year old migrant with history of
  trauma and suicide. Injecting ice (2-3) points a
  day, homeless and HIV positive.
• Case managed by a number of community-based
  support services, therefore a coordinated
  approach was needed with regular case
  conferencing to address basic needs such as
  housing etc

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Future Plans

• Promotion initially (2006-07) information was
  sent to health service providers in the local
  areas of both services. Further promotion is
  planned with the release of the first evaluation
  report.
• Further evaluation
• Dexamphetamine options and trials
• Alternative therapies
• Community partnerships

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Acknowledgments

• Clients involved in the service who gave of their
  time for the evaluation
• St Vincents Hospital
• Alex Wodak, Tarra Adam, Rosara Squirchuk, Jim
  Villamor, Donna Brady, Bronwyn Crosby, Carol
  Stubley, Sue Ivanyi, Samantha Forbes, Jeanette
  Wong.
• Hunter New England Area Health Service
• Adrian Dunlop, Bill Robertson, Julie Humphreys,
  Raka Tierney, Bruce Tulloch, Liz Knock.
• National Drug and Alcohol Research Centre
• Rebecca McKetin, Amanda Baker
• New South Wales Health STP Steering Committee
• Joe Barry, Robert Batey, Rafe Champion, Kanan
  Gandecha, Chris Shipway