ECBC is a developing new service for Primary Care. It uses a reward system to nudge Class A addicts into healthier social and personal behaviour. This helps clinicians who want to provide stress-reducing personal community care. It is a concept that is approved and recommended by NICE. The service awards credits called Carecreds for clinically validated beneficial behaviour e.g. testing street-clean for drugs, becoming fit, caring for others etc. It reduces this Credit when there are reports of negative behavior. Based on the records of these earned and independently validated credits, it issues Official Personal Testimonials and vouchers to help its participants develop caring counter habits to their substance abuse. A randomized comparative study, partially funded by the Strategic Partnership on Alcohol & Drugs (Kingston, Surrey) has compared giving a monthly flat-rate of £5 Boots voucher with giving vouchers of up to £14 per month varying with number of Carecreds earned.
Dr D'Souza & Partners
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
To measure how Class A addicts respond to being given CareCreds. To see if CareCreds can: 1. Increase successful Opioid Detoxification and eliminate street drug use. 2. Reduce chaotic binging behaviour 3. Encourage better behaviour towards family and friends 4. Reduce other health-damaging habits such as obesity, smoking and alcoholism 5. Reduce crime and nuisance behaviour 6. Encourage patients to get physically fit and go on self-development courses (particularly become literate) 7. Encourage return to voluntary and paid work.
44 patients have started the ECBC scheme since April 2009 aged between 23 and 62yrs old. Of these, 70% are male. They represent over 10% of all the Class A patients being treated in Kingston Upon Thames. Most had already been under care but 64% were chaotic users of street drugs on top of their methadone with 17% injecting opiates. 34% had additional alcohol problems, 45% used Cannabis and 86% smoked tobacco. 70% were depressed and only 10% did any exercise. In the previous year 25% had been hospitalized and 47.5% imprisoned. 55% were stressed by housing problems and 72% by shortage of money. 60% had had difficulties with reading and writing. There were barriers to setting up this study in General practice. These mainly centered on the added (unpaid) workload and bad behavior of these disturbed patients. This was initially overcome by limiting recruitment to 30 patients. Then we delivered a quality, calming personal service that our patients did not want to lose. Thereafter the CareCreds provided an additional incentive. Obtaining our funding was also a barrier aided by only requesting a very modest sum (£6000). However even this was not continued because it was apparent that some of the Drug and Alcohol team middle management did not understand the point of a scheme that focused on social intervention and the fact that we were trying to achieve street-cleanliness which was not a part of National Outcomes they are charged to collect. This inadequate funding impeded our intension of widening the recruitment to other practices. However we were able to analyze 31 patients who had spent six months or more in study by Spring 2010.
The findings for these patients were surprisingly good as follows: 1. Over 75% were street clean on urine testing. 25% are off all class A drugs. Home Detox using Subutex or Methadone has succeeded in 6 of our patients at a cost of £35 per patient. This compares with 5 others who, although no different, had a £6000 Clinic Detox and a Rehab costing at least £40,000. Our own home rehab costs little more than ordinary GP care (£480) and because it is done in the community appears to be having a greater chance of long-term success. We have had 100% retention in care (NTA national average=48%). 2 Chaotic behaviour has dramatically reduced. Only 25% now use any street class A vs. 64% at start (only one patient injects and even he is no longer chaotic) Additionally 24% of our patients are being maintained on a regular low dose of Methadone while 36% are reducing prior to being offered home detox. 3 Only one patient is still too ill to care for others. 4 Reduction of cigarette smoking has so far not been effective and alcohol intake has remained a problem for two patients. 5 Nuisance behaviour has been dramatically reduced in nearly all participants and annual crime rate has dropped to 13% with no imprisonments. 6 Only 5% have so far taken up courses of self- improvement. 7 10 % are however now engaged in paid jobs and others are looking for work. Overall Carecred earnings have risen by 30%. The Carecred score is, in itself, a measure of healthcare improvement. At the start 13/31 (41.9%) were earning 14 or more CareCreds i.e. half of those available to them. After three months 26/31 (83.9%) had reached this target. This is statistically highly significant p=0.00075. These preliminary results indicate that giving earnings-related vouchers is the most effective strategy; 82% of this group shows improvement in their Carecred scores as opposed to only 54% in Flat rate earners. This difference was significant (p=0.041).
This service is set up to be continuously evaluated via its website data collection. Many independent trials have been done confirming the value of Contingency Management so the focus of this exercise has been on the feasibility and continuous creative improvement in designing a practical service. We now have many new ideas on how this scheme could be rationalized and streamlined so that it could be easily applied throughout the country following further independent evaluation. Of interest that since stopping the scheme two who were doing well have gone on to have home detox while two who were not improving have become even more unstable.
1 It is feasible to manage a Contingency Management service on-line but many patients with substance abuse cannot read so audio material or direct clinical approach is needed. 2 CareCreds have proved to be highly effective in helping substance abusers and earnings related vouchers were more effective than flat rate vouchers. 3 They improve patient behavior. This is important, because to maximize benefits, long-term personal care by the same clinician is required and bad behavior can prevent this. 4 It is still unclear how long this service needs to be continued to prevent relapse. (We have been stopping it when patients have been opiate-clean for 9 months) 5 If a small proportion of the existing clinic-based Rehab budget were to be diverted into such schemes, it could not only increase effective opioid detoxification but also make major savings in both Home Office and NHS costs and this study supports their recommendation by NICE.
Dr Michael D'Souza
Dr D'Souza & Partners
Is the example industry-sponsored in any way?