Medication Assisted Treatment (MAT) standards: access, choice, support

Standard 5 Retention

All people will receive support to remain in treatment for as long as requested.

A person is given support to stay in treatment for as long as they like and at key transition times such as leaving hospital or prison. People are not put out of treatment. There should be no unplanned discharges. When people do wish to leave treatment they can discuss this with the service, and the service will provide support to ensure people leave treatment safely.

Treatment services value the treatment they provide to all the people who are in their care. People will be supported to stay in treatment especially at times when things are difficult for them.

Rationale

Evidence shows elevated mortality risks during the first four weeks of treatment and the first four weeks after leaving treatment and that the health of individuals with opioid dependence is safeguarded while in substitution treatment for at least six months. This demonstrates that these are critical intervention points to support people in substitution treatment and prevent drug-related deaths. The Orange Guidelines recommend that appointment frequencies should reflect clinical need and the efficient use of resources (p38). What is needed is a flexible response that offers different care packages ranging from low intensity for people who do not require or want more involvement, to intensive recovery packages for those that do.

Stigma, dose reduction or punitive actions due to ongoing substance use actively discourages engagement and retention in treatment. Combined peer outreach and treatment interventions, that target out-of-treatment individuals, have been shown to support people into MAT, optimize care and prevent people dropping out.

More socially stable people using services who may not need frequent attendance can be over treated or over supervised and this can have a detrimental effect on their ability to return to or sustain a stable lifestyle. Attendance requirements must not be arbitrary and should respect peoples' personal circumstances (p38). There should be flexible arrangements for appointments, particularly for people who are homeless and with co-morbidities or social issues that affect their ability to engage or organise their time (p94). Offering people only fixed appointment times is an unjustifiable barrier to access, ties up practitioner capacity and is an unnecessary waste of resources.

Criteria

All service providers should:

5.1 have pathways in place or models of support that are flexible and offer different care packages that range from low intensity for people not requiring or wanting more involvement, to intensive recovery focused packages for others. These packages should be for as long as a person wants;

5.2 have a detailed understanding of the caseload that can identify the following:

a) people with complex needs requiring intensive specialist input, e.g. the titration/re-titration phase of treatment, ongoing high-risk poly pharmacy, multi-morbidity or polysubstance use;

b) people whose needs and risk only require 2-3 monthly MAT reviews and who may be receiving support from other agencies;

c) people who can be appropriately managed in primary care through shared care arrangements.

5.3 have pathways in place to ensure that people are supported to access appropriate primary care services including GPs, community pharmacy, opticians and dentists;

5.4 have established shared care arrangements with GPs that includes proactive and supported transfer of people stable on MAT;

5.5 ensure they are effectively utilising the workforce to improve the flow of people across multidisciplinary and cross sectoral teams. This means providers must work to the highest point of their professional capacity. For example, third sector organisations provide key-working and mental health nurses conduct MAT assessments, initiation and reviews;

5.6 have information sharing protocols in place to allow for shared record keeping between the multiagency team providing care including social care, housing, community pharmacy, GPs, Police Scotland, SAS, primary and secondary care and third sector providers;

5.7 employ a variety of strategies to manage caseloads and appointment systems e.g. including group or café style clinics, 'corporate' caseloads, a mix of drop-in and fixed appointments, after-hours provision, and pharmacy-based maintenance clinics;

5.8 have monitoring and service improvement plans in place that include feedback from people in their care, and from their family members or nominated person(s), to reduce non-attendance at appointments;

5.9 have a plan, agreed with the person in advance, describing how it will respond in the event of disengagement from treatment with a focus on the value of care. It should incorporate the responses from all partners, including the persons family member or nominated person(s), and include the option of anticipatory care planning
(Standard 3).