Models of care for the treatment of drug misusers

Transcription

1 Models of care for the treatment of drug misusers Promoting quality, efficiency and effectiveness in drug misuse treatment services in England Part 2: Full reference report

2 National Treatment Agency More treatment, better treatment, fairer treatment The National Treatment Agency (NTA) is a special health authority, created by the Government in 2001, with a remit to increase the availability, capacity and effectiveness of treatment for drug misuse in England. The overall purpose of the NTA is to: double the number of people in effective, wellmanaged treatment from 100,000 in 1998 to 200,000 in 2008; and to increase the proportion of people completing or appropriately continuing treatment, year on year. This is in line with the UK drug strategy targets. Models of care Models of care sets out a national framework for the commissioning of treatment for adult drug misusers in England. It is published in two parts, both of which are available in hard copy and online at Part 1: A summary for drug treatment commissioners and those responsible for local implementation of Models of care. Part 2: This report is a detailed reference document for drug treatment managers and providers, and those responsible for assuring quality and appropriate delivery of local drug treatment services. An implementation strategy to assist the commissioners of drug treatment services is also available, together with lessons learned from pilot sites. For further details visit Department of Health Models of care was initially funded by the Department of Health and has similar status to a national service framework. To order further copies of Models of care, contact the NTA, [email protected], tel or visit ISBN Published by: National Treatment Agency for Substance Misuse 5 th Floor, Hannibal House, Elephant and Castle, London SE1 6TE Tel Fax National Treatment Agency, London, December The text in this document may be reproduced free of charge in any format or media without requiring specific permission. This is subject to the material not being used in a derogatory manner or in a misleading context. The source of the material must be acknowledged as the National Treatment Agency and the title of the document must be included when being reproduced as part of another publication or service.

3 Models of Care Contents Acknowledgements Introduction 1 Introduction and definitions 2 Overview and action required 3 Policy and context 10 Chapter 1 An integrated model of care Commissioning and providing a four-tier framework for drug 16 and alcohol treatment services 1.2 Integrated care pathways Assessment within a tiered system Commissioning, care planning and care co-ordination Monitoring 46 Chapter 2 Drug misuse treatment modalities Advice and information Needle exchange facilities Care-planned counselling Structured day programmes Community prescribing Inpatient substance misuse treatment Residential rehabilitation 99

4 Chapter 3 Special groups Stimulant users Women drug users Black and minority ethnic populations Young people and substance misuse Substance misusing parents Alcohol and alcohol misuse in drug misusers 150 Chapter 4 Cross-cutting issues Overdose Blood-borne diseases Psychiatric co-morbidity (dual diagnosis) Outreach work Criminal justice Users, carers and self-help groups Complementary therapies Performance and outcome monitoring 196 Appendices 207 Appendix 1 Consultation process 208 References 209

5 Acknowledgements Project team Dr Dima Abdulrahim Jan Annan Richard Cyster Annette Dale-Perera Prof Colin Drummond Fiona Hackland Don Lavoie Dr John Marsden Dr Sally Porter Prof John Strang Substance Misuse Advisory Service (SMAS) (now with National Treatment Agency) St George s Hospital Medical School Resource and Service Development Centre (RSDC) DrugScope (now with National Treatment Agency) St George s Hospital Medical School DrugScope Substance Misuse Advisory Service (SMAS) (now with National Treatment Agency) Institute of Psychiatry St George s Hospital Medical School Institute of Psychiatry Other acknowledgements The Models of care team expresses their thanks to the Department of Health and to Rosemary Jenkins from the Drug Misuse Team for originally commissioning the project. Thanks to: Prof Hamid Ghodse (St George s Hospital Medical School) for his contributions to Chapter 1. Pauline Bissett (Broadway Lodge) who contributed to the section on residential rehabilitation in Chapter 2. Jill Britton (DrugScope) who contributed to the section on young people in Chapter 3 Sherife Hasan (SMAS now at the Department of Health) for her extensive comments. Paula McDiarmid for proof-reading and editorial work.

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7 Introduction 1

8 Introduction and definitions Introduction Models of Care: part one sets out a national framework for the commissioning of adult treatment for drug misuse in England. It is based on this more detailed reference document Models of care: part two. The framework of Models of Care (comprising the four tiers, integrated care pathways, care planning and co-ordination and monitoring) applies equally to drug and alcohol treatment. The more detailed descriptions of treatment modalities and service specifications to guide implementation (described in Models of care: part two) have been developed and consulted on for drug treatment only. Further work on developing guidance on alcohol treatment will take place following the consultation for the national alcohol strategy. Definitions Treatment This term describes a range of interventions which are intended to remedy an identified drug-related problem or condition relating to a person's physical, psychological or social (including legal) well-being. Structured drug treatment follows assessment and is delivered according to a care plan, with clear goals, which is regularly reviewed with the client. It may comprise a number of concurrent or sequential treatment interventions. Drugs The term drugs used in this document refers to psycho-active drugs including illicit drugs and non-prescribed pharmaceutical preparations. Misuse The term misuse in this document refers to the illegal or illicit drug taking or alcohol consumption which leads a person to experience social, psychological, physical or legal problems related to intoxication or regular excessive consumption and/or dependence. Drug misuse is therefore drug taking which causes harm to the individual, their significant others or the wider community. By definition those requiring drug treatment are drug misusers. Substance misuse Substance misuse is therefore drug and/or alcohol taking which causes harm to the individual, their significant others or the wider community. By definition those requiring drug or alcohol treatment are substance misusers. These definitions are consistent with previous definitions adopted by the Advisory Council on the Misuse of Drugs (ACMD 1982, 1988, 1989, 1993, 1998 and 2000) and the Health Advisory Service (HAS 1996). 2

9 Overview and action required What is Models of care? The Models of care document overall sets out a national framework for the commissioning of adult treatment for drug misuse (drug treatment) expected to be available in every part of England to meet the needs of diverse local populations. According to the Department of Health, Models of care has the same status, in terms of local planning and delivery, as a national service framework for drug treatment. Models of care provides the framework required to achieve equity, parity and consistency in the commissioning and provision of substance misuse treatment and care in England. It will support drug action teams (DATs), joint commissioners and providers in the development of an efficient and effective treatment and care system for drug misusers. Models of care also provides specific guidance to support the coordination of drug and alcohol treatment and effective management of care across drug misuse treatment services and general health, social and other care. Models of care advocates a systems approach to meeting the multiple needs of drug and alcohol misusers. This is achieved through the development of local systems which maximise the gains achieved through drug and alcohol treatment by having explicit links to the other generic health, social care and criminal justice services including throughcare and aftercare. Models of care reflects professional consensus of what works best for drug misusers, resulting from an extensive consultative process that was used for its development. Models of care is based upon current evidence, guidance, quality standards and good practice in drug treatment in England. It was developed from key national documents as well as national and international research evidence. All guidance is in line with the recommendations contained in Drug misuse and dependence: guidelines on clinical management (Department of Health et al. 1999) and other current guidance and legislation. It is also consistent with the NHS Plan (Department of Health 2000e) and agendas to modernise health and social care services. The development of Models of care was funded by the Department of Health. Final consultation and dissemination of Models of care has been the responsibility of both the Department of Health and the National Treatment Agency for Substance Misuse (NTA). The NTA is responsible for monitoring the national implementation of this service framework for drug treatment. What Models of care does not cover Alcohol The primary focus of the September 2002 edition of Models of care: part one and December 2002 edition of Models of care: part two is adult drug treatment. Models of care does have great relevance to the development of alcohol service provision, but it does not provide specific guidance on the commissioning or implementation of this framework for alcohol treatment generally. However, it is important for commissioners and providers of alcohol treatment to recognise the applicability of the 3

10 framework elements of Models of care (ie the four tiers, integrated care pathways, care planning and co-ordination and monitoring) to alcohol treatment services. More than half of all drug and alcohol services are currently commissioned by DATs joint commissioning mechanisms. Many drug services are drug and alcohol (or substance misuse) services, many quality standards cover both drugs and alcohol (e.g. Quality in Alcohol and Drugs Services (QuADS) and the Drugs and Alcohol National Occupational Standards (DANOS), and many drug service users require alcohol misuse to be addressed within this framework. Given this reality, it is neither feasible nor desirable to develop a different conceptual commissioning framework for alcohol services. The conceptual framework elements of Models of care thus refer to drug and alcohol treatment or substance misuse treatment and should be used by commissioners and providers of alcohol treatment in informing future developments. Prescription drugs, nicotine, etc Models of care does not address detailed consideration of the misuse of prescribed drugs (particularly benzodiazepines), volatile substances (or solvents), or steroid misuse. However, all drugs and alcohol misuse should be considered, including hallucinogens and cannabis, when assessing the needs and planning care of an individual. Nicotine dependence is also not considered by this document. However, this is an important issue for drug treatment services as many clients are nicotine dependent and would benefit from treatment for addiction. Young people under 18 Models of care focuses on commissioning drug treatment for adults, that is those aged 18 years and older. The provision of drug and alcohol treatment for adolescents and young people is extensively covered elsewhere (Health Advisory Service 1996, 2001b). Commissioning these services should be within the existing frameworks for commissioning health and social care for young people, to provide adequate links to generic services for children and families. There should be explicit links to DATs and commissioning processes for adult drug and alcohol treatment, with particular reference to commissioning interface services for those in transition from adolescence to adulthood (for those aged 16 to 21). Treatment in prisons Models of care does not currently cover drug treatment within prisons. However, Models of care does have specific relevance to the commissioning and provision of drug treatment in prisons. It is hoped that prisons and the community will have equity of quality and explicit interfaces to enhance the quality and effectiveness of throughcare for those leaving or entering prison or custody. The NTA and the prison drug strategy unit are committed to working together to take this agenda forward in partnership. Models of care does cover drug treatment as commissioned and provided as part of Drug Treatment and Testing Orders. Models of care in two parts Models of care is being published as two documents. Models of care: part one This document was published in September 2002 for drug treatment commissioners and those responsible for local implementation of Models of care. This document will enable the implementation of Models of care for drug treatment and will be accompanied by a more detailed implementation strategy published September 2002 in the context of the Drug Action Team Treatment Plans. 4

11 Models of care: part two this document, Models of care: part two, is the full document for Models of care. It is over 200 pages in length, and is meant to be used as a detailed reference document. This document is for drug treatment managers and providers and those responsible for assuring quality and appropriate delivery of local drug treatment services. The full document contains: An extended version of Models of care: part one Drug treatment modalities Open access services, advice and information services, needle exchange facilities, care planned counselling, structured day programmes, community prescribing, inpatient drug misuse treatment and residential rehabilitation Special group considerations Stimulant misusers, women drug misusers, black and minority ethnic populations, young drug misusers, substance misusing parents, alcohol misuse in drug misusers Cross-cutting issues Interface with criminal justice (arrest referral, Drug Treatment and Testing Orders and prison throughcare and aftercare), blood-borne disease, psychiatric comorbidity (dual diagnosis), outreach work, users, carers and self-help groups, and complementary (alternative) therapies. Development of Models of care Models of care was initially commissioned by the Department of Health, and development work was undertaken by a team of drug and alcohol specialists (see Appendix 1). The team drafted an initial document outlining the key principles of Models of care and consulted with a wide range of stakeholders using paper consultation and regional events. The final documents were then written and a threemonth formal consultation was conducted by the Department of Health and the National Treatment Agency (NTA). The Models of care project has also been informed by early learning from the regional Models of care/enhancing Treatment Outcomes pilot sites. Implementation of Models of care The NTA issued guidance in October 2002 on the implementation of the Models of care. The implementation note summarises some of the main concepts contained within Models of care, explains what the NTA expects DATs to do to pursue their implementation of these principles, and outlines the forms of support the NTA will provide to help with this process. The note is set out in full below (Box 1). Box 1 NTA implementation note October 2002 The overriding concept behind Models of care is that DATs should be seeking to develop an integrated drug treatment system in their area, not just a series of separate services. In the last few years, DAT members have received increasing funding to expand the capacity of the various modalities of treatment, but it is also felt that efforts must be made to combine these modalities into a seamless system of care pathways for patients. The Models of care approach describes how these processes of care would work, based on the menu of treatment services that have already been incorporated into DAT treatment plans, but now expressed in terms of 4 treatment tiers. 5

12 (NTA implementation note October 2002 cont) Screening and assessment Critical to the effective use of the available services is good screening and assessment of drug users needs. Models of care proposes the development of consistent screening, triage, assessment and referral protocol in each DAT area that: allows generic (Tier 1) agencies to identify drug problems and conduct a basic level assessment (screening) provides an agreed approach to more specialist assessment (triage), that defines which agencies are tasked with conducting these assessments, and which assessment instruments are to be used defines a simple map of local services and the processes of referral into the system backs up the operation of this system with a programme of training for assessors (in line with Drug and Alcohol National Occupational Standards DANOS) and information-sharing protocols. The four-tiered framework Models of care outlines a four tier framework for the commissioning and provision of drug treatment. Commissioners should review local provision against the four tier framework and plan to ensure that drug misusers in their area have access to the full range of services based on local needs. The local system should have transparent referral, eligibility and exclusion criteria between and within services in the four tiers. Drug misusers should always have access to at least part of the local system e.g. Tier 2, open access and harm reduction services. Care planning and care co-ordination Good systems of care planning and care co-ordination will ensure that service provision is client-centred and aid continuity between care pathways. For those with additional needs, care co-ordination is advocated to maximise retention and ensure that a range of needs are met. A number of models of care co-ordination are emerging in England in the Enhancing Treatment Outcomes/Models of care pilot sites. The NTA will disseminate early lessons from pilot sites. Service level agreements DATs will need to ensure that any service that they fund is explicitly working within the integrated system. Every contract for service provision should incorporate a service level agreement that details the expected level of delivery, unit cost, maximum waiting time, and target retention or completion rate. In addition, the service level agreement should be accompanied by a service specification that details: eligibility and exclusion criteria referral mechanisms treatment protocols programme duration care planning and co-ordination arrangements departure planning. Commissioners of services should seek to ensure that these service specifications become consistent with the evidence base presented in Models of care. 6

13 (NTA implementation note October 2002 cont) DAT implementation targets The NTA want to see significant progress in the development of integrated treatment systems in every DAT area over the coming two years. In the Treatment Planning documentation for 2003/4 (issued at the end of September 2002), there is a specific planning grid for the recording of progress on implementing the principles outlined above. In this grid, the NTA requested that joint commissioners record plans for implementing the following four actions: By January 2003 To agree the joint planning mechanism, and lead individual, that will be responsible in your DAT area for pursing the implementation of Models of care. We expect that, in the majority of cases, the appropriate group will be the joint commissioning group of the DAT, but there may be particular circumstances in your area that lead to the setting up of a sub-group, or nominating another forum. The key stipulation is that this issue must be shared across all stakeholders PCT, social services, probation, police and prisons, providers and service users and carers. By October 2003 To complete an assessment of whether the assessment and referral mechanisms (and treatment providers) in your DAT area are operating according to the evidencebased patient placement criteria and treatment protocols outlined in the Models of Care document. You may choose to undertake a comprehensive independent review, or simply discuss these issues with your treatment providers, but the joint commissioning group will be expected to use this assessment as the basis for adjustments to providers service specifications for 2004/05. By November 2003 To agree and publish a local referral, screening and triage system, supported by an information-sharing policy. This should make clear to all interested parties how the referral points into the drug treatment system work, who is responsible for conducting the various levels of assessment, how referrals are made into the main modalities of treatment, the protocols for information sharing and exchange, and the assessment forms and instruments that will be used. By March 2004 To agree and publish locally defined care pathways, and a local system of care coordination. You will wish to discuss the different possible approaches to care coordination with all of the stakeholders in your area before deciding which model to adopt. Whichever approach is preferred, clear roles and responsibilities should be allocated, the incorporation of existing care management roles (e.g. community care assessors, probation officers) into a comprehensive system should be ensured, and a single set of care planning documentation agreed. Progress against these tasks should be recorded on the Drug Action Team Treatment Planning Grid No 9, covering Models of care Implementation. You will also wish to use the other planning grids to record your plans to address the gaps in services across the four tiers, and to take steps to build the size and competence of the workforce required to deliver this agenda. It is expected that DATs and joint commissioners will use local resources, including the central government s pooled budget for drug treatment, to implement Models of care as appropriate to their local needs and local matrix of drug treatment services. (NTA implementation note October 2002 cont) 7

14 The role of the NTA in implementation The NTA will support the implementation of Models of care in a number of ways, including: hosting a series of regional events between October and December 2002 for those responsible for implementing Models of care sharing early learning from the regional pilot sites on a quarterly basis and creating an interactive site on the NTA website ( publishing guidance and updates on national progress on the implementation of Models of care bringing existing DAT treatment planning and monitoring mechanisms into line with Models of care. This will inform the national monitoring system for the implementation of Models of care monitoring the implementation of Models of care via local drug treatment planning processes via NTA regional managers. This includes allocation of the drug treatment pooled budget to ensure planning and spending in line with Models of care. They will also act as a conduit and support for local areas on implementation supporting professionals implementing Models of care through the NTA workforce strategy. The NTA s national leadership and development programme running in each region from December 2002 will enhance the ability of commissioners and managers to manage change. The new drug and alcohol national occupational standards (DANOS) are fully consistent with Models of care, and training modules consistent with DANOS will be available for delivery from early The NTA recruitment initiatives, including the development of the new modern apprenticeship in drug treatment, will attract extra practitioners supporting reductions in waiting times. The NTA waiting times initiative with the Modernisation Agency (MA) will bring together the two agendas of reducing waiting for drug treatment and developing local drug treatment systems. Implementation of Models of care in each local area is seen as the long-term solution to reducing waiting times. This joint initiative between the NTA and the MA will produce regular guidelines and training, as well as providing active consultancies in each region from autumn 2002 developing user and carer involvement. The NTA aims both to provide guidance on user and carer involvement and also to develop regional users and carers networks to feed into national groups, and ultimately into the NTA Board. In this context, the NTA will enable users and carers to be informed about Models of care and supported in participating in its implementation as local stakeholders future work such as the development of a new information strategy (by March 2003) and a new accreditation/inspection system (March 2004), which will be consistent with Models of care and will support its ongoing implementation and maintenance. 8

15 Target audiences for Models of care Commissioners and joint commissioners of drug misuse treatment services (strategic health authorities/primary care groups and primary care trusts (PCGs and PCTs); social services departments; probation service; prison service; joint commissioning managers, Drug Prevention Advisory Service For action Drug (and Alcohol) Action Team members; Drug (and Alcohol) Reference Group members; D(A)AT co-ordinators For action Managers of specialist drug treatment and care services in the statutory, voluntary and independent sectors Chief executives of primary care groups and primary care trusts; Directors of Social Services; Chief Probation Officers; Police Area Commanders For action Directors of public health General practitioners and primary care teams involved in drug treatment, including shared care monitoring groups and community pharmacists For action For action Providers of allied and ancillary services (acute medical care, housing, employment and leisure services, general psychiatry, child and adolescent mental health psychiatry, children and family services); chief executives of strategic health authorities For information Service users of drug treatment services For information 9

16 Policy and context Drug policy context The Models of care project was established to enhance the planning, commissioning and provision of drug treatment services to meet the objectives of the government s ten-year drugs strategy (UKADCU 1998a). The national drugs strategy emphasises the central importance of drug treatment as the main means of assisting people with drug misuse problems to reduce and overcome their problems and live healthy and crime-free lives (UKADCU 1998a). Cross-government commitment to tackling drug misuse is based on recognition of the value of well-implemented treatment and on investment in the further development of drug treatment services in the community and in prison. A key national target set in 1998 was to increase participation of drug misusers in treatment by 100 percent by This target was recently broadened to include increasing the proportion successfully completing or appropriately continuing treatment, year on year (Crown Copyright, 2002). At local level, drug action teams (DATs) are expected to co-ordinate a strategic response to meet the aims of the national drugs strategy. Joint commissioning between health, social care and criminal justice agencies is now expected, and all DATs are expected to have a dedicated joint commissioning manager. The NHS Act 1999 now allows for pooled funds, lead commissioning by one health and social care commissioner on behalf of another, and integrated provision. A central pooled budget for drug treatment has been created to supplement the existing funding allocated by individual health, social care and criminal justice agencies. There has been a substantial increase in funding by the government, through the spending reviews, to increase drug treatment capacity; an extra 217 million was invested over three years from The 2002 investment will consolidate and build on these resources, and will be used to increase drug treatment capacity and implement Models of care. Other funding has, and continues to be, allocated to complement available drug treatment and support drug misusers by enhancing the aftercare and re-integration of drug misusers into housing, employment and education. Wider policy agendas The national agenda to improve the quality and capacity of drug treatment has been heavily influenced by wider developments for improving health and social services in general. In 1998, drug treatment services were identified for the first time in NHS Priorities and Planning Guidance. Models of care and the development of the National Treatment Agency (NTA) are consistent with the NHS guidelines and the NHS Plan (Department of Health 2000e) with its ten-year action plan to put patients at the heart of the health service. In line with the NHS plan, Models of care takes into account the need to reduce waiting times for treatment and the need to develop consistent, high-quality care centred on patients. It highlights partnerships between health, social services and other agencies, investment in staff and provision of a voice for service users. It also promotes the reduction of inequality and identifies work across statutory, voluntary and independent sectors. 10

17 Models of care mirrors other national policies that encourage all treatment and care services to strive to deliver higher quality and more effective services that are closely informed by research evidence and guided by performance monitoring (Department of Health 1997b and 1999c). Clinical governance (NHS Executive 1999a) established the need to focus on activities that lead to the delivery of high-quality care. It is the framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. The Commission for Health Improvement (CHI) regularly inspects every NHS trust against agreed standards, and the Modernisation Agency provides a wide range of initiatives to improve the quality and effectiveness of the NHS. In relation to social care, Best Value has made it a statutory duty for local authorities to deliver services by the most effective, economical and efficient means possible, taking into account quality and cost. The National Care Standards Commission has a range of standards for services, which they inspect on a regular basis. The Supporting People policy framework for supported housing provides further opportunities to support drug misusers in the community. Finally, there are multiple initiatives to improve the competence and numbers of skilled and qualified professionals in health, social care and criminal justice. The role of the national training organisations and others has been to promote national workforce strategies, standards and qualification frameworks in many fields including drugs and alcohol. The drugs and alcohol national occupational standards (DANOS), provide competency-based occupational standards for drug and alcohol commissioners and for practitioners (Skills for Health 2002). In the NHS, initiatives to improve working lives and create work environments that foster reflexive, life-long learning are paramount, including the role of workforce confederations. Models of care is published at a time when many organisations are undergoing major structural changes. Primary care trusts (PCTs) now play a pivotal role in drug (and alcohol) treatment and are central to the development of effective systems. PCTs have a central strategic and commissioning responsibility and a role in overseeing the clinical practice of doctors and other healthcare professionals. Other new health policy initiatives that will affect drug treatment include the introduction of salaried options for general practitioners (GPs) in England, Local Development Schemes, GP commissioning pilots and the conversion of GPs General Medical Services (GMS) to Personal Medical Services (PMS). The Health and Social Care Act 2001 mentions care trusts, which will provide integrated health and social care in one agency. Similarly, nurse prescribing may offer new ways of delivering and managing drug treatment services. The new strategic health authorities will also play an important role in substance misuse treatment through their performance monitoring. It is also expected that DATs will work more closely with Crime and Disorder Reduction Partnerships, and there are plans to bring the work of these two organisations together (Home Office 2001a) from October It is also imperative for drug treatment commissioners and services to adopt the principles and recommendations of the Race Relations (Amendment) Act 2000 (Home Office 2000b), which extends the scope of the 1976 Race Relations Act to include all functions of all public authorities. The 2000 Act places a general duty on 11

18 all major public authorities to promote racial equality and also sets out specific duties with which they must comply. Drug treatment effectiveness In 1996, the influential Task Force to Review Services for Drug Misusers examined the evidence base for drug treatment. It reported that there was a clear evidence base that drug treatment was effective in reducing harm to individual drug misusers and communities. The National Treatment Outcome Research Study (Gossop et al, 1998a) calculated that for every 1 spent on drug treatment, 3 was saved in costs to the criminal justice system and victims of crime. The NTORS follow-up study of 1,100 drug misusers in treatment found that a wide range of drug treatment interventions commonly employed in England are effective in reducing drug misuse, criminal activity and health risks. Significant reductions were also found in drug injecting and the sharing of injecting equipment. Improvements in drug misuse were largely maintained at four to five years after treatment, with 47% of those who had attended drug residential rehabilitation services and 35% of those who attended community drug treatment reporting abstinence from illicit opiate use. NTORS also found that less than half (44%) of those who attended drug treatment for problems with crackcocaine were still misusing crack at four to five years follow-up. However, NTORS also found that some individual drug treatment services achieved markedly better client outcomes than others. The recent Audit Commission report (2002) Changing habits, which looked at the commissioning and management of community drug treatment services for adults, found a range of problems with drug treatment services. While some effective approaches and innovation were found, many areas in England had limited drug treatment options, had lengthy waits for access, and were characterised by underdeveloped care management which allowed too many people to fall through the net. The Audit Commission found that the needs of crack misusers, black and minority ethnic drug misusers, women drug misusers, and drug misusers with alcohol problems were poorly met in many areas. Some drug treatment was also found to be inflexible and poorly co-ordinated within and between services, especially for drug misusers leaving prison. Shared care schemes with GPs were also underdeveloped in some areas. The planning, co-ordination and commissioning of drug treatment were also found to be lacking, with improved joint commissioning relationships required in many DAT areas. The Audit Commission recommended a range of solutions to rectify and improve drug treatment over time. These include the National Treatment Agency promoting improvements in the national framework and developing more coherent models of service standards and good practice. Models of care is cited as a solution to many of the difficulties in drug treatment, with implementation needing to be incremental and well-planned. Drug misusers: the in-need population The prevalence of drug misuse in Britain is a changing picture which is difficult to assess. The British Crime Survey indicates that in 2000, around one-third of those aged 16 to 59 had taken illegal drugs at some time in their lives, with 11% using in the past year and 6% describing themselves as regular users. Most drug use is cannabis use, with only 1% of the population reporting the use of heroin and crackcocaine. Only a minority of those who use drugs will develop problems and require drug treatment. 12

19 Estimating the number of people who require drug treatment is highly problematic. The National Drug Treatment Monitoring System (NDTMS) is based on those seeking help and therefore does not reflect the whole drug misusing population and mirrors problems inherent in service utilisation (eg the under-representation in treatment of women, stimulant users and Black and minority ethnic communities. The Audit Commission (2002) reports that 0.5% of the population of Britain may be drug dependent, that is, 226,000 people. While drug misuse can affect rich and poor alike, deprivation and social exclusion are likely to make a significant contribution to the causes, complications and intractability of drug misuse. Deprivation relates statistically to the types and intensities of drug misuse that are problematic. Similarly, poor housing, or lack of access to affordable housing, is another contributory factor in drug misuse. Other important factors include educational disadvantage, criminal involvement, unemployment and low income (ACMD 1998). Recent research indicates that many drug misusers are also offenders, although the relationship between drugs and crime is complex. The criminal justice system is increasingly a referral source and venue for the provision of drug treatment. Drug misuse has been called a chronic relapsing condition (Task Force to Review Services for Drug Misusers 1996). While many drug misusers do successfully recover from drug dependency or addiction, most make several attempts to do so, lapsing or relapsing into drug misuse in intervening periods. Drugs of misuse include: opiates (e.g. heroin and illicit methadone); stimulants (e.g. amphetamines, cocaine and crack-cocaine); and alcohol misused by drug misusers. Many drug misusers, however, take a cocktail of drugs and alcohol including hallucinogens, cannabis and prescribed drugs such as benzodiazepines. The use of heroin and cocaine or crack-cocaine is also becoming increasingly common, with NDTMS reporting an increase in the use of both drugs, from 18% of those presenting for drug treatment in 1998, to 24% in Drug misusers present with a myriad of other health and social problems, particularly in relation to physical and psychiatric co-morbidity and social care needs. Drug misusers may present with: physical health problems (e.g. thrombosis, abscesses, overdose, hepatitis B and C, HIV, weight loss, respiratory problems); mental health problems (e.g. depression, anxiety, paranoia, suicidal thoughts); social problems (e.g. relationship problems, unemployment, homelessness); and criminal problems (e.g. legal and financial problems). Thus, a multi-disciplinary range of health, social care and other responses is required. Treatment domains and hierarchy of goals The range of difficulties experienced by drug misusers are sometimes conceptualised as domains. These are often grouped into four key domains to assess whether drug misusers are improving or achieving better outcomes in these areas. The four key domains are as follows: Drug and alcohol use drug use, including type of drug(s), quantity/frequency of use, pattern of use, route of administration, source of drug alcohol use, including quantity/frequency of use, pattern of use, whether above safe level, alcohol dependence symptoms 13

20 Physical and psychological health psychological problems, including self-harm, history of abuse/trauma, depression, severe psychiatric co-morbidity, contact with mental health services physical problems, including complications of drug/alcohol use, pregnancy, bloodborne infections/risk behaviours, liver disease, abscesses, overdose, enduring or severe physical disabilities Social functioning social problems (including childcare issues, partners, domestic violence, family, housing, employment, benefits, financial problems) Criminal involvement legal problems (including arrests, fines, outstanding charges/warrants, probation, imprisonment, violent offences, criminal activity). For some years now a range, or hierarchy, of goals of drug treatment has been identified in the UK (ACMD 1988, 1989; Task Force to Review Services for Drug Misusers 1996). These relate to the above domains and are: reduction of health, social and other problems directly related to drug misuse reduction of harmful or risky behaviours associated with the misuse of drugs (e.g. sharing injecting equipment) reduction of health, social or other problems not directly attributable to drug misuse attainment of controlled, non-dependent, or non-problematic, drug use abstinence from main problem drugs abstinence from all drugs. This hierarchy of drug treatment goals endorses the principle of harm minimisation, which refers to the reduction of the various forms of drug-related harm (including social, medical, legal, and financial problems) until the drug misuser is ready and able to come off drugs (Department of Health et al 1999). Harm minimisation strategies in this country have achieved considerable success in preventing a more severe HIV epidemic in the UK (ACMD 1998). Reviews of commissioning and practice may be required, given the rates of hepatitis C and overdose, together with reports from the Advisory Council on the Misuse of Drugs (ACMD) on reducing drug-related death and from the Department of Health (2002) on hepatitis C. 14

21 Chapter 1 An integrated model of care 15

22 1.1 Commissioning and providing a four-tier framework for drug and alcohol treatment services A four-tier framework for all areas in England Some drug action teams (DATs) commission services for alcohol treatment alongside their drug treatment services. The conceptual framework described in this section applies to drugs and alcohol, and therefore has relevance for the commissioning of all substance misuse services. Models of care provides a conceptual framework to aid rational and evidence-based commissioning of drug treatment in England. Services for drug misusers can be grouped into four broad bands of tiers. Tiers for drug treatment are also described in the forthcoming NHS Executive Framework document on needs assessment. Commissioners should ensure that drug misusers in all local areas or DATs in England have access to the full range of Tiers 1 to 4 services and to the types of generic and drug treatment modalities outlined below. Drug treatment services should address the range of drug problems, including problems with: opiates (e.g. heroin and illicit methadone); stimulants (e.g. amphetamines, cocaine and crackcocaine); and polydrug and alcohol misuse. In planning the overall range of care provision for drug misusers, commissioners need to take account of the high level of need that drug misusers present with, particularly in relation to physical and psychiatric co-morbidity and social care needs. The Models of care four-tier framework is not intended to be a rigid blueprint for provision. It is expected that local commissioners will be able to demonstrate that local services have been commissioned to cover each treatment modality within the four tiers. The balance of local drug treatment services and their detailed delivery mechanisms should be tailored to fit the needs of the local population. This will provide equitable access to drug treatment service availability across the country Description of the tiers and services required Tier 1: Non-substance misuse specific services requiring interface with drug and alcohol treatment Tier 1 services work with a wide range of clients including drug and alcohol misusers, but their sole purpose is not drug or alcohol treatment. The role of Tier 1 services, in this context, includes the provision of their own services plus, as a minimum, screening drug misusers and referral to local drug and alcohol treatment services in Tiers 2 and 3. Tier 1 provision for drug and alcohol misusers may also include assessment, services to reduce drug-related harm, and liaison or joint working with Tiers 2 and 3 specialist drug and alcohol treatment services. Tier 1 services are crucial to providing services in conjunction with more specialised drug and alcohol services (e.g. general medical care for drug misusers in community-based or residential substance misuse treatment or housing support and aftercare for drug misusers leaving residential care or prison). Tier 1 consists of services offered by a wide range of professionals (e.g. primary care or general medical services, social workers, teachers, community pharmacists, probation officers, housing officers, homeless persons units). Such professionals need to be sufficiently trained and supported to work with drug (and alcohol) 16

23 misusers who, as a group, are often marginalised from, and find difficulty in, accessing generic health and social care services. Commissioners should ensure Tier 1 professionals have clear local guidelines on the referral of drug misusers to specialist drug treatment services. It may be beneficial to have link professionals (particularly from Tier 2 and Tier 3 services) who can train and support Tier 1 professionals. Where prevalence of drug misusers is high, there may be a need for a specialised drug treatment or addiction liaison service to provide a co-ordinated response. Models of such services include drug misuse pregnancy and antenatal liaison nurses in localities with high rates of pregnant drug misusers or women in drug treatment. Drug misusers in all DATs in England must have access at local levels to the following Tier 1 services located within local general health and social care services: a full range of healthcare (primary, secondary and tertiary), social care, housing, vocational and other services drug and alcohol screening, assessment and referral mechanisms to drug treatment services from generic, health, social care, housing and criminal justice services the management of drug misusers in generic health, social care and criminal justice settings (e.g. police custody) health promotion advice and information hepatitis B vaccination programmes for drug misusers and their families. Commissioners of alcohol services are advised to ensure that alcohol misusers have access to a range of Tier 1 services as appropriate Tier 2: Open access drug and alcohol treatment services Tier 2 services provide accessible drug and alcohol specialist services for a wide range of drug and alcohol misusers referred from a variety of sources, including selfreferrals. This tier is defined by its low threshold to access services, and limited requirements on drug and alcohol misusers to receive services. Often drug and alcohol misusers will access drug or alcohol services through Tier 2 and progress to higher tiers. The aim of the treatment in Tier 2 is to engage drug and alcohol misusers in drug treatment and reduce drug-related harm. Tier 2 services do not necessarily require a high level of commitment to structured programmes or a complex or lengthy assessment process. Tier 2 services include needle exchange, drug (and alcohol) advice and information services, and ad hoc support, including harm reduction support, not delivered in the context of a care plan. Specialist substance misuse social workers can provide services within this tier, including the provision of access to social work advice, childcare/parenting assessment, and assessment of social care needs. Tier 2 can also include low-threshold prescribing programmes aimed at engaging opioid misusers with limited motivation, while offering an opportunity to undertake motivational work and reduce drug-related harm. Tier 2 services require competent drug and alcohol specialist workers. This tier does not imply a lower skill level than in Tiers 3 and 4 services. Indeed, many of the functions within this tier require a very high level of professional training and skills. Drug misusers in all DATs in England must have access to the following Tier 2 open-access specialist drug interventions within their local area: 17

24 drug- and alcohol-related advice, information and referral services for misusers (and their families), including easy access or drop-in facilities services to reduce risks caused by injecting drug misuse, including needle exchange facilities (in drug treatment services and pharmacy-based schemes) other services that minimise the spread of blood-borne diseases to drug misusers, including service-based and outreach facilities services that minimise the risk of overdose and other drug- and alcohol-related harm outreach services (detached; peripatetic and domiciliary) targeting high-risk and local priority groups specialist drug and alcohol screening and assessment, care planning and management criminal justice screening, assessment and referral services (e.g. arrest referral, CARATS) motivational and brief interventions for drug and alcohol service users community-based low-threshold prescribing services. Commissioners of alcohol services are advised to ensure that alcohol misusers have access to a range of Tier 2 services as appropriate Tier 3: Structured community-based drug treatment services Tier 3 services are provided solely for drug and alcohol misusers in structured programmes of care. Tier 3 structured services include psychotherapeutic interventions and structured counselling (e.g. cognitive behavioural therapy), motivational interventions, methadone maintenance programmes, community detoxification, or day care provided either as a drug- and alcohol-free programme or as an adjunct to methadone treatment. Community-based aftercare programmes for drug and alcohol misusers leaving residential rehabilitation or prison are also included in Tier 3 services. Tier 3 services require the drug and alcohol misuser to receive a comprehensive assessment and to have a care plan which is agreed between the service provider and client. The drug and alcohol misuser attending Tier 3 services will normally have agreed to a structured programme of care which places certain requirements on attendance and behaviour (e.g. a certain number of days or hours attendance per week with a programme review triggered if attendance becomes irregular). The drug and alcohol misuser should also expect the care plan to be provided by the agency as agreed. For clients whose needs cross several domains, there should be a care co-ordinator, responsible for co-ordination of that individual s care on behalf of all the agencies and services involved. Changes to the care plan would take place in consultation with the drug and alcohol misuser. Like the other tiers, Tier 3 services will need to take account of urban and rural differences. For example, structured day programmes may be more difficult to provide in rural areas and will need to be adapted for this setting. Tier 3 services may be required to work closely with other specialist services to meet the needs of specific client groups. For example, Tier 3 services and mental health services should work closely together to meet the needs of drug misusers with dual diagnosis (psychiatric co-morbidity). In this instance, providers should have access to medical clinical leadership and/or advice from mental health specialists in line with good practice guidelines (Department of Health 2002). 18

25 Drug misusers in all DATs in England must have access to the following Tier 3 structured drug treatment services normally provided within their local area and occasionally by neighbouring DAT or regionally located facilities: specific community care assessment and care management new care co-ordination services for drug misusers with complex needs (provided by suitably trained practitioners) specialist structured community-based detoxification services a range of specialist structured community-based stabilisation and maintenance prescribing services shared-care prescribing and support treatment via primary care a range of structured, care planned counselling and therapies community-based Drug Treatment and Testing Order drug treatment structured day programmes (in urban and semi-urban areas) other structured community-based drug misuse services targeting specific groups (e.g. stimulant misusers, young people in transition to adulthood, black and minority ethnic groups, women drug misusers, drug misusing offenders, those with HIV and AIDS, drug misusers with psychiatric problems) liaison drug misuse services for acute medical and psychiatric sectors (e.g. pregnancy, mental health) liaison drug misuse services for local social services and social care sectors (e.g. child protection, housing and homelessness, family services) throughcare and aftercare programmes or support. Commissioners of alcohol services are advised to ensure that alcohol misusers have access to a range of Tier 3 services as appropriate Tier 4 services: Residential services for drug and alcohol misusers Tier 4a: Residential drug and alcohol misuse specific services Tier 4 services are aimed at individuals with a high level of presenting need. Services in this tier include: inpatient drug and alcohol detoxification or stabilisation services; drug and alcohol residential rehabilitation units; and residential drug crisis intervention centres. Tier 4a services usually require a higher level of commitment from drug and alcohol misusers than is required for services in lower tiers. Tier 4a services are rarely accessed directly by clients. Referral is usually from Tiers 2 or 3 services or via community care assessment. Tier 4a services may be abstinence-oriented programmes, detoxification services or services which stabilise clients (e.g. on substitute drugs). Access to Tier 4a requires careful assessment and preparation of the client in order to maximise readiness, compliance and programme effectiveness. Access to Tier 4a may also require sequencing of other care pathways such as detoxification prior to placement in a drug- and alcohol-free residential programme. By definition, such programmes are highly structured. Drug and alcohol misusers receiving Tier 4 services will require a designated care co-ordinator, allocated before entry to this tier. Inpatient provision for drug and alcohol treatment is often in psychiatric wards rather than specialist inpatient units. There is evidence that drug (and alcohol) specialist provision has better outcomes. Commissioning of high-cost, low-volume services such as those at Tier 4a should be considered at sub-regional and regional levels. 19

26 Tier 4b: Highly specialist non-substance misuse specific services Tier 4b services are highly specialised and will have close links with services in other tiers, but they are, like Tier 1, non-substance misuse specific. Examples include specialist liver units that treat the complications of alcohol-related and infectious liver diseases and forensic services for mentally ill offenders. Some highly specialist Tier 4b services also provide specialist liaison services to Tiers 1 4a services (e.g. specialist hepatitis nurses, HIV liaison clinics, genito-urinary medicine). Drug misusers in all DATs in England must have access to the following Tier 4 services, most likely provided at a multi-dat or regional or national level: specialist drug and alcohol residential rehabilitation programmes (including a range of 12-step, faith-based, and eclectic programmes) generic and drug specialist semi-structured residential care (e.g. half-way houses, semi-supported accommodation) specialist Drug Treatment and Testing Order treatment (residential options) inpatient drug misuse treatment, ideally provided by specialist drug misuse units, or alternatively by designated beds in generic (mental) health services highly specialist forms of residential rehabilitation units or other residential services (inpatient, prison) with a drug misuse treatment component (e.g. women and children, crisis intervention, dual diagnosis) relevant Tier 4b services, including HIV or liver disease units, vein clinics, residential services for young people, and so forth. Commissioners of alcohol services are advised to ensure that alcohol misusers have access to a range of Tier 4 services as appropriate Principles of the four-tiered system The four-tiered model of drug and alcohol treatment for adults was developed from the four-tiered approach for a variety of mental health and drug misuse services for young people outlined by the Health Advisory Service (1996). Key principles which underpin the four tiers for adult drug and alcohol treatment commissioning are outlined below. The full range of services described in the tiered framework should be available in each local region. Not all drug and alcohol misusers will require access to all types of services or all tiers, but within each locality a proportion will require access to each of these services at any given time. Access to all services should therefore be available in all areas in England. Service modalities (described above) within the four tiers are not alternatives, and commissioners should ensure all modalities are commissioned based upon local need. Each drug treatment modality described in Tiers 2, 3 and 4a are complementary. Each is a necessary building block of a comprehensive drug treatment system, together with the interfaces and modalities described in Tiers 1 and 4b. Drug treatment services described within each tier are modalities, not specific agencies. It is possible for one agency in a given locality to provide services located in more than one tier, or provide a range of modalities from within tiers (see Table 1). 20

27 Drug and alcohol misusers may require access to services within a number of different tiers simultaneously, for example needle exchange services (Tier 2), structured counselling (Tier 3) and housing services (Tier 1). The care plan or care co-ordinator should facilitate access to a range of services based on client need. Explicit links may be required between different care pathways in order to provide an integrated care pathway approach. Future commissioning of drug and alcohol misuse services should be needs-led and in line with the four-tier framework rather than being based on historic commissioning patterns. This requires responsive commissioning which can plan and develop new drug treatment responses to cope with changing drug trends (e.g. growing high levels of stimulant misuse or drug misuse affecting new groups). Drug and alcohol treatment services should be commissioned strategically. This means that the impact of the commissioning on any one service should be viewed in the strategic context of the four-tier drug and alcohol treatment system for a locality or region. Commissioners should seek to ensure that no groups of drug and alcohol misusers have more limited access to relevant drug treatment modalities outlined in the fourtier framework by virtue of their location, gender, ethnicity, or drugs of misuse. All drug treatment services should be easily accessible to substance misusers (by virtue of location, entry criteria, assessment procedures, waiting times, etc). Commissioners (and providers) should recognise that motivational work may be crucial in engaging clients in drug and alcohol treatment and improving their outcomes in a number of domains. A service provider s ability to motivate a drug misuser is a greater factor in client success than the expressed motivation of the client (Fiorentine et al. 2000). Client motivation should not be used as an exclusion criterion: it should be a trigger for motivational work which should be commissioned and provided by each drug treatment provider. Commissioners should ensure that both open access and structured drug treatment services are available in each area. Less structured modalities tend to be more accessible and can act as a gateway to more intensive treatment. Some treatments require a more structured setting and/or programme in order to be effective (e.g. cognitive behaviour therapy, inpatient detoxification). Other treatments, however, lend themselves to less structured settings (e.g. motivational interviewing, needle exchange programmes). More structured modalities can involve more costly and more intensive programmes, and hence tend to cater for a smaller proportion of drug misusers. More intensive programmes may also require a higher level of client commitment. Similar principles apply to the alcohol field. Commissioners and providers should ensure that staff involved in drug treatment are competent. The new drug and alcohol national occupational standards (DANOS) and forthcoming qualification framework will provide national competency benchmarks. An investment approach may be required to build the drug and alcohol treatment workforce to meet local needs. It is important to note that more intensive or structured programmes do not necessarily require more highly skilled staff than less structured or intensive programmes. Indeed the converse may be the case, in that complex and chaotic substance misusers often present to open access services at a time of crisis by virtue of the agency s accessibility, and a high level of competence is needed to provide safe and effective management. 21

28 1.1.4 How the four-tier system will assist commissioning The tier system described here will be of most benefit in the rational planning and commissioning of substance misuse services that is undertaken when working towards equity of access to services. The tiers should therefore be viewed as a pragmatic commissioning framework. The four tiers should assist local commissioners and providers in the following ways: they define the function of different services and interventions they help define entry and exit criteria for each tier they help define target groups and maximise targeting of resources they assist in planning and commissioning a comprehensive system of care nationally and within each locality and region they define the points at which different levels of assessment and care coordination take place. At any given time there are likely to be more substance misusers in contact with Tier 1 services (at the base of the pyramid ) than with Tier 4 (the apex). One of the aims of the drug treatment system is to engage drug misusers in specialist drug treatment (Tiers 2, 3 and 4a); the more effective and more comprehensively funded the system is, the broader the apex will be. The client need not be aware of the tier system. Within this framework, drug and alcohol misusers should be able to move seamlessly between services within and across tiers. At any given time, drug and alcohol misusers should be able to attend simultaneously services that span across tiers in a way that best meets their needs Commissioning standards The commissioning of drug (and alcohol) treatment services should be in line with existing commissioning standards (Substance Misuse Advisory Service 1999). As such, commissioners must take into account local needs, the configuration of existing services, and gaps in service provision. It is the responsibility of DATs, through their joint commissioners and joint commissioning groups (JCGs), to ensure that the diverse range of drug and alcohol misusers within their locality are catered for. Local variations in provision will include: demographic and socio-economic factors (e.g. population age, ethnic diversity, levels of deprivation); substance misuse trends and patterns (e.g. opiates, stimulants, polydrug use, routes of ingestion such as injecting practices or smoking) and geography (e.g. urban and rural considerations). It may be more difficult to deliver drug and alcohol treatment services in rural areas than in urban areas. Commissioning of such services needs to take account of practical delivery issues to increase accessibility for drug and alcohol misusers needing these services, especially in rural areas. It is expected that JCGs will co-ordinate the commissioning of drug treatment services on behalf of their DATs and the member organisations of the DAT. Many joint commissioning groups are co-terminus with DAT boundaries but some are not; for example, some new primary care trust arrangements are not necessarily coterminus. Clearly defined commissioning functions are important. All commissioners working through their JCGs should ensure that an investment approach to drug treatment is taken in order to improve the quality of drug misuse treatment services. This requires adequate investment in human resources to ensure a competent workforce and enable treatment services to meet recommended clinical 22

29 guidelines (Department of Health et al. 1999) and relevant quality and occupational standards (QuADS 1999; HM Prison Service 2000; Substance Misuse Advisory Service 1999; Skills for Health 2002) Local commissioning partners To ensure communication between mainstream health and social care services, drug and alcohol treatment commissioners need to work in close liaison with those who commission Tier 1 and 4b services to ensure that drug and alcohol misusers have access to the wide range of generic services necessary to provide comprehensive and effective packages of care. Such services include housing and vocational, social, primary and specialist health care, and psychiatric services. Drug treatment services cannot be commissioned in isolation. Drug treatment JCGs should work in liaison with a number of bodies responsible for the planning and commissioning of local services. Close liaison is required between DATs, other local partnerships, PCTs and strategic health authorities in planning and commissioning services. It is expected that DATs and JCGs will work closely with criminal justice commissioners to maximise the interface between criminal justice drug treatment referral and provision, and other drug treatment services. This work includes commissioning for arrest referral services, prison drug treatment, and drug treatment required in local DTTOs. The interface between DATs and local crime and disorder reduction partnerships will increase over the next year (Home Office 2001a). Joint commissioning arrangements also need to be considered in respect of the statutory obligations on agencies providing services for people with severe and enduring mental health problems, specifically those with psychiatric co-morbidity (dual diagnosis). Opportunities should be maximised where services are provided jointly by mental health and specialist substance misuse services (Department of Health 2002). Commissioning and planning mechanisms for children s and adolescents services (including substance misuse) should have clear links and interfaces with adult drug and (alcohol) treatment commissioning undertaken by JCGs and DATs. This should include commissioning drug (and alcohol) treatment services for those in transition from adolescence to adulthood (16 to 21 years). Commissioning mechanisms for children and young people s health and social care services should be the primary mechanism for commissioning drug and alcohol treatment for those under 16 years. Guidelines are expected in 2003 from the Home Office and Department of Health. Clear links to those commissioning children and families services is also expected, as many families of substance misusers may be in need and some children of substance-misusing parents may require statutory child protection services Sub-regional and regional commissioning Equitable access to drug treatment services in all DATs does not always equate with the availability of all of these services within the boundaries of all DATs. Many of these services must be available at local DAT levels, but others may be available at multi-dat, regional and national levels (e.g. inpatient facilities, residential rehabilitation services etc). Table 1 outlines drug treatment tiers by modality and commissioning level. Some drug treatment services are best commissioned by two or more DATs. In these cases, DATs may establish a single joint commissioning group, or two or more joint commissioning groups (JCGs) may work together. Working in this way, JCGs may 23

30 commission a range of services including: low-volume and high-cost services, e.g. residential crisis intervention services, residential rehabilitation for mothers and children; and drug treatment services covering more than one DAT or local area, e.g. services covering several local areas. Two or more JCGs can jointly develop and commission Tiers 2 or 3 services, e.g. gender or race specialist services can be developed to serve adjoining DATs. Other ways of joint working between JCGs include jointly setting costing bands or reaching agreements on shared monitoring arrangements where they purchase services from the same provider. The NTA will advise on regional and sub-regional commissioning and utilising the regional analysis of the DAT treatment plans. Similar principles apply to alcohol treatment provision and commissioning. 24

31 Table 1: Drug misuse treatment tiers and commissioning levels Tier no. Tier title Service modality Commissioning level 1 Non-substance misuse specific services For example: Personal/general medical services (primary care) Non-drug misuse (DM) specific social services including children and family services; non-dm specific assessment and care management Housing and homelessness services Non-substance misuse (SM) specific probation services Vaccination / communicable diseases Sexual health / health promotion Accident and emergency services General psychiatric services Local DAT*/ PCT/PCG 2 Open access drug misuse services 3 Structured community-based specialist drug misuse services 4a 4b Residential substance misuse specific services Highly specialist non-substance misuse specific services Vocational services Drug-related advice and information Open access or drop-in services Motivational interviewing / brief interventions Needle exchange (pharmacy/service/outreach) Outreach services (detached/domiciliary/peripatetic) Low-threshold prescribing Liaison with drug misuse services for acute medical and psychiatric sector DM specific assessment and care management Drug specialist care planning and co-ordination Structured care planned counselling and therapy options Structured day programmes (urban and semi-urban) Community-based detoxification services Community-based prescribing stabilisation and maintenance prescribing Community-based drug treatment for offenders on DTTOs Other structured community-based drug treatment services targeting specific groups Structured aftercare programmes Liaison with drug treatment services Inpatient drug detoxification and stabilisation services Drug and alcohol residential rehabilitation services Residential drug and alcohol crisis centres Residential co-morbidity services Specialist drug and alcohol residential units targeting specific groups, e.g. mother and child units services For example: Specialist liver disease units Forensic services Specialist psychiatric units including: personality disorder units; eating disorders units Terminal care services Young people s hospital and residential services providing drug and alcohol treatment services (16 to 21 years) HIV specialist units Local DAT/ PCT/PCG Commissioners of alcohol services are advised to ensure that alcohol misusers have access to a range of services in each tier as appropriate. Local DAT*/ Multi- DAT Multi-DAT/ Regional/National Regional/National 25

32 1.2 Integrated care pathways Commissioning integrated care pathways An integrated care pathway (ICP) describes the nature and anticipated course of treatment for a particular client and a predetermined plan of treatment. So far, the drug and alcohol treatment system has been described in a structural way, with services grouped into four broad tiers. Any system of care, however, should be dynamic and able to respond to changing individual needs over time. It should also be able to provide access to a range of services and interventions that meet an individual s needs in a comprehensive way. In many areas of health and social care, an integrated care pathway (ICP) approach is increasingly used as the preferred methodology to apply packages of care in a coordinated and integrated way. ICPs are known by various names, including critical care pathways, treatment protocols, anticipated recovery pathways, or treatment algorithms. All of these are designed to standardise elements of care with professional consensus, and thus improve treatment efficiency, effectiveness and value for money. ICPs should be developed for drug and alcohol misusers for the following reasons: Drug and alcohol misusers often have multiple problems which require effective co-ordination of treatment. Several specialist and generic service providers may be involved in the care of a drug and alcohol misuser simultaneously or consecutively. A drug and alcohol misuser may have continuing and evolving care needs requiring referral to different tiers of service over time. ICPs ensure consistency and parity of approach nationally (i.e. a drug misuser accessing a particular treatment modality should receive the same response wherever they access care). ICPs ensure that access to care is not based on individual clinical decisions or historical arrangements. Commissioners should encourage the development of local ICPs for drug treatment modalities in line with Models of care, as described in the implementation plan The elements of integrated care pathways Commissioners should ensure that each drug and alcohol treatment modality should have an ICP. ICPs should be agreed between and with local providers and built into service specifications and service level agreements. Integrated care pathways should have the following elements: a definition of the treatment modality provided aims and objectives of the treatment modality definition of the client group served eligibility criteria (including priority groups) exclusions criteria or contraindications referral pathway screening and assessment processes (see below) development of agreed treatment goals description of the treatment process or phases care co-ordination (see below) 26

33 departure planning, aftercare and support onward referral pathways services with which the modality interfaces. These elements are designed to provide clarity as to the type of client the drug and alcohol treatment modality caters for, what the client can expect the agency to provide, and the roles and responsibilities of the modality/programme within the integrated care system and towards the individual client. The ICP approach allows commissioners to map the whole care system in a locality so that gaps and overlaps can be identified and rectified via the commissioning process. ICPs also provide a means of agreeing local referral and treatment or protocols to define when particular clients should be referred and to whom. ICPs should be sufficiently comprehensive to allow effective drug and alcohol treatment planning, including all the necessary elements of care and support that an individual drug and alcohol misuser may need. This should include links and referral pathways between specialist drug treatment services and generic services in Tiers 1 and 4b such as primary care, housing and vocational services. These services may be key to maximising improvements achieved through drug treatment and are formal links that may be vital for effective joint working and appropriate referral. The ICPs for drug treatment described in Models of care: part two are illustrative rather than prescriptive. Local ICPs should be based and developed on these nationally defined ICPs that describe the structure and content of recognised drug treatment modalities. However, they can be adapted to local needs and drug treatment providers as appropriate. Commissioners should consider developing local ICPs with agreed referral flow diagrams linked to a service directory for each drug treatment modality. Commissioners should ensure that the development of ICPs and the clinical protocols that stem from them is carried out in an inclusive way, with all relevant agencies and professionals reaching a consensus. Service users and carers should be involved in the development of ICPs to develop a more effective drug treatment system. ICPs should not be applied in an overly rigid way. They should guide, but not override, clinical decisions concerning individual drug and alcohol misusers, and clinical decisions should always be applied individually. Departures from ICPs are sometimes required due to individual need or local considerations, such as delivery in rural areas, but they should be justifiable. ICPs should be developed to address pathways both within and between the four tiers. All drug and alcohol misusers receiving structured care should have a care plan which describes component ICPs. For example, a client may receive methadone maintenance and structured counselling simultaneously or consecutively as part of a co-ordinated plan of care. It is advantageous for commissioners to encourage all services within the four tiers to have agreed protocols for referral pathways, eligibility criteria, and joint working arrangements, in order to deliver a seamless and co-ordinated programme of care. This may take time to develop, particularly between Tiers 1 and 4b services and drug and alcohol specialist services. 27

34 Interfaces between the specific drug treatment ICPs and non-substance misuse specific services are important, not least because many service users have continuing care needs when an index treatment intervention has been completed. Therefore a particular inter-agency pathway for a service user may involve movement up and down the four treatment tiers as the needs of the service user change over time. There are useful texts on developing integrated care pathways from other health sectors including Integrated care pathways: a practical approach to implementation by Middleton and Roberts, 2000, and Developing care pathways by De Luc,

35 1.3 Assessment within a tiered system Commissioning and providing local screening and assessment systems Effective use of drug and alcohol treatment modalities and appropriate matching of drug and alcohol treatment type and intensity to presenting need depends crucially on adequate assessment of the individual drug (and alcohol) misuser. This is particularly important in the context of a complex system of care and the development of integrated care pathways. Effective assessment needs to be tailored in terms of comprehensiveness and complexity in such a way that it does not present a barrier to entry to, and engagement in, appropriate drug and alcohol treatment. When a drug and alcohol misuser presents in crisis with complex needs, it is particularly important to provide rapid access to urgent or emergency treatment. Assessment at all levels can provide opportunities for services to reduce harm (e.g. preventing drug-related overdose or needle sharing). In Tiers 3 and 4, assessment should result in the formulation of a care plan with the client at the start of structured treatment. Assessment should be needs led. Furthermore, assessment should be an ongoing process rather than a one-off event, as an individual s needs are likely to evolve over time. Review and reassessment at regular intervals are necessary for good care planning and co-ordination. The three levels of assessment required are: Level 1: Screening and referral assessment (Tiers 1 and 4b) Level 2: Drug and alcohol misuse triage assessment (Tiers 2, 3 and 4) Level 3: Comprehensive drug and alcohol misuse assessment (Tiers 3 and 4a and some Tier 2). The levels of assessment reflect the different levels of complexity and expertise required to carry out the assessment at each stage. In this system there is a broad base of personnel to carry out less complex drug (and alcohol) misuse assessment, allowing more points of access to the drug and alcohol treatment system and less delay in treatment entry. However, the effectiveness of such a system depends on standardisation of approach. Specifically, commissioners should ensure the following elements are present in each locality: clear and standardised screening assessment processes used across all agencies clear criteria for referral and eligibility for entry to each part of the drug treatment system a local directory of services for drug and alcohol misusers clear criteria for priority treatment entry and emergency access adequate training of personnel carrying out screening assessment at each level adequate sharing of appropriate information between agencies in the drug treatment system a system of monitoring, auditing and reviewing of the screening and assessment system. Drug treatment commissioners and providers should ensure that local areas develop an agreed hierarchical assessment process with three levels of 29

36 assessment. These three levels of assessment can be broadly mapped onto the service tiers already described in Models of care. Different levels of assessment require different levels of competency of assessors. Commissioners and providers should ensure that local training in screening, triage and comprehensive assessment is available following the development of locally agreed processes, criteria, information-sharing protocols, and monitoring. Level 1 screening and assessment can be carried out by non-drug and alcohol specialists (with training). More complex drug and alcohol assessment is a highly skilled activity and should only be carried out by professionals who have reached a required level of competence. The purpose of sharing relevant information between agencies following assessment is to maximise the safety and effectiveness of drug (and alcohol) treatment interventions and to avoid repeated assessment of clients without action. Information sharing is also important in terms of risk management. Commissioners should ensure that locally agreed policies on information sharing, including informed client consent, are developed. Information-sharing protocols should be sensitive to client confidentiality while facilitating referral to treatment options required by the client. Assessment and subsequent care planning needs to be an inclusive process in which the client and the assessor work in partnership to identify need and plan care appropriately. The assessment should achieve sufficient agreement between client and assessor on the needs to be addressed by treatment and the most appropriate course of action. Without a sufficient level of consensus, future referral and effective engagement in treatment may be compromised, or at worst fail. Issues of cultural diversity and the development of culturally competent services are essential ingredients of effective treatment systems. Evidence from other areas of healthcare, and mental health in particular, show a need for assessment procedures and instruments that take into account the cultural diversity of local populations. During implementation, commissioners should ensure that the assessment tool used: is agreed locally and adapted to meet local needs and local service provision achieves referrals against agreed criteria is categorical, concise, comprehensive, and straightforward to apply can be audited against locally agreed standards. Figure 1 opposite illustrates levels of assessment, desired outcomes and the professionals responsible for each level. In this system, assessment is seen as an ongoing process rather than a one-off event. Assessment should continue through the episode of contact with the drug and alcohol treatment system. Ongoing assessment should be linked to care planning and co-ordination and is essential to the effectiveness of integrated care pathways. 30

37 Figure 1. The assessment system Level 1: Screen and referral assessment Content of assessment and outcome Identification of drug and alcohol misuse problem Identification of related or coexistent problems Identification of immediate risks Assessment of urgency of referral OUTCOME: Identification of an appropriate service for onward referral Target group and professionals responsible All drug and alcohol misusers presenting to Tiers 1 and 4b services Carried out by all Tiers 1 and 4b professionals Level 2: Triage substance misuse assessment Risk assessment Assessment of urgency of referral Brief assessment of substance misuse problem Brief assessment of client motivation to engage in treatment Assessment of need for comprehensive assessment/care coordination OUTCOME: Identification of treatment/ care needs Need for comprehensive assessment Need for onward referral All drug and alcohol misusers presenting to Tier 2, 3 and 4a services Carried out by all Tier 2, 3 and 4a professionals Level 3: Comprehensive substance misuse assessment Risk assessment Assessment of client motivation Drug use Alcohol use Psychological problems Physical problems Social problems Legal problems OUTCOME: Identification of treatment/care needs, based on comprehensive assessment Development of a comprehensive care plan 31 All substance misusers with one or more of the following: Significant substance misuse problems in two or more problem domains In need of structured and/or intensive intervention Significant psychiatric and/or physical comorbidity In contact with multiple service providers History of disengagement from substance misuse treatment services All Tier 3 and 4 and some Tier 2 services

38 1.3.2 Level one: Initial screening Screening and referral assessment is an activity that all Tier 1 and 4b services should be able to carry out (i.e. non-substance misuse specialist service providers). Often drug misusers present initially to non-substance misuse specialist services (e.g. general practitioners, accident and emergency departments, children and families social services). The aim should be for all personnel in Tiers 1 and 4b services to have basic training in the identification of drug misuse problems. All professionals in these services should have access to a directory of drug misuse services in their locality and clear criteria for referral, including eligibility criteria (e.g. priority, catchment area, age ranges). Level 1 assessment is less complex than Levels 2 or 3, but at a minimum it needs to include the following: identification of a drug or alcohol misuse problem identification of related or co-existent problems (e.g. physical, psychological, social) identification of immediate risks (e.g. self-harm, harm to others, physical and/or mental health emergencies) an assessment of the urgency of referral. The outcome of Level 1 assessment will be referral of the drug or alcohol misuser, with the appropriate degree of urgency, to the appropriate service. In many cases, the most urgent problems to address may be secondary to the drug misuse (e.g. suicide, para-suicide, overdose, child protection), in which case immediate referral may be to another Tier 1 service. In the case of medical or psychiatric emergencies, immediate referral is most likely to be to the nearest accident and emergency department or emergency psychiatric service, depending on locally agreed criteria. In the case of child protection concerns, immediate referral will be to children and families social services, according to local Area Child Protection Committee (ACPC) guidelines. In non-emergency cases, referral can be made to the most appropriate drug or alcohol treatment specialist service, or if appropriate, to another Tier 1 service. Again, such referrals will be subject to clear local protocols and criteria. In some cases it may be appropriate to make a referral to a drug treatment service at the same time as, or shortly after, referral to an emergency service, so that the drug misuser can access the appropriate drug treatment service after the immediate crisis has been addressed. The Level 1 screening assessment tool needs to have the following characteristics: It needs to be agreed locally and adapted to meet local needs and local service provision. It must achieve referrals against agreed criteria. It must be categorical, concise, comprehensive and straightforward to apply. It can be audited against locally agreed standards. The results of referrals resulting from Level 1 screening assessment should be fed back to the original screener to refine decision making and referral practices Level two: Drug misuse triage assessment Level 2 assessment should be carried out by all drug treatment services (and alcohol services if locally agreed) (i.e. Tiers 2 4a). Each drug service should have at least one individual (preferably more than one) who is trained and approved to carry out this level of assessment. 32

39 Level 2 assessment needs to be carried out in a standard way according to locally agreed criteria and with a standard format across all drug treatment services in a given locality. Information obtained in a Level 2 assessment should be appropriately shared with all agencies to which the drug and alcohol misuser is subsequently referred. This is particularly important in terms of identified risks and risk management. Further Level 2 assessments should be discussed within the assessor s team, preferably a multidisciplinary team, and in supervision, to maximise consistency and quality of approach. The Level 2 triage assessment tool needs to have the following characteristics: It needs to be agreed locally and adapted to meet local needs and local service provision. It must achieve referrals against agreed criteria. It must be categorical, concise, comprehensive, and straightforward to apply. It can be audited against locally agreed standards. The assessor carrying out a Level 2 assessment is accountable for the results of the assessment and the choice of treatment programme. Referrals are justified according to the agreed local criteria. This will help to ensure that staff carrying out Level 2 assessments are not tempted to keep hold of clients in order to meet performance targets or because of beliefs that their own approaches are best. Triage assessment is a filtering process that aims to establish which intervention or tier of service would best suit an individual drug (and alcohol) misuser at the time of assessment. Triage assessment should take place when the drug misuser first contacts specialist drug treatment services. It is recommended that personnel trained to carry out Level 2 triage assessment are available in all drug and alcohol treatment services and community care assessment teams. This will help ensure that a drug misuser is referred to the most appropriate agency as a result of their first contact with drug and alcohol services wherever they may present. Level 2 assessment is less complex than the comprehensive (Level Three) assessment and aims to identify which service the drug misuser requires and the level of urgency. It shares common elements with the Level 1 assessment on the basis that many drug misusers will present directly to a drug or alcohol treatment service without having had a Level 1 assessment. However, in addition to the common elements with Level 1 assessment, Level 2 assessment aims to provide a fuller assessment of the drug and alcohol misuse problem and the specialist drug and alcohol treatment that is needed. The decision for referral is based on the complexity of presenting need as well as readiness to engage with a particular programme. Level 2 triage assessment is not intended to be a comprehensive assessment. The aims of Level 2 assessment are to: identify and respond to emergency or acute problems identify risks to the substance misuser or others (through risk assessment) ensure appropriate referral based on the level of expertise and intensity of the intervention required ensure common processes and criteria across a range of local drug (and alcohol) treatment services for professionals undertaking triage assessment route drug and alcohol misusers with more complex needs into a care coordinated programme of care, including comprehensive drug and alcohol misuse assessment allow individuals with less complex needs to access less complex and/or less structured drug services (e.g. advice services, harm reduction services). 33

40 Level 2 assessment needs to include the following: risk assessment: identification of immediate risks (e.g. self-harm, harm to others, physical and/or mental health emergencies) an assessment of the urgency of referral brief assessment of drug and alcohol misuse problem brief assessment of client readiness to engage in types of treatment assessment of whether or not the client meets the criteria for needing more comprehensive (Level 3) assessment and care co-ordination. We recommend that only named (or approved) staff with the appropriate skills, training and competence should undertake Level 2 assessment of drug and alcohol misusers. Staff undertaking Level 2 assessment must have had special training which includes: standardised training on how to interpret guidelines and criteria and also how to apply them learning about the expertise and skills of professionals in the various treatment modalities (training sessions carried out by staff in the different modalities) risk assessment and risk management basic drug and alcohol misuse assessment skills. Risk assessment should be carried out according to a locally agreed protocol and using standardised documentation across all drug and alcohol treatment services. Risk assessment should consider risks to the individual drug and alcohol misuser (e.g. self-harm, self-neglect, exploitation) and risks to others (e.g. homicide, child protection issues, violence). Assessment of risk needs to consider any historical risk factors disclosed (e.g. past history of self-harm, history of disengagement from services) as well as presenting risk factors (e.g. threats to kill, suicidal ideas). The outcome of risk assessment needs to be shared with all agencies to which the drug and alcohol misuser is subsequently referred (see below). Risk assessment should also take account of risk of drug overdose and preventive measures in reducing drug-related death identified in the recent ACMD report (2000). Risk assessment, however, should not be imported unmodified from the mental health field. Drug and alcohol misusers who are not suffering from a mental disorder that might affect their capacity to make rational judgements require a different response to risk compared to people with a mental illness or disorder. Nevertheless, significant identified risks need to be appropriately managed and where appropriate reported to the relevant agency (e.g. police, social services) whether or not the client has a mental disorder. Locally agreed appropriate risk assessment and risk management policies and protocols need to be in place to guide drug and alcohol professionals. Risk assessment should be ongoing. Level 2 assessment should be carried out at the beginning of each episode of presentation to drug and alcohol services. Client readiness and initial motivation to engage in drug treatment can vary and change quickly. Level 2 assessment is a good opportunity for drug and alcohol services to undertake motivational interventions with patients. Low initial client readiness or motivation for structured drug treatment should not become a barrier to structured drug treatment: it should trigger motivational work by staff. Research indicates that the ability of staff in drug treatment services to motivate clients is as important, if not more important, than initial measures of client motivation. The purpose of the Level 2 assessment process is therefore to gather information to identify need and guide the client to appropriate services, and also to maximise the likelihood of client engagement in treatment. 34

41 1.3.4 Level 3: Comprehensive substance misuse assessment Level 2 triage assessment will have identified the need for comprehensive (Level 3) assessment, and referral will have been made to an agency that is able to carry out such an assessment. In practice, all Tier 3 and Tier 4a services need to have personnel who can carry out a comprehensive Level 3 assessment. Some Tier 2 services will also have the expertise to carry out a Level 3 assessment. Level 3 assessments should not be carried out by personnel who have not been trained or approved to do so. The Level 3 comprehensive assessment tool should have the following characteristics: It needs to be agreed locally and adapted to meet local needs and local service provision. It must achieve outcomes against agreed criteria. It must be comprehensive and inclusive. It must provide clear conclusions and form the basis of a clear care plan. It can be audited against locally agreed standards. Level 3 assessments should be targeted at drug and alcohol misusers with more complex needs and/or at those who require more complex and/or structured care programmes. The criteria for comprehensive assessments are identical to the criteria for care co-ordination (see 6 below), namely drug and/or alcohol misusers who present with one or more of the following: significant drug and alcohol misuse problems in two or more problem domains (see Assessment domains below) in need of structured and/or intensive intervention significant psychiatric and/or physical co-morbidity significant risk of harm to self or others in contact with multiple service providers pregnancy or children at risk history of disengagement from drug treatment services. In the system proposed here, comprehensive assessment is seen as an ongoing process rather than a one-off event. Assessment should continue throughout the episode of contact with the service and the wider drug treatment system. Ongoing assessment must be linked to Care Co-ordination and is essential for the effectiveness of integrated care pathways Assessment domains Many comprehensive assessment tools have been developed, and there is evidence that some are valid and reliable. Rather than proposing a specific tool, the NTA recommends that local assessment tools should be agreed between drug treatment providers and joint commissioners. Any assessment tool used for Level 3 assessment should, at a minimum, allow assessment of the following domains: drug use (including type of drug(s), quantity/frequency of use, pattern of use, route of administration, source of drug) alcohol use (including quantity/frequency of use, pattern of use, whether above safe level, alcohol dependence symptoms) psychological problems (including self-harm, history of abuse/trauma, depression, severe psychiatric co-morbidity, contact with mental health services) physical problems (including complications of drug/alcohol use, pregnancy, blood-borne infections/risk behaviours, liver disease, abscesses, overdose, enduring or severe physical disabilities) 35

42 social issues (including childcare issues, partners, domestic violence, family, housing, employment, benefits, financial problems) legal problems (including arrests, fines, outstanding charges/warrants, probation, imprisonment, violent offences, criminal activity) Skills and competence required for assessment The new Drug and Alcohol National Occupational Standards (DANOS) outline basic competencies required by professionals for different levels of screening and assessment of clients with drug and alcohol problems (Skills for Health 2002). These are available via the Skills for Health or NTA website. A professional should only assess a drug or alcohol misuser or a particular need if they have the required level of competence to do so. Where medical intervention is required for substitute prescribing, an appropriately trained doctor must assess the substance misuser. Factors such as the gender or the cultural awareness and sensitivity of the professional undertaking the assessment may be important in some circumstances. It is recommended that comprehensive assessments should be multidisciplinary in approach so that drug misusers can benefit from a wide range of skills and expertise. Competence for assessment must be judged on the following levels: level of competence (expertise, qualification and training) of individuals augmented by specialist supervisory and consultation arrangements aggregate competence of the agency or the service the aggregate competence of the staff from a range of health and social care agencies who are engaged in working jointly or providing shared care. Local systems of screening, assessment, information sharing (as appropriate) and referral should be developed. Local agencies and drug and alcohol specialist services should be identified as being competent to carry out screening or assessment at a particular level in accordance with the assessment levels described above. The local screening and assessment system also needs to be able to take account of, and work with, the statutory requirements of local services including mental health, child protection, criminal justice and the assessment of social care needs. Recent developments in the integration of health and social care should be applied to drug and alcohol services where possible and in particular to the process of assessment. With specific reference to community care assessments (CCAs) a range of professionals should be trained to carry out a CCA as part of an integrated assessment process with drug and alcohol treatment services Risk assessment and management Clinical governance (NHS Executive 1999a) has introduced at local levels systematic processes and systems to monitor care and to assure the quality of care. Risk assessment and management is intended to identify health and other risks and predicting factors to reduce accidents, ill health and disease, mortality and morbidity. Substance misuse services are faced with a number of concerns, such as accidents and drug-related deaths including overdose, blood-borne infections, suicide and homicide. The needs and safety of children living with drug misusers should be assessed and appropriate support and more detailed risk assessment should be 36

43 carried out. Risk assessment is an ongoing process which must be integrated into care planning and co-ordination. Risk management concerns managing the risks identified in the risk assessment process. It should cover individual staff responses to risk and an organisation s culture in managing health and safety and providing appropriate training. It is likely that drug and alcohol misusers will come into contact with a wide range of agencies, so it is recommended that a joint risk assessment and management policy is developed and agreed by all the relevant health, social care and criminal justice agencies User and carer involvement All screening and assessment must be needs led, with the service user central to the process. Staff should ensure that service users and carers (where appropriate) are actively involved in the assessment process. This should be encouraged by the assessment process and communication style. A drug service users charter of rights and responsibilities is part of the suite of national quality standards for drug and alcohol treatment (Alcohol Concern and Standing Conference on Drug Abuse 1999); these are reproduced on page 190. Drug treatment commissioners and providers should ensure these standards are adhered to and opportunities to encourage active involvement of users and carers in service provision, planning and development are maximised (see also section 4.6: Users, carers and self-help groups) Cultural diversity Issues of cultural diversity and the development of culturally competent services are essential ingredients of effective treatment systems. Evidence from other areas of healthcare, and mental health in particular, show a need for assessment procedures and instruments to take into account the cultural diversity of local populations Assessing children and adolescents Staff working with under-18s should be able to demonstrate the following: communication and engagement skills with young people, especially with young people who may be hard to engage an awareness of local children s specialist services, including those with child protection responsibilities, and when and how to refer an understanding of when and how to engage those with parental responsibility knowledge of the law relating to the principles of confidentiality and the need to disclose information in certain circumstances an ability to contribute to the development of young people s drug services in-depth knowledge of child and adolescent development an understanding the implications of major events such as abuse, bereavement and other traumatic incidents in the lives of children and young people the ability to conduct assessments based on the guidance Framework for the assessment of children in need and their families (Department of Health 2000a) an understanding of the issues of confidentiality and consent to treatment that involve the rights of children and the responsibilities of parents and professionals the ability to assess the severity and risks of substance misuse, the complexity of a planned intervention and the competence of a young person to consent to treatment the ability to manage and work within the Area Child Protection Committee child protection guidelines and to understand the relationship between substance misuse and the vulnerability of children and young people. 37

44 Further guidance on skill levels for practitioners working at each tier can be found in Young people and drugs: policy guidance for drug interventions (Standing Conference on Drug Abuse and the Children s Legal Centre 1999). It is essential that all young people s drug treatment services are closely aligned to local children services, especially statutory services. 38

45 1.4 Commissioning, care planning and care co-ordination Principles of care planning and co-ordination This section describes the roles of care planing and care co-ordination as key elements of an integrated system of treatment for drug (and alcohol) misusers. Drug treatment commissioners and providers should ensure that improved systems of care planning and co-ordination are implemented in local areas. Good systems of care planning and care co-ordination will ensure that services are client-centred and not determined by the modalities provided by a particular agency. Such systems are intended to facilitate access to a programme of integrated and coordinated health and social care and to maximise client retention and minimise disengagement ( drop out ) from the drug and alcohol treatment system. All service users who meet the criteria should have access to appropriate and effective assessment, care planning and care co-ordination. A range of professionals should be able to undertake care planning and care co-ordination. Broadening access to assessment, care planning and care co-ordination with clear local agreements on the criteria for access to different modalities of care will enable local drug and alcohol treatment systems to meet the needs of a greater number of drug and alcohol misusers more effectively. The overarching principle of care planning and care co-ordination is that those who enter into structured drug and alcohol treatment services receive a written care plan which is agreed with the client and subject to regular review with the key worker or care co-ordinator. Drug and alcohol misusers who meet the criteria for care coordination should have access to a named person who acts as the care co-ordinator, to ensure that the care provided by different services is co-ordinated by one person to provide a comprehensive and integrated approach. Treatment may be provided by a range of professionals and from more than one service at the same time or consecutively. The aims of care planning and care co-ordination are to: develop, manage and review documented care plans ensure that drug and alcohol misusers have access to a comprehensive range of services across the four tiers of local drug treatment systems ensure the co-ordination of care across all agencies involved with the service user ensure that there is continuity of care and that clients are followed throughout their contact with the treatment system maximise client retention within the treatment system and minimise the risk of clients losing contact with the treatment and care services re-engage clients who have dropped out of the treatment system avoid duplication of assessment and interventions prevent clients falling between services Care planning and review Commissioners should ensure that structured drug and alcohol treatment uses a care-planned approach with clients. The assessment of the drug and alcohol misuser should result in a written care plan. A care plan is a structured, often multidisciplinary, and task-oriented individual care pathway plan, which details the essential steps in the care of a drug and alcohol misuser and describes the drug and alcohol misuser s 39

46 expected treatment and care course. The care plan involves the translation of the needs, strength and risks identified by the assessment into a service response. It is used as a tool to monitor any changes in the situation of the drug and alcohol misuser and to keep other relevant professionals aware of these changes. The care plan must do the following: set the goals of treatment and milestones to be achieved (taking into account the views and treatment goals of the drug and alcohol misuser, and developed with their active participation) indicate the interventions planned and which agency and professional is responsible for carrying out the interventions make explicit reference to risk management and identify the risk management plan and contingency plans identify information sharing (what information will be given to other professionals/ agencies, and under what circumstances) identify the engagement plan to be adopted with drug and alcohol misusers who are difficult to engage in the treatment system identify the review date (the date of the next review meeting is set and recorded at each meeting) reflect the cultural and ethnic background of the drug and alcohol misuser, as well as their gender and sexuality. A care plan should be reviewed and evaluated at regular intervals and at the request of a member of the care team, the service user or their carer. The date of the next review meeting is set and recorded at each meeting. In reviewing the care plan the following is assessed: the relevance of the care plan the effectiveness of care plans/outcomes any unmet needs client satisfaction with the care. Drug and alcohol misusers with less complex needs who do not meet the criteria for standard care co-ordination (SCC) or enhanced care co-ordination will not need to be managed within the care co-ordination system. However, it would be good practice for all drug and alcohol misusers in Tier 2 services to have, at a minimum, a written care plan and a named keyworker. Drug and alcohol misusers with less complex needs who do not meet the criteria for care co-ordination will: require support or intervention from one agency or discipline, or will require only low-level support be relatively stable pose little danger to themselves or others be likely to maintain appropriate contact with services. Care planning and care co-ordination should not represent a bureaucratic burden on providers and increase unnecessary paper work. However, it is essential to ensure that central records are maintained on all drug misusers, that care planning and review takes place regularly, and that notes are kept with dates recorded. Copies of care plans and reviews should be available for clients. The results of risk assessment and risk management plans must always be recorded Main elements of effective care co-ordination Levels of care co-ordination The level and intensity of care co-ordination will depend on the complexity of individual need. We recommend the following levels of care co-ordination: Standard Care Co-ordination (equivalent to Standard Care Programme Approach [SCPA]) 40

47 Enhanced Care Co-ordination (equivalent to Enhanced Care Programme Approach [ECPA]) Standard care co-ordination Standard care co-ordination (SCC) applies to those drug and alcohol misusers who meet the criteria for care co-ordination but not the criteria for enhanced care coordination. Under SCC, the care co-ordinator is expected to carry out the roles and responsibilities described in The responsibilities of the care co-ordinator and the function of SCC is co-terminus with SCPA. However, this does not imply that users of drug treatment services are placed on mental health CPAs. Commissioners should ensure that all those who enter into drug and alcohol services receive a comprehensive, seamless approach to care and treatment. All drug and alcohol misusers in structured treatment should have a care plan and key workers. Care co-ordination should apply to all individuals with more complex needs. Care co-ordination has the following main elements: systematic and ongoing assessment of the health and social care needs of those presenting to drug (and alcohol) services care planning which identifies health and social care needs and responds to these identification of a named care co-ordinator to organise care across health and social agencies and maintain contact with the drug and alcohol misuser regular reviews of the plan of care (care plan). The principle of care co-ordination is not new to health and social care; however, the implementation of formal care co-ordination in drug treatment systems is. Drug treatment commissioners should phase-in requirements for this approach, recognising that providers require the resources and capacity to do so. The framework for care co-ordination described here is consistent with existing CPA legislation and practice for drug and alcohol misusers with mental disorder. The framework is also consistent with care management arrangements under the Community Care Act. Where treatment is being delivered within the framework of a Drug Treatment and Testing Order (DTTO), the care co-ordinator s remit to facilitate and encourage the drug misuser s consensual engagement in treatment needs to be balanced against the Probation Service obligation to enforce the order. DTTO National Standards (PC 25/2001) set out the expectations in terms of compliance with the treatment and testing elements of the order and dictate the amount of time the offender needs to be engaged in treatment on a weekly basis and the frequency of testing. It does not, however, specify the content of treatment programmes. The care co-ordinator s role involves encouraging the drug and alcohol misuser to utilise appropriate help and assisting their access to and engagement in treatment, while accepting the individual drug and alcohol misuser s choice as to whether they accept treatment or not. Consequently, the care co-ordinator should not be held responsible for that individual s choice or their subsequent actions. However, if the drug and alcohol misuser is assessed as presenting significant risks to themselves or others, the care co-ordinator has the same duty as any other professional, namely to communicate this to the appropriate authorities in line with local protocols. For drug misusers who are under statutory requirements to attend treatment (i.e. subject to Mental Health Act CPA or a Drug Treatment and Testing Order), locally 41

48 agreed guidelines should be followed if the drug and alcohol misuser fails to comply with treatment. Commissioners should ensure that care co-ordinators are adequately supported in their role. Adequate support should be provided by the agency that employs the care co-ordinator. Care co-ordinators should inform commissioning bodies of agencies that are unwilling to co-operate with care co-ordination arrangements, and appropriate remedial action should be taken by the commissioners. Commissioners should consider pooled budget funding for drug treatment being contingent on full cooperation with the care co-ordination system Client criteria for standard care co-ordination The criteria for care co-ordination are identical to the criteria for comprehensive assessment, namely drug and alcohol misusers who present with one or more of the following: significant drug and alcohol misuse problems in two or more problem domains (see 1.3.5: Assessment domains) a need for structured and/or intensive intervention significant psychiatric and/or physical co-morbidity significant risk of harm to self or others contact with multiple service providers a pregnancy or children at risk a history of disengagement from drug and alcohol treatment services. In practice, many drug misusers who present to Tier 3 and 4a services will automatically fall into this category. Some clients in Tier 2 services will also require care co-ordination, but may need to be referred to an agency that is able to provide such a level of assessment and co-ordination of care. When a drug and alcohol misuser with complex needs presents to a Tier 2 service that cannot provide comprehensive assessment or care co-ordination, referral should be made to an appropriate agency, as suggested by the Level 2 assessment. If an individual in this situation is unwilling to be referred, the agency should record the fact that referral had been discussed. If the Tier 2 service has overriding concerns about the client that justify sharing information without consent (with reference to local guidelines), the relevant statutory agency should be contacted (e.g. social services, mental health team) and appropriate information shared to prompt assertive follow-up according to local protocols. In these circumstances, the Tier 2 service is not responsible for a client s decision not to accept appropriate referral Enhanced care co-ordination Client criteria for enhanced care co-ordination Under enhanced care co-ordination and CPA, the expectation is that the client has severe mental health co-morbidity (e.g. schizophrenia, bipolar affective disorder, severe depression) and is thus subject to the national guidelines for enhanced CPA. In most cases, the client will be under the care of a community mental health team (CMHT), which will often be caring jointly with a drug and alcohol misuse service. Under these circumstances, the responsibility for follow-up is greater than under SCC if the client disengages from treatment due to their high level of vulnerability or risk. The CMHT should have responsibility for care co-ordination for clients on ECPA, with the drug and alcohol treatment service being responsible for specific elements of the care plan. Joint working arrangements between specialist substance misuse services and mental health services needs to take account of the recent Department of Health guidance on dual diagnosis (Department of Health 2002). 42

49 Enhanced CPA currently applies to those clients with severe mental health problems resulting in chronic disability or those clients who: need a high level of support generally from more than one professional or agency are subject to Section 117(2) of the Mental Health Act or Supervised Discharge under Section 25(a) are on the Supervision Register Drug misusers on Drug Treatment and Testing Orders (DTTOs) Under enhanced care co-ordination for criminal justice, the service user will be the subject of a sentence order as well as receiving care planned treatment. The care planning and sentence planning processes will therefore require integration. The goals set in care and sentence plans will need to be regularly reviewed and monitored to ensure that treatment is effective in meeting its aims. Where treatment is not deemed to be effective it may require adjusting (Home Office and Standing Conference on Drug Abuse 2000). Probation Circular 25/ Appendix A, makes it clear that DTTOs must be managed jointly by the Probation Service and the treatment provider and that, apart from in exceptional circumstances, neither party shall take major decisions in respect of any order without consulting the other. The need for effective partnership working is essential because, although the treatment provider will normally take the lead in terms of the care co-ordination role, this will need to take place within the statutory constraints and national standards framework that govern the enforcement of DTTOs Roles, responsibilities and competencies of the care coordinator New national occupational standards for drugs and alcohol (DANOS) include care planning and care co-ordination. National training modules for DANOS are under development for drug treatment providers and will be available in Drug treatment commissioners should ensure that the new roles of care coordinators are implemented in local drug treatment systems. Care co-ordinators may be existing staff co-opted into these roles or new staff recruited and trained for the tasks. The development of these new roles within drug treatment systems will take planning and additional resources Role and responsibilities of the care co-ordinator The role of a care co-ordinator may involve the following responsibilities, depending on the locally agreed system: to develop, manage and review documented care plans based on ongoing assessment (including risk assessment) to ensure that the care plan takes account of the service user s presenting needs, and their culture, ethnicity, gender and sexuality to carry out ongoing risk assessment and co-ordinate an appropriate risk management plan to work towards engaging and retaining the drug (and alcohol) misuser in the treatment and care system to co-ordinate care across the range of health and social care agencies to act as a facilitator to help the service user to access other appropriate services to generate referrals 43

50 to advise other professionals involved in the care of the service user of changes in the circumstances of the service user which may require a review or change of the care plan to ensure essential and appropriate information is shared between agencies (see below) to develop contingency and crisis management plans for service users with complex needs, where required to keep in touch with the service user to carry out an early follow-up of discharged service users to aim to re-engage service users who have dropped out of the drug treatment system. Where drug and alcohol misusers are in contact with mental health services and placed under a mental health Enhanced CPA, close liaison must be established between the substance misuse services and the ECPA care co-ordinator. This must include effective communication protocols concerning care arrangements, including ongoing risk assessment and management. The expectation is that the mental health team will have primary responsibility for care co-ordination in these cases. Where drug misusers are the joint responsibility of drug and alcohol misuse services and the criminal justice system (e.g. Probation) close liaison and effective communication is essential between services Competencies of the care co-ordinator It is essential that the care co-ordinator has the training and competence, and is given the authority locally, to co-ordinate the delivery of the care plan, and that this is respected by all providers regardless of which agency employs the care co-ordinator. To achieve this, the care co-ordinator must be able to demonstrate competencies outlined in the new DANOS standards. These are the following: an understanding of drug and alcohol misuse comprehensive assessment skills, using locally agreed tools and protocols care co-ordination skills knowledge of local drug and alcohol treatment services and other relevant services and their respective roles knowledge of drug and alcohol misuse (including opiate, stimulant and polydrug misuse) competence in working with diversity, including awareness of race, culture and gender issues competence in the delivery of care to drug and alcohol misusers (including an understanding of substance misuse treatment and care) an understanding of the principles of and local policies on client confidentiality and appropriate sharing of information (including child protection in line with local ACPC guidelines). In practice, care co-ordinators will probably be experienced members of a team or service. Only some staff will be competent to undertake this role and it is likely that staff undertaking this role will require additional training in line with DANOS and local drug treatment systems. Those with a care co-ordinator role may need to have a smaller caseload than others. Care co-ordination may involve extensive work with some individuals. The regional pilots sites for Models of care may also inform the way in which local commissioners and providers may implement the roles of care co-ordination. Two models are being piloted: one involving a discrete team of care co-ordinators, the other involving a virtual team of care co-ordinators with nominated and trained staff in 44

51 each local drug treatment (Tiers 2 and 3) service. The NTA will provide quarterly briefings on learning from the pilot sites Information sharing to enable client care planning and coordination Commissioners should support providers to ensure that local protocols are agreed which balance the client s right to confidentiality with the safe and effective delivery of integrated care. Such protocols may require the sharing of essential information, particularly around issues of risk. An important part of effective communication between agencies is the need for adequate and appropriate sharing of information about clients who are in contact with multiple agencies or whose care is transferred from one agency to another. It is the role of the care co-ordinator to ensure that relevant and appropriate information is passed between agencies with the client s written informed consent, within local guidelines. A client may refuse to give permission to share essential information. In exceptional cases, essential information should be shared where there are significant risks to the client or others in not sharing information, e.g. in the case of child protection issues under Section 115 of the Crime and Disorder Act. A clear explanation must be given to the client about what information sharing means and how it affects confidentiality. Mechanisms to safeguard confidential client information must be in place in line with data protection legislation. Information about these mechanisms must be available to clients in written form Transferring care co-ordination Commissioners and providers should ensure that local protocols are in place to ensure adequate transfer of care co-ordination where appropriate. Sometimes it may be appropriate to transfer care co-ordination to a different agency. The general principle for transfer of care co-ordination is that care co-ordinators are allocated from Tier 3 services, normally the highest community-based service with which the drug and alcohol misuser is involved. Some drug and alcohol misusers will no longer require Enhanced CPA (by virtue of recovery from mental health problems, or completion of a DTTO), but may continue to attend a Tier 3 community drugs service. In these cases, care co-ordination can be transferred from the community mental health trust or Probation Service to the drug and alcohol service care co-ordinator, if appropriate and with joint agreement. When a formal transfer of care co-ordination is carried out with agreement of the transferring and receiving agency, the name of the new care co-ordinator must be written in the care plan. The client, and all relevant agencies involved in their care, must be informed in writing. Referral of the drug and alcohol misuser to a new agency must lead to a care co-ordinator being allocated. Where a formal transfer of the drug and alcohol misuser has not occurred, responsibility for care co-ordination will remain with the transferring agency. 45

52 1.5 Monitoring Monitoring activity and outcome in drug misuse treatment There is an increasing imperative to monitor the activity, cost and outcomes of drug and alcohol treatment services. This reflects a desire to gauge the return on local and national investment and to ensure that resources are directed to effective treatment. Clinical governance frameworks in the NHS and Best Value frameworks in local authorities are also frameworks of accountability to ensure that organisations are continuously improving the quality of their services and safeguarding high standards of care. In drug and alcohol treatment services, QuADS standards on organisational management include specific standards on monitoring service activity and client outcome. Existing commissioning standards for those responsible for drug and alcohol treatment (Substance Misuse Advisory Service 1999) includes explicit standards on contract monitoring and information gathering vis-à-vis local population needs. Commissioners have a critical role to play in developing local systems for monitoring activity and outcome Developing local systems for monitoring drug treatment activity and outcome Commissioners are currently expected to routinely monitor drug treatment services in their locality through contract monitoring and participation in the National Drug Treatment Monitoring System (NDTMS). Some commissioners have been active in developing information-gathering initiatives for outcome monitoring, in addition to the routine monitoring of drug treatment services in their areas through contract monitoring. All commissioners should move towards activity and outcome monitoring, although it is recognised that this will be an incremental process. Commissioners and DATs should develop, in the first instance, reliable activity reporting and move towards monitoring outcomes over time. Commissioners and providers responsible for implementing these systems should read each treatment modality section in this document. These sections outline suggested data requirements based on the recommendations of the Task Force to Review Services for Drug Misusers (1996) National drug treatment data sets Information on people presenting for drug treatment has been collected systematically for a number of years across England and includes data for the Regional Drug Misuse Database, now the National Drug Treatment Monitoring System (NDTMS), and the DAT templates and treatment plans. The NTA is currently developing an informational strategy and minimum data set to support the implementation of Models of care. The data set will be published as an addendum to Models of care. The NTA data set will describe care received by the service user during each period of care and will be person-centred. It will also record outcome achieved through the treatment process. It is intended that the primary function of this data set will be to determine whether desired outcomes are achieved by drug treatment services. It is also intended that the data set will provide managers, clinicians and other professionals with better-quality information for clinical audit, service planning, management and contract monitoring. 46

53 Chapter 2 Drug misuse treatment modalities This chapter describes the main modalities of treatment that should be provided for drug misusers. Each modality is described in a standard format with the evidence base detailed, and the aims and objectives of the modality presented. Illustrative care pathways have been described but must be tailored to the local environment. Access to treatment along with referral pathways are also described. 47

54 2.1 Advice and information Description Advice and information services provide accurate, appropriate and factual information which is accessible and meaningful (in terms of context, language and comprehensibility) to the recipient. Advice and information may be provided by a variety of means, including verbal, written, audio-visual aids (e.g. videos), face-toface or by telephone. Access to advice and information should be provided by services in Tier 1 (see Chapter 1), and may be a core component of services in Tier 2. Specific services offering advice and information are characteristic of open access services. However, the provision of advice and information on drug and alcoholrelated issues should be provided by staff in all treatment tiers Aims and objectives The aim of advice and information services is to provide appropriate and professional advice and up-to-date information on all aspects of drug and alcohol misuse, including: the potential psychological and physical complications of drug and alcohol misuse how to safely reduce and stop the misuse of various illicit drugs and alcohol how to reduce the harms associated with drug and alcohol misuse how and where to access help for problems associated with drug and alcohol misuse how to access appropriate, related generic services (e.g. housing department, sexual health clinics, etc). Furthermore, it is important that all health, social care and criminal justice agencies provide basic information and advice to clients with whom they have contact Client group served Advice and information should be available to drug and alcohol misusers and their families, friends, the wider community and other professionals, for example, teachers, generic social workers, primary care staff and criminal justice agencies Eligibility Advice and information services are open access services and should be made available to anyone concerned about a drug-related problem including the individual themselves, their family or friends Research evidence base Drug and alcohol misusers and their families will require information and advice around changing their lifestyles, minimising the complications associated with substance misuse, and accessing resources within the community. Certain groups of drug and alcohol misusers, such as stimulant users, rate information as being an important part of service provision (Farrell et al. 1998). Other groups require information in an accessible format (e.g. culturally appropriate literature for those from black and minority ethnic populations (see Black and minority ethnic populations in Chapter 3). 48

55 Advice and information may help drug and alcohol misusers to reduce their use of substances. It has been demonstrated that advice on alcohol intake can reduce consumption (Department of Health 1999a, 2001b; NHS Centre for Reviews and Dissemination 1997; Wallace et al. 1988). Advice and information may help to reduce the risks associated with drug use (e.g. injecting risk behaviours). The provision of information in relation to the reduction of harms associated with injecting and safer sexual behaviours has long been recognised as important for the health of substance misusers and the community (Advisory Council on the Misuse of Drugs (ACMD) 1988; Department of Health 2001b). Advice and information should be offered to reduce the risk of drug-related mortality, for example, from overdoses (ACMD 2000; Department of Health 2001d). Information must be accurate, up-to-date and consistent. This requires a regular review of knowledge and appropriate supervision of staff (Department of Psychiatry of Addictive Behaviour 1998; Department of Health 2001b, Skills for Health 2002). All staff should receive the necessary training required to provide advice and information to drug users on a wide range of issues. Training should also be made available for administrative staff who may be required to provide the necessary preprinted information about advice and information and other local services (Department of Health 2001b). All staff should be able to provide advice and information to other colleagues within the health and social care and criminal justice agencies, service users, families and carers on drug-related issues and local services. It is good practice that health information, education and advice on substance use is provided by all health professionals who come in contact with drug and alcohol misusers (Marshall et al. 1999) Location Advice and information services should be easily accessible and provided through a range of options including face-to-face contacts in all drug treatment agencies and other agencies, such as community drop-in and advice centres. Advice and information should also be available through generic services and health promotion agencies. Literature should be made available to drug and alcohol misusers, their families and friends, as well as to the wider community Telephone advice Telephone helplines are especially valuable to people who initially prefer not to seek help from statutory services (Task Force to Review Services for Drug Misusers 1996). It is important that drug and alcohol misusers, their families and their carers are informed of services that provide an information service, including NHS Direct. Local service provision may include information telephone helplines, in addition to the service provided by the national helplines. Such services may provide: an advisory service to individuals working in statutory and non-statutory settings advice on how to access support and treatment services locally a confidential advice line to drug users and carers (Department of Psychiatry of Addictive Behaviour 1998). 49

56 Tier 1 services Pharmacists are in an ideal position to offer health promotion advice to clients attending for dispensing medication or needle and syringe exchange schemes, particularly to those not in contact with other services (Task Force to Review Services for Drug Misusers 1996). They can also provide information about local drug and alcohol misuse services and how to access them. Individuals with drug and alcohol misuse problems attend accident and emergency (A&E) departments following accidental overdoses and in a state of crisis (Stimson et al. 1995). It is therefore important that A&E staff are equipped to proactively manage drug and alcohol misusers and to provide advice and information on the prevention of such occurrences and the reduction of other harms associated with substance misuse. They should also be able to provide information on local services and how to access them. Leaflets on overdose prevention should be available (Task Force to Review Services for Drug Misusers 1996; ACMD 2000). Maternity services should provide advice and information on the health risks of drug and alcohol misuse to mothers and the unborn child (Task Force to Review Services for Drug Misusers 1996). When individuals come into contact with the criminal justice system there is an opportunity to provide advice and information about drug and alcohol misuse issues. This may include changing lifestyle, reduction of harm associated with drug and alcohol misuse and access to services for further help and treatment as appropriate (Task Force to Review Services for Drug Misusers 1996). The expansion of arrest referral schemes and interventions arising from the Prison Drug Strategy (e.g. CARATs) are important delivery mechanisms for advice and information services. It is important that service providers obtain accurate information on the resources provided by services in the statutory and the non-statutory sector. They should provide accessible and appropriate information to young people and their parents (Health Advisory Service 1996). Tier 1 services are ideally placed to provide advice and information to drug users with whom they come into contact about minimising the risks associated with hepatitis B, C and HIV (Department of Health 2001b). See also Blood-borne diseases in Chapter Tier 2 services All Tier 2 services will have a component of their service that provides advice and information. In some Tier 2 services advice and information may be the main function of the service, while in others, advice and information will be one of a number of services provided (see, for example, Needle exchange facilities in Chapter 2 and Outreach work in Chapter 4) Tier 3 and 4 services Information and advice should be provided by all Tier 3 and 4 services to drug misusers (and their families) in treatment. However, the core functions of these services are structured programmes, and these services are not open access. These tiers of service may also provide advice and information to other service providers Standards Core management and commissioning standards National standards on the commissioning and management of the delivery of advice and information services are available and include QuADS (QuADS organisational standards for alcohol and drug treatment services, Alcohol Concern and Standing 50

57 Conference on Drug Abuse 1999) and the Substance Misuse Advisory Service commissioning standards, Commissioning standards for drug and alcohol treatment and care (Substance Misuse Advisory Service 1999) Training and competencies Relevant competencies are outlined in the Drugs and alcohol national occupational standards (DANOS) (Skills for Health 2002) Access Advice and information should be provided to drug and alcohol users, carers, professionals and the wider community. Advice and information should be free of charge. Advice and information should be confidential and should be available and anonymous (as appropriate) for those wishing to enquire through telephone contact and helplines. Advice and information should be available to suit a range of diverse needs including those with literacy problems. Advice and information should be culturally sensitive and individuals should have access to information in a variety of languages and an interpreter where required Referral pathways Tier 2 services provide advice and information, and are usually open access. This means that referrals are accepted from a wide variety of sources, including selfreferral (see Chapter 1) Assessment Assessment may not be indicated (e.g. advice to professionals). Triage assessment may be necessary and appropriate, progressing to comprehensive assessment as needed Management All services should be aware of how drug and alcohol misusers, carers and professionals can access help and advice. Provision may include literature published in a variety of languages, information for individuals from culturally diverse backgrounds, and access to interpreters. Drug and alcohol misuse services should work closely with non-specialist services to ensure they have up-to-date information on drug services, and they should provide advice about posters and leaflets that are available. Health promotion departments can also assist in identifying appropriate literature which can be made available to non-specialist substance misuse services. It is important that service providers obtain accurate information on the resources provided by services in the non-statutory sector. They should provide accessible and appropriate information to young people and their parents (Health Advisory Service 1996). All A&E departments should display posters and have leaflets available about drug and alcohol issues including health promotional messages, harm reduction strategies and information about how to get help (Task Force to Review Services for Drug Misusers 1996). Maternity services should provide advice and information as part of routine screening on medicines, alcohol, smoking and drugs (licit and illicit). 51

58 Leaflets and information should be available at all times to be given out by staff or to be taken by the public (discreetly or otherwise). Such materials should be the latest editions and every effort should be made to acquire the most up-to-date advice and information leaflets. Services locally may wish to arrange a regular updating process of printed information to ensure that all services are involved and information is kept up-to-date Performance and outcome measurement For guidance on performance measurement of advice and information services, see Performance and outcomes monitoring in Chapter 4. 52

59 2.2 Needle exchange facilities (See also sections on Overdose and Blood-borne Diseases in Chapter 4.) Description Needle exchange facilities are Tier 2 services, although some (most commonly, community pharmacies) are located in Tier 1. Needle and syringe exchange schemes were developed within the wider context of harm minimisation or risk reduction, which refers to the reduction of the various forms of drug-related harm, including social, medical, legal, and financial problems, until the drug misuser is ready and able to come off illegal drugs (Department of Health et al. 1999). They are important for preventing blood-borne diseases, most particularly HIV and hepatitis, as well as being important public health measures (Department of Health 2001b) Context In 1998, there were 2,000 needle and syringe exchange outlets in the UK distributing over 25 million syringes annually (Hunter et al. 2000). The majority of needle exchange schemes are those where sterile needles and syringes are given out and their safe disposal is offered. There are also facilities where sterile equipment is given or sold, but where facilities are not available for the return of used equipment. Some services provide additional injecting equipment, including swabs, filters, sterile water ampoules, citric acid and so forth Philosophy and approach The policy of supplying sterile injecting equipment was developed in the UK in the late 1980s, in light of the HIV epidemic. Policy was initially framed within a public health perspective, which saw the prevention of HIV as more important than the prevention of injecting drug misuse (Advisory Council on Drug Misuse (ACMD) 1988, 1989 and 1993). The major objective of needle exchanges was the minimisation of the risk of infection by making injecting equipment accessible to all injectors, and thus reducing sharing (Task Force to Review Services for Drug Misusers 1996). Needle exchanges were developed within a wider approach that advocated a hierarchy of goals: stopping sharing injecting equipment, moving from injectable to oral drug use, to decreasing drug use, and ultimately to abstinence (ACMD 1988). Preventing the sharing of injecting equipment remains high on the policy agenda. One of the targets of the government s ten-year strategy, Tackling drugs to build a better Britain, is to reduce the proportion of drug misusers who share injecting equipment in the previous month (UKADCU 1998a). Needle exchange has had a crucial and well-documented role in keeping rates of HIV low in England. The recent Department of Health guidance on hepatitis C mentions its importance, along with other harm reduction measures, in reducing the spread of hepatitis C virus (HCV). The guidance states: It is important that those working with drug users are aware of, and actively promote, the use of local schemes and provision (Department of Health 2001b). The need to ensure that such services are commissioned at local levels cannot be stressed enough. Commissioners must also meet the government s agenda to reduce drug-related death and prevent overdose (ACMD 2000; Department of Health 2001d) and ensure that local misusers have access to a wide range of harm reduction initiatives. Published materials include Derricott et al. 1999, 2001; Hunt et al. 2001a, 2001b. 53

60 Location The Task Force to Review Services for Drug Misusers (1996) recommends that there is a comprehensive range of local syringe exchange facilities. These must be available in a number of settings, including the following: in community pharmacy outlets in specialist drug treatment services through outreach workers in mobile needle exchanges in hospital A&E departments. Needle exchanges can also be available in other settings, and DATs and commissioning groups must ensure that there is comprehensive coverage of the catchment area. In particular, they must consider issues for delivery of needle exchange services in rural areas Staffing and competencies Professional competencies in needle exchange have been identified as part of the QuADS professional qualifications. Job components include the establishment of the extent and type of injecting behaviour, the provision of harm reduction advice, the provision of injecting equipment and the monitoring and evaluation of services (for more information see DrugScope and Department of Health 2001a and 2001b. Occupational competencies have subsequently been identified in Drugs and alcohol national occupational standards (DANOS) (Skills for Health 2002). It is recommended that fixed-based or dedicated needle exchanges employ nurses to check injecting sites and deal with minor infections and dressings (National Needle Exchange Working Party, Undated). It is also recommended that basic health checks are provided to service users where required, and that needle exchange staff are provided with training to enable them to do that (Task Force to Review Services for Drug Misusers 1996). It is acknowledged that these services may be limited in some settings, and community pharmacies in particular, although these can play a role in prevention (see for example Sheridan et al. 1996). It is nonetheless recommended that service users be referred to community agencies where such services are available Aims and objectives Aims and objectives of the intervention The objectives of syringe exchange schemes as identified by the Task Force to Review Services for Drug Misusers (1996) are to: offer sterile syringe and needle distribution offer safe syringe and needle disposal, usually by return offer advice and counselling on HIV, hepatitis and drug problems offer hepatitis B immunisation offer overdose prevention and response advice and information reduce the number of new initiatives into injecting offer advice on safer sex and sexual health offer advice and counselling on other health, social and welfare problems provide referral to other treatment services provide easy access and a user-friendly service for all injecting drug misusers collect routine information Client groups served Exchange schemes aim to contact all injectors, particularly those not in contact with other services. Injectors are much more likely to be dependent and experiencing 54

61 some drug-related harm. They constitute a priority group that must be attracted to, and retained by, harm reduction initiatives and structured treatment programmes (Marsden and Strang et al. 2000). There is evidence from the UK and elsewhere that a large percentage of users of needle exchange facilities are not known to other local services (Task Force to Review Services for Drug Misusers 1996 p. 48; Des Jarlais 1994). These facilities are therefore their only contact with the treatment and care system. Needle exchanges are, nonetheless, not reaching all groups of injectors equally. Research shows that needle exchange schemes have had most difficulty in attracting younger injectors, women injectors, injectors from minority ethnic groups and injectors of non-opiate drugs (Donoghoe et al. 1992a). It is widely acknowledged that the accessibility of needle exchange facilities to these groups must be greatly improved, including their accessibility to injectors in rural areas. The opiate-bias of many needle exchange schemes is also acknowledged. Research shows that the needs of non-opiate injectors, as well as opiate injectors, must be reflected in service delivery and commissioning. Indeed, research shows that a substantial proportion of injectors are amphetamine misusers (Klee 1992). The national analysis of Regional Drug Misuse Database (RDMD) data for the six months ending September 1999 also shows that approximately 50% of amphetamine misusers were recorded as injecting their drug (Department of Health 2000c). Generally speaking, injectors of amphetamines and of crack-cocaine inject more frequently than heroin injectors, a fact that must be taken into account in the provision of sterile injecting equipment. Although it is impossible to accurately determine the prevalence of injecting in the UK, studies show that injectors form more than 50% of drug misusers in treatment (Moot 1994, pp ). Over 60% of the National Treatment Outcome Research Study (NTORS) cohort had injected drugs in the three months before entry into treatment; almost a quarter reported sharing. Similarly, RDMD data for the six months ending in September 1999 show that 63% of misusers whose injecting status is known had ever injected and 44% injected in the last four weeks, reflecting similar levels to those of previous periods (Department of Health 2000c). Men were more likely to have injected in the last four weeks than women were, and injecting was less common among misusers under the age of 20 (Department of Health 2000c). In terms of high-risk injecting behaviours, the above mentioned analysis of RDMD data shows that 48% of misusers, whose sharing and injecting status is known, ever shared injecting equipment; 19% shared in the last four weeks (Department of Health 2000c). The overall level of sharing for 1999 was 33%. However, rates of sharing equipment, which includes borrowing and lending filters, spoons and water, could be higher than those reported to the RDMD. Indeed, in-depth injecting risk behaviour questionnaires have shown equipment sharing rates as high as 77% (Stimson et al. 1998b). Research data show that women and young people are at particular risk. Women who have injected in the last four weeks were more likely to share than men, although they were also less likely to have injected in that period. Younger misusers were also more likely to have shared in the last four weeks, although older misusers were more likely to have injected during that period (Department of Health 2000c). Other studies have also shown that younger injectors are more likely than older ones to report sharing (Rhodes et al. 1996; Hutchinson et al. 2000a). Women who have an injecting partner are more likely to share and often wrongly view this as a low-risk activity (Davies et al. 1996; Ross et al. 1994). This may partially explain the findings of research, which suggest a higher rate of HIV infection among women injectors than among male injectors (Waight et al. 1992). 55

62 Other variables found to be associated with high risk injecting practices include: the use of heroin (Donoghoe et al. 1992b; Baker et al. 1995) the use of crack-cocaine (Hunter et al. 1995; Watters et al. 1994) dependence on opiates with frequent use of stimulants (Gossop et al. 2000a) benzodiazepine use (Klee et al. 1990; Drake et al. 1993) polydrug use (Frischer et al. 1993) severe drug dependence (Gossop et al. 1993) frequent injecting (Frischer et al. 1993; Latkin et al. 1994) more time spent in prison (Myers et al. 1995; Baker et al. 1995) more time spent with other injectors (Donoghoe et al. 1992b; Latkin et al. 1994) having a sexual partner who is an injector (Donoghoe et al. 1992b; Baker et al. 1995) being out of treatment (Baker et al. 1995; Lonshore et al. 1993) being homeless or in poor accommodation (Donoghoe et al. 1992b; Rosenthal et al. 1994) there is anecdotal evidence that risk-taking behaviour may increase when clients are injecting crack Contraindication or cautions This document focuses on the needs of adult substance misusers and issues pertaining to adolescents and young people are discussed elsewhere (Health Advisory Service (HAS) 1996; 2001b). It is, however, important to reiterate that where an injector is, or appears to be, less than 18 years of age, it is recommended that a designated worker with appropriate training and knowledge relating to young people conduct a full assessment. Ideally this should be in the context of a service which is separate and distinct from adult provision especially for those under 16 years. There are a number of statutory considerations when offering needle exchange services to young people (in particular those under 16 years) which are: firstly the ability of the young person to give consent for treatment if they are a minor; and, secondly child protection issues. Consent for their own treatment may be given by a young person aged 16 or 17 years, though it is still good practice to encourage involvement of those with parental responsibility. For those under 16 consent must be sought from the adult with parental responsibility for the young person or an assessment of the young person s competency to consent must be carried out. If the under-16-year-old is deemed as not competent to consent to their own treatment following assessment, the adult with parental responsibility should be involved. Even if a young person under 16 is competent to consent to their own treatment it is still good practice to encourage involvement of those with parental responsibility. If a young person under 16 is thought to be at risk of significant harm either through their drug misuse or lifestyle factors, the service should inform social services according to local Area Child Protection Committee guidelines. The young person may still need drug treatment while child protection assessment and interventions are being carried out and may still require support from a service. In all circumstances it should be clear that needle exchange should only be provided where the risk of providing needles and syringes outweighs the risk of not providing this facility. In some settings, particularly pharmacy and outreach work, it may be necessary to refer young people to a specialist service for assessment (see the section on young people in Chapter 3; also see Standing Conference on Drug Abuse 56

63 and the Children s Legal Centre 1999; DrugScope 2000a; DrugScope and Department of Health 2001a; Health Advisory Service 1996, 2001b) Research evidence base Key findings There is evidence from observational studies from several countries that, on average, the provision of needle exchange facilities is associated with a reduction of risk behaviour, including a reduction of the frequency of sharing (Hunter et al. 1995; Stimson et al. 1998a) and it is likely that needle exchange facilities have greatly contributed to the control of HIV among injectors (Des Jarlais et al. 1996; Hurley et al. 1997; Drucker et al. 1998; Peters et al. 1998). Some recent evidence from the US has shown a mixed or negative effect of needle exchanges, but the general evidence base for these interventions is positive (Marsden and Strang et al. 2000). Research carried out in the UK shows that injectors who attend exchange schemes report lower levels of sharing, fewer sharing partners and longer periods between occasions on which they share (Donoghoe et al. 1992a, 1992b). In addition, research shows that injectors not attending needle exchanges also made changes in risk behaviour, suggesting a wider cultural change among drug misusers and injectors (Burt and Stimson 1993). Overall, the proportion of injectors sharing equipment continues to decline and sharing has become less the norm and less indiscriminate (Burt and Stimson 1993). There is also plenty of evidence highlighting the continued importance of targeting sexual and intimate relationships as a unit of behavioural change (Rhodes and Quirk 1998). In the UK, there is evidence that the low and stable HIV prevalence rates have resulted, in part, from the quick response of policy makers and an early distribution of sterile equipment (Stimson 1995). Syringe exchanges are also likely to have contributed to public health efforts to reduce prevalence of markers of exposure to hepatitis B virus (HBV). UK studies show lower rates of HBV exposure for people with shorter injecting careers (Rhodes et al. 1996; Hunter et al. 1998), with those who start to inject after the introduction of risk-reduction interventions having considerably lower rates of HBV exposure than those injecting before harm minimisation interventions were in place (Marsden and Strang et al. 2000). All of this indicates that needle exchange facilities are effective. However, it is also important to remember that many injectors are still vulnerable to HBV infection because of poor levels of vaccination and that only a minority of drug agencies offer on-site vaccination to their clients. National and international data show high prevalence rates of hepatitis C infection, even in cities where needle exchange facilities are widely available (Van Beek et al. 1998; Wodack and Crofts 1996; Taylor et al. 2000). It has been argued that successful interventions have lead to risk reduction; however, no intervention has resulted in the elimination of risk behaviour. Thus, whereas risk reduction has been sufficient to reduce HIV risk, the control of HCV may necessitate the use of injecting practices that guarantee the elimination of exposure to equipment contaminated with even the smallest amount of blood (Hagan and Des Jarlais 2000). Nonetheless, there is emerging evidence from the UK that rates of HCV infection appear to be stable among injectors with a history of less than five years injecting since 1995 and there is evidence that infection among injectors is less than previously expected. This suggests that needle exchanges and other harm reduction measures are having a key role in reducing the spread of hepatitis C as well as HIV (Hope et al. 2001; Department of Health 2001b). Combined evidence strongly 57

64 suggests that the promotion of safer injecting continues to be an important public health issue with regard to reducing blood-borne infections (Hunter et al. 2000). Research in the UK and elsewhere suggests the need to intensify the provision of needle exchange facilities. Studies in Glasgow and New York show that improving the convenience and proximity of access to needle exchange facilities and increasing the numbers of needles and syringes available to injectors is likely to result in the reduction of sharing and therefore in the transmission of HCV (Hutchinson et al. 2000a; Rockwell et al. 1999). Research has also shown that injectors who had obtained sterile injecting equipment only from a legitimate source (defined as needle exchange, pharmacy, drug agency, hospital or GP) were significantly less likely to have shared than those who had obtained sterile equipment from other sources such as friends, other drug misusers, sexual partners and so forth (Hutchinson et al. 2000a). This does not imply that secondary distribution of sterile injecting equipment must be stopped, as it may be the only source of clean injecting equipment for people who do not want to access services. There is now increasing interest in the development of interventions aimed at preventing and curtailing injecting and in route transition interventions (RTIs) (Hunt et al. 1999, 1998). It has been argued that policy must focus on encouraging people away from injecting in order to control HCV and overdose death (Wodack 1997; Strang et al. 1997a). Materials are now available in the UK (Derricott et al. 2001). The development of interventions that prevent transition to injecting are also particularly needed among Bangladeshi and other South Asian heroin users, black users and users from other minority ethnic groups who exhibit much higher prevalence rates of smoking than injecting heroin Access Referral pathway(s) Needle exchange facilities are open-access services to which injectors can self refer. Drug treatment and other health and social care professionals working across all tiers are highly encouraged to refer clients to needle exchange schemes and must make available to potential service users a list of all facilities available locally Assessment Contact with services The evaluation of needle exchange facilities has pointed to the importance of adopting a comprehensive approach to service delivery for capturing and retaining clients. A flexible approach to the provision of injecting equipment, condoms and advice is required, as well as user-friendly communication strategies and options for referral into services (Hart et al. 1989) Assessment dimensions It is good practice for clients to be assessed on their first visit (Substance Misuse Advisory Service 1999). It is also good practice for health checks and health information to be provided regularly, and for a range of relevant harm reduction campaigns to be delivered periodically. Assessment is good practice, but it must not be a prerequisite for accessing sterile injecting equipment. 58

65 Assessment should cover: reasons for providing injecting equipment and risks of unsafe injecting and sexual practices the risks of unsafe disposal of injecting equipment. Request for return of used equipment risk of overdose and advice on overdose prevention access to HBV immunisation basic physical examination, including checks on injecting sites advice on safer sex/sexual health information about the range of services provided by needle exchange schemes and other services the risks of particular drugs and alcohol or drug combinations being taken. Assessment should also cover: local and systemic infections, including HIV, HBV, HCV venous and arterial thrombosis abscesses damaged blood vessels TB endocarditis. It is also good practice for a health promotion element of the intervention to consider: increased overdose risk and strategies to reduce those risks and to respond to overdose strategies to reduce the number of new initiatives into injecting increased levels of paranoia, hallucinations and violent behaviour among amphetamine injectors. It is not always possible to fully assess a service user, especially in community pharmacies. In such cases, as much information as possible on safer injecting practices should be provided to the service user, as well as written information on a range of relevant issues. The service user is also referred to agencies where appropriate services are available (for more information about perceptions of community pharmacists and clients see Clarke et al. 2001). In addition to the initial assessment, it is good practice for a service user to be assessed at regular intervals Management Treatment phases Clients are assessed on their first visits; harm reduction information is reinforced periodically. A range of needles and syringes are provided, as are safe disposal units for used needles and syringes (sharps bin). Needle exchange facilities provide harm reduction advice, including advice on the prevention of HIV, hepatitis, overdose and other drug and injecting-related problems. Advice is also given on safer injecting and safer sex. Needle exchange facilities provide written information on safer injecting and other harm reduction. Needle exchange facilities provide hepatitis B immunisation or refer clients to appropriate services. Needle exchange facilities provide basic health checks. These services may be restricted in community pharmacy schemes. 59

66 Needle exchange facilities provide or refer to HIV and hepatitis counselling and testing. Needle exchange facilities provide information about local treatment and care services and referral to these services. Needle exchange facilities ensure that there is safe syringe and needle disposal, usually by return. Needle exchange facilities collect routine information. Needle exchange facilities provide injectors with access to interventions and/or written materials aimed at preventing and curtailing injecting or with access to route transition interventions (RTIs) Care co-ordination A care co-ordinator is allocated to the service user if they are amenable and meet the criteria for care co-ordination agreed locally (see Chapter 1) Standards Core management and commissioning standards National standards on the commissioning and management of the delivery of needle exchange facilities are available and include: QuADS organisational standards for alcohol and drug treatment services, Alcohol Concern and Standing Conference on Drug Abuse (1999) Commissioning standards for drug and alcohol treatment and care, Substance Misuse Advisory Service (1999) Training and competencies Relevant competencies are outlined in Drugs and alcohol national occupational standards (DANOS), Skills for Health (2002) Protocols It is recommended that needle exchange schemes have policies and protocols. Policies and protocols must cover the following areas: individual assessment risk assessment risk assessment of provision of sterile injecting equipment for young people. Written policies and procedures are agreed with the local Area Child Protection Committee and the DAT dealing with difficult or obstructive clients blood spillage/needle stick injuries hepatitis immunisation confidentiality and information sharing referral clinical waste and disposal of used equipment HIV, hepatitis B and C, and TB maximising return of used equipment working with local environmental health agencies. Written strategies must also be in place to deal with issues such as improving access to needle exchange schemes for under-represented groups such as women or minority ethnic injectors. Written strategies can also tackle the maximisation of the return of used injecting equipment. 60

67 Performance and outcome monitoring For details on the measurement of the performance of needle exchange facilities, refer to the Performance and outcome monitoring section in Chapter 4. 61

68 2.3 Care-planned counselling Description Care-planned counselling is defined in the Drug Action Team template as formal structured counselling approaches with assessment, clearly defined treatment plans and treatment goals and regular reviews, as opposed to advice and information, drop-in support and informal key-working. Service providers should be aware of the clear distinction between information and advice-giving and structured counselling approaches with clearly defined goals (Substance Misuse Advisory Service 1999). Care-planned counselling is also different from the use of counselling skills by many health and social care professionals as part of their keyworking activity. While this type of informal counselling is an important component of an overall treatment package, it should not be seen as a substitute for care-planned counselling that may be required in particular cases. Structured care-planned counselling is a skilled activity, which must be provided by competent and accredited counsellors. Service providers will utilise counselling skills within their practice, but this should not be equated with the provision of structured care-planned counselling Context Counselling is an intervention that can be employed in all of the main treatment modalities described in this document. It is usually offered as part of a care package that may also consist of prescribing, education and training, and the management of physical and psychological health problems and social and forensic issues Philosophy and approach A number of theoretical approaches may be employed including brief interventions, cognitive-behavioural and motivational approaches. The Effectiveness Review (Task Force to Review Services for Drug Misusers 1996) identified three structured approaches to counselling: cognitive behavioural approaches 12-step addiction counselling other approaches including gestalt and family therapy Location Care-planned counselling in the context of substance misuse treatment will take place in one or more of the main treatment modalities in Tiers 3 and 4. In all these modalities, care must be taken to differentiate structured care-planned counselling from the giving of advice and guidance. While counsellors may come from different modalities, they should be able to demonstrate and use a variety of approaches within a structured programme Programme duration This is dependent on the modality of counselling employed. Programme duration can vary along a continuum, from brief interventions through motivational interviewing and cognitive-behavioural to longer-term psychotherapeutic interventions. Duration of the counselling intervention depends on the counselling model employed: for example, often six-week duration in brief interventions, mid-term for other models such as cognitive-behavioural and motivational interviewing, longer for more specific areas (e.g. sexual abuse). Duration of the programme of counselling will also depend 62

69 on the modality in which the counselling intervention takes place (e.g. residential rehabilitation, inpatient and community prescribing, structured day programme see relevant section) Staffing and competence The QuADS standards state that, The service ensures that counselling and psychotherapy services are based on written procedures and demonstrable staff competence (Alcohol Concern and Standing Conference on Drug Abuse 1999). This includes counsellors having access to regular supervision from a member of staff skilled in the intervention being used. Former service users can be effective counsellors providing appropriate safeguards are in place, including an adequate period of recovery before engaging in this type of work as well as adequate training and supervision. Services providing counselling should: employ staff who are British Association of Counselling (BAC) accredited, National Vocational Qualification (NVQ) qualified or some equivalent adhere to relevant Codes of Practice, which may include British Association of Counselling (BAC) or UK Council of Psychotherapists (UKCP) have supervision protocols which identify the purpose, regularity and process of counselling supervision employ appropriately competent and accredited counselling supervisors (BAC or other equivalent) have established, clear links with other specialist counselling services for referral and joint provision have clear outcome and output measures for counselling services monitor and report on outcome measures use outcome and other performance monitoring measures to inform strategic/business planning/service delivery and policies and practices of the service. Staff need skills across a range of counselling modalities, for example, motivational interviewing, brief interventions, cognitive-behavioural, gestalt, person-centred and humanistic. Service users may wish to have access to a counsellor who reflects their ethnicity, gender or sexuality Aims and objectives Counselling is defined by the British Association of Counselling as providing an opportunity for the service user to work towards living in a way he or she experiences as more satisfying and resourceful. This activity takes place within a deliberately undertaken contract with clearly agreed boundaries and commitment to privacy and confidentiality. It requires explicit and informed agreement (British Association of Counselling 1998). CAMPAG, the body charged with developing standards for advice, guidance, counselling and psychotherapy, describes counselling as the principled use of a relationship to provide someone with the opportunity to work towards living in a more satisfying and resourceful way Service user groups A number of studies suggest that service user characteristics are not the most important determinant in predicting positive outcomes from counselling. Characteristics of counsellors themselves have a more positive impact upon outcomes (Fiorentine et al. 1999; Fiorentine and Hillhouse 1999). 63

70 Type of drug used Service users with problematic drug use over a range of substances can make effective use of care-planned counselling. For opiate or benzodiazepine dependent drug misusers, counselling may take place in conjunction with substitute prescribing. For other service users, particularly stimulant users, counselling may be part of a limited range of treatment options and is therefore an important determining factor in achieving positive outcomes Research evidence base Summary The Task Force Review of international literature found only six articles on the use of counselling in the drugs field (Task Force to Review Services for Drug Misusers 1996). The main points drawn from this review are that: counsellor characteristics are an important factor the provision of counselling with methadone prescribing improves outcomes in relation to drug use, depressive symptoms and criminal activity styles of counselling vary, with less structured approaches generally used in the UK Key findings Studies have shown a positive correlation between access to counselling and improved outcomes for methadone prescribing. Where this positive correlation exists, it is primarily due to the quality of the counselling offered and access to other services such as housing, employment and training opportunities (Kraft et al. 1997). A study conducted with a cohort of predominantly stimulant-using service users found that perceptions of the receptiveness of a counselling service were closely linked to a service user s engagement with that service (Fiorentine and Hillhouse 1999). Similarly, in another study, perceptions of the degree of empathy felt between the service user and counsellor were also related to engagement (Fiorentine and Hillhouse 1999). Quality drug counselling was found to be as effective as professionally delivered psychotherapy in a study conducted with a cohort of cocaine dependent service users. However, the counselling offered was delivered in a structured format by professionally qualified and competent counsellors (Critschristoph et al. 1999). The relationship between frequency of counselling and better treatment outcomes was examined in a 1996 US study. The study found that more frequent counselling was associated with lower levels of relapse. This association did not hold true for all types of counselling intervention, but was associated with individual and group counselling. Participating in self-help (12-step meetings) in the post-treatment phase also lowered the relapse rates (Fiorentine and Anglin 1996). Conversely, a study conducted with cocaine-dependent service users found that the critical factor in achieving successful outcomes was not the counselling interventions, but the duration of, and retention in, the treatment process as a whole. The cohort studied took part in either long-term residential programmes, short-term inpatient programmes or outpatient drug-free programmes (three modalities included in the US Drug Abuse Treatment Outcome Study DATOS). Outcomes across three domains were examined: cocaine use, heavy alcohol use and illegal activity. A range of counselling interventions were used, including individual and group counselling, selfhelp groups and combinations of all three. Post-treatment participation in self-help 64

71 was also found to reduce the likelihood of relapse of cocaine use (Etheridge et al. 1999). An Australian randomised-controlled trial examined the use of cognitive-behavioural therapies (CBT) with cannabis users. A cohort of 229 participants was randomly allocated to one of two interventions, either a programme of six CBT sessions or a single CBT intervention. A control group had treatment delayed. The groups receiving either one or six CBT sessions had better treatment outcomes than those who had received no treatment at all. They were more likely to report abstinence during the follow-up period, were significantly less concerned about their control over cannabis use and were more likely to have significantly fewer cannabis-related problems than those in the delayed treatment group. Further, those receiving six sessions of treatment significantly reduced their level of cannabis consumption. These outcomes were unaffected by the therapist delivering the intervention, but were affected by treatment compliance (Copeland et al. 2001). Two Australian studies have examined the use of brief interventions with cannabisdependent users. In the first study, a cohort of cannabis users was exposed to a oneto-one assessment interview and provided with a range of self-help materials. Those who were available for follow-up at one and three months (approximately 50%) reported marked reductions in frequency of use and/or quantity of cannabis used. This, in turn, resulted in improved health and social functioning (Lang et al. 2000). The evidence for motivational interviewing is drawn mainly from research investigating use of the technique for smoking cessation and alcohol dependency. There is a relatively limited evidence base for use with drug misusers. However, there are some published studies supportive of the use of motivational interviewing when prescribing methadone or benzodiazepines (Saunders et al. 1995). There is also some evidence demonstrating the effectiveness of cognitivebehavioural therapy. Project Match, the largest-ever alcohol treatment trial, tested three therapeutic modalities with 1,726 problem drinkers. These service users were randomly assigned to one of three therapies in two types of setting outpatient and aftercare. Those dependent on drugs were excluded from the trial, as were service users who were under 18, psychotic, homeless, violent or currently under criminal justice supervision. However, despite these exclusions, nearly half the outpatient sample were using illicit drugs, had a prior psychiatric diagnosis and were unemployed (Findings 1999). Project Match found little demonstrable difference between the three counselling modalities researched, which were cognitive-behavioural therapy, motivational enhancement therapy (adapted from motivational interviewing) and 12-step facilitation. Motivational enhancement therapy was also found to have increased efficacy with angry service users and was most successful when used with those service users who demonstrated high self-efficacy. One of the primary findings from Project Match was that the factors that did demonstrate some contribution to improved outcomes were counsellor characteristics. This was partly due to the counsellor s personal characteristics, such as being warm and empathetic, and being able to demonstrate their commitment to the therapy and to the service user. The quality of staff, their training and management is also highlighted in Project Match. The therapists used were well trained in the therapeutic modalities, were regularly assessed for competence through videotaped service-user sessions, and were provided with weekly supervision by experienced and qualified staff. Therapeutic interventions were delivered in accordance with manuals developed for the Project Match study. Other studies have been conducted examining the use of manuals in delivering counselling 65

72 interventions. These studies concluded that key factors to ensuring successful outcomes by using manuals were, as in Project Match, staff training and supervision (Godley et al. 2001). A recent review summarises the evidence on the effectiveness of relapse prevention in addiction in a meta-analytic review (Irvin et al. 1999) Access Services offering counselling interventions should provide information on: modalities of counselling offered waiting times place of counselling within the treatment programme offered characteristics of counsellors (e.g. gender, ethnicity, sexuality) Referral pathway(s) Referral pathway(s) mirror those for the modality within which the counselling service is provided (e.g. inpatient and community-based prescribing, residential rehabilitation, structured day programmes). Open-access, low-threshold services can also provide care-planned counselling. This can take place in conjunction with treatment provided by other organisations (e.g. prescribing services) Assessment Contact and referral Services offering care-planned counselling as part of their modality should have clear protocols for referral, whether self-referral in the case of low-threshold services, or referral from outside agencies. Within modalities, counselling interventions are planned as part of an overall package of care Assessment dimensions Services offering care-planned counselling should have clear assessment procedures, which must be completed prior to the commencement of the intervention. For more details see Chapter Management Treatment phases consist of: service specification for counselling services, including how services will be provided and how they will target service users assessment based upon a clear procedure allocation to counsellor based upon criteria including: gender, ethnicity, sexuality, presenting problem, preferred/indicated modality of counselling goals for achievement agreed and set with the service user counselling/therapy reviewed as part of the care plan review process procedures for case/closure/transfer are adhered to service user satisfaction is audited upon completion of counselling Care planning and review Counselling intervention should be planned as part of the overall package of care. The care plan should be devised in partnership with the service user. Service users should be clearly informed about all timescales relating to the counselling component 66

73 of the care plan (e.g. number of sessions, timing of sessions, timing of review of progress, etc). Goals for the counselling aspect of the care plan should be agreed and reviewed with the service user. These goals should relate to dimensions of behaviour change related to the user s substance misuse Departure planning Service users may end the care-planned aspect of counselling without departing from the modality/service providing that counselling, or without terminating other aspects of their care plan; that is, they may continue to receive other forms of treatment or models of counselling. For example, service users may progress through and complete a programme of brief interventions therapy as part of a plan of care in a prescribing service. This may result in no immediate further need for structured counselling, or may result in referral and assessment for longer-term counselling. In both instances clarity is needed around the rationale for either contingency. Service user satisfaction should be monitored upon departure Aftercare/continued support Access to more specialised counselling services may be required following initial assessment or review of service user needs. Such services may include bereavement therapy or counselling/therapy related to physical and/or sexual abuse. The substance misuse service must have clear protocols for referral and/or shared care with these services. Onward referral can also be considered to other modalities of care, such as substitute prescribing, residential rehabilitation or structured day programmes Standards Core management and commissioning standards National standards on the commissioning and management of care-planned counselling are available and include: QuADS organisational standards for alcohol and drug treatment services, Alcohol Concern and Standing Conference on Drug Abuse (1999) Commissioning standards for drug and alcohol treatment and care, Substance Misuse Advisory Service (1999) Training and competencies Relevant competencies are outlined in Drugs and alcohol national occupational standards (DANOS), Skills for Health (2002) Performance and outcome monitoring For detailed information about performance and outcome monitoring, see Performance and outcome monitoring in Chapter 4. 67

74 2.4 Structured day programmes Definitions Structured day programmes (SDPs) provide intensive community-based support, treatment and rehabilitation. They should offer clear programmes of defined activities for a fixed period of time with specified attendance criteria usually four to five days a week. The five main types of SDPs were identified in 1996 as: those for drug-using offenders those for stimulant users those for former residents of residential services (as aftercare) services with an educational or vocational focus services based on a 12-step programme (Standing Conference on Drug Abuse 1996). Since this time, this type of service provision has expanded and many SDPs offer a combination of the above types of categories. It may be useful locally to distinguish SDPs from other forms of less intensive day care provided in a locality which may have less intensive requirements to attend or expectations on service users Context SDPs tend to be funded from a number of sources and in ways which encompass block and spot funding. These sources can include: direct commissioning from health authorities, probation services or joint commissioning bodies community care funding on an individual client basis funding from probation services Programme duration SDPs are based on models used widely in other fields of service provision. Programmes normally meet the following criteria. Clients are expected to attend four to five days a week, during office or collegelike hours. A structured approach is provided either a compulsory rolling programme of fixed activities, or individually negotiated timetables for each drug user. The programme has a finite length. SDPs may operate a holding group or introductory phase for clients awaiting admission to the programme. Provision is generally based on standard programmes of between 10 and 16 weeks or individually tailored programmes or a combination of both (Standing Conference on Drug Abuse 1996) Staffing Those who staff SDPs should: be drawn from a wide range of professional backgrounds, including nursing, social work, probation hold relevant counselling qualifications when providing either individual or group counselling sessions (see care-planned counselling) hold relevant qualifications (e.g. NVQ assessor, training or education qualifications) where vocational or educational training activities are provided hold appropriate management competencies if fulfilling a management role be trained (and preferably qualified) in working with the service user group have relevant professional skills and qualifications if working on a sessional basis. 68

75 SDPs should also: respond flexibly to opportunities for ex-drug users to be employed as staff or volunteers and, if they are so employed, supervision and training for them should be provided regularly have training strategies and policies for staff and volunteers which include provision for regular assessments of training needs and regular reviews and updates of personal development plans (Standing Conference on Drug Abuse 1996) Aims and objectives Structured day programmes (SDPs) may have different aims, but most include work in the following areas: help to improve social functioning and community rehabilitation life skills and vocational or educational goals taking a holistic approach to rehabilitation personal independence and responsibility enabling drug users to maintain family and social support networks (where they exist) while in treatment movement through outcome domains, including aspects of drug use, physical and psychological health and social functioning and life context. The aims and objectives of SDPs are achieved through programmes that can include: counselling, groupwork and support advice and information about safer drug use and safer sex complementary therapies (e.g. acupuncture) links with primary healthcare and prescribing services education for example, joint work with local colleges, literacy development and access to non-vocational learning (on and off site) training for example, links with local Learning Skills Councils, National Vocational Qualification (NVQ) assessment centres, social skills training employment for example, support from careers advisory services, work placement schemes housing support (from housing associations and local authorities) (Standing Conference on Drug Abuse 1997a) Client groups served Clients can participate before or after (and sometimes during) other forms of drug specialist care, including detoxification or substitute prescribing and residential rehabilitation. Some may attend as part of a sentencing order such as a Drug Treatment and Testing Order, and can be referred to a programme that explicitly addresses both drug use and offending behaviour. The primary client groups served are: offenders stimulant users former residents of residential rehabilitation services those needing educational and/or vocational rehabilitation and support those who wish to remain in their own community while addressing either detoxification or relapse issues. In addition, a number of SDPs operate the following eligibility criteria. Service users must be able to demonstrate stable housing arrangements. Service users must be funded (e.g. probation for probation orders and Drug Treatment and Testing Orders, social services for community care funding). 69

76 The following groups may be prioritised for entry into SDPs: black and Asian drug users in certain communities this may include targeted services women, with consideration given to the provision of, or access to, childcare facilities such as crèches, etc offenders those on probation orders, including Drug Treatment and Testing Orders. Generally, SDPs have been models of drug treatment provision in urban or semiurban areas with good transport links and with higher concentrations of drug and alcohol misusers. SDPs may not be suitable for clients who live in remote areas, rural areas or areas with poor transport facilities. Issues concerning accessibility including transport (including payment of fares) and arrangements for dependants (e.g. children of service users), should be considered when planning and delivering SDPs. In accordance with the general rules operated by many drug services, SDPs may exclude potential service users convicted of: arson certain types of violence certain sexual offences. Services may also impose further exclusion criteria including: service users with mental health problems homeless service users. Depending on the focus of the programme, services may exclude those who are current drug users or those who are abstinent Research evidence base Summary To date, SDPs in the UK have not been systematically evaluated. Some research indicates an expressed preference among substance misusers for the type of intervention provided by SDPs. For example, an assessment of the needs of stimulant users was undertaken by Project Star. Seventy-six stimulant users were interviewed and asked to identify the range of services they would find beneficial; 50 respondents identified SDPs. Access to employment and training and to education opportunities (an integral part of many SDPs) were identified, by 51 and 50 respondents respectively, as potentially beneficial services (APA 1997). More research is needed on the effectiveness and cost effectiveness of this modality of treatment in the UK Access Accessibility Consideration must be given to issues of accessibility when purchasing structured day programmes (SDPs), as with other types of service provision. Where attendance at treatment is a requirement, care must be taken that factors outside the control of the substance user do not contribute to lack of engagement with the treatment programme. These could include problems of accessibility due to: geographical isolation and lack of transport infrastructure childcare issues physical disability 70

77 participation in current education or employment that might contribute towards rehabilitation, but which clashes with a treatment programme. Such issues exist for either whole populations of substance users (geographical factors) or individuals (physical disability). Issues for populations should be addressed at the commissioning level, where commissioners should consider the best configuration of services for their local populations, while also considering factors regarding the accessibility of the service for their locality and their populations Referral pathway(s) SDPs are Tier 3 services. Referral is usually initiated by other services such as prescribing, residential care or probation (see below). Referral should arise as a result of the care planning process, and should be planned on the basis of reviewing levels of need and planning throughcare or aftercare needs with the service user. SDPs should provide clear information about their programme, including: service user eligibility prioritised service user groups programme duration programme content. This information should be made available to service users and all referring organisations. Clear information should also be made to referring organisations clarifying: referral pathways timescales for referral protocols for information-sharing during and following the referral process. Where the SDP accepts drug misusers on probation orders, there should be clear protocols and agreements between the SDP and probation to clarify the working arrangements between the two organisations, particularly where the probation service is acting as both commissioner and joint provider of DTTOs. Such protocols should include, for example: service specification contract monitoring and review waiting times for assessment and access into treatment programme integration of sentence and care plans protocols on roles and responsibilities of staff protocols on sharing of service user information. 71

78 Assessment Contact and referral Contact is made by the appropriate referring organisation (see above). Referral protocols should be established between organisations within and across localities Assessment dimension Information on the principles and levels of assessment is described in detail in Chapter 1. Three levels of assessment are described: Level 1: Screening and referral assessment Level 2: Substance misuse triage assessment Level 3: Comprehensive substance misuse assessment. SDP staff should be competent to assess at Levels 1 and 2. Chapter 1 also outlines the primary assessment domains to be used at these levels Management Treatment phases: clear referral pathways assessment within defined period following referral immediate entry to treatment following probation order (e.g. DTTO) care planning in partnership with service user clear timetable for service user s programme focused short-term counselling group work setting of clear goals agreed by service user and care worker addressing of issues such as: - offending behaviour - training/vocational needs - social needs relapse prevention care plan reviews established throughcare systems established aftercare systems Care planning and review The processes of Care Co-ordination, planning and review are described in detail in Chapter 1. These processes should be supported by written and shared protocols. Service users must be involved in care planning and review processes throughout any episode of care Departure planning Departure will occur when the service user: has successfully completed the programme, as evidenced by achievement of outcomes set out in the care plan (and the sentencing plan, if DTTO) breaches attendance requirements of the programme self-discharges or does not attend programme moves into another treatment format (e.g. residential rehabilitation) Aftercare and continued support Aftercare support can be provided through a number of sources including: probation services, if involved in DTTOs 72

79 court, if involved in DTTOs primary care practitioners education and training organisations employment services social services housing complementary therapists welfare benefit advice counselling residential rehabilitation services sexual health other community-based service/s prison-based services self-help groups primary care Standards Relevant standards for the provision of structured day programmes are contained in: QuADS: organisational standards for alcohol and drug treatment services (Alcohol Concern and Standing Conference on Drug Abuse 1999) Structured day programmes: new options in community care for drug users (Standing Conference on Drug Abuse 1996). Standards for the commissioning of drug services are contained in: Commissioning standards for drug and alcohol treatment and care (Substance Misuse Advisory Service 1999) Performance and outcome monitoring Detailed information about monitoring and suggested performance indicators for structured day programmes can be found in Outcome and performance monitoring, Chapter 4. 73

80 2.5 Community prescribing Description Community prescribing programmes are Tier 3 services. They involve the provision of a medically supervised substitute to an illicit drug misuser. The substitute maintains the individual s tolerance to the drug of misuse. The prescribing programme is the basis for providing medical and psychosocial counselling and support. A wide range of harm-reduction and abstinence-oriented interventions are available and acceptable from NHS and other services (Rosenberg et al. 2001). Most prescribing in the UK is for opiate dependence, although the use of multiple substance (polydrug use) is the norm (Marsden and Strang et al. 2000). The most common pharmacotherapy in the UK concerns substituting an opioid substitute (usually oral methadone, and increasingly buprenorphine) for illicit heroin, at a level that will prevent the onset of withdrawal symptoms. Pharmacotherapy for dependent users of amphetamines is also available, albeit less common. There is currently no pharmacotherapy aimed at cocaine and crack-cocaine dependence Context In UK policy, it is recommended that community prescribing takes place within a context in which the co-existing physical, emotional, social and legal problems are addressed as far as possible. Prescribing must also be complemented by counselling or structured psychotherapy. Other services sometimes referred to as ancillary or wrap around are also provided, and include welfare advice, help with housing, employment, vocational agencies and so forth (Task Force to Review Services for Drug Misusers 1996). Prescribing, or pharmacotherapy, is therefore an enhancement of psychological therapy, rather than an intervention on its own. The treatment of opiate misusers not using pharmacotherapy can also be effective, especially but not exclusively for young people. Detailed guidance on prescribing has been developed by the Department of Health and is contained in Drug misuse and dependence: guidelines on clinical management (Department of Health et al. 1999). This chapter is in line with that guidance Philosophy and approach Community prescribing may comprise: stabilisation on substitution opioids (e.g. methadone) withdrawal from substitution opioids (e.g. methadone) withdrawal from opioids with non-opioid medications (e.g. lofexidine) maintenance on substitution opioids (e.g. methadone) stabilisation and withdrawal from sedatives (benzodiazepines and alcohol) relapse prevention prescribing (e.g. naltrexone, disulfiram) prescribing for stimulant users, including symptomatic prescribing maintenance prescription of substitution medication for opioids. Withdrawal from all classes of drugs may be achieved with no prescribing intervention. Symptomatic interventions, which do not involve the use of substitute drugs, may be an effective treatment in some cases. Withdrawal may also be achieved with substitution prescribing, for example, for benzodiazepines, alcohol and opiates. Reduction programmes are abstinence-oriented programmes in which an individual is given, in reducing doses, related drugs that provide effective chemical substitution to give relief from withdrawal. 74

81 For opiates, reduction programmes vary in duration from a few weeks to a few months until detoxification is achieved. However, not all drug misusers are able or willing to reduce or stop their drug taking. Longer-term, or maintenance, prescribing is therefore carried out and stable doses of methadone are thus prescribed to opiate misusers. It is part of a wider process of helping the drug misuser reduce the various forms of drug-related harm, including social, housing, legal and financial problems, until they are ready, able and willing to withdraw from the substitute (Department of Health et al. 1999). There are different models of longer-term or maintenance prescribing for opiate misusers, ranging from highly structured regimens to lowthreshold programmes. In reality, however, the distinction between rapid or gradual withdrawal and maintenance programmes is not always clear-cut. Follow-up data from the National Treatment Outcome Research Study (NTORS) show that, whereas most service users receiving methadone maintenance received maintenance, only about a third of those allocated to reduction programmes received methadone reduction and many actually received a form of methadone maintenance. NTORS follow-up data show that service users on reduction programmes were more likely to receive low doses of methadone and were less likely to remain in treatment. Among users on maintenance programmes, higher doses and retention in treatment were associated with reduction in heroin use. Among service users on reduction programmes, the more rapidly the methadone was reduced, the worse the outcome in heroin use. Reduction in heroin use among service users in both types of programmes was associated with improvements in other outcome areas. The more severely dependent service users showed better outcomes in maintenance programmes. Methadone reduction programmes were associated with poor outcomes, and many of those in reduction programmes did not receive reduction treatment as intended. NTORs researchers believe that this calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between the two types of programmes and treatment goals should be made more explicit to service users and treatment staff. It is also suggested that a reappraisal of the goals and procedures of methadone reduction treatment is required (Gossop et al. 2001b) It also shows the importance of adequate dosage. There may be a limited role for prescribing substitution amphetamines (Department of Health et al. 1999), although there is little evidence of its efficacy. Symptomatic prescribing may be of use, such as antidepressants for depressive episodes and anti-psychotic medication for psychotic symptoms (Ghodse 1995a) Location Community prescribing is carried out in specialist multidisciplinary teams or by general practitioners in shared care with specialist services. Specialist agencies are usually multidisciplinary and are resourced to offer specialist treatment and referral. There is now a diversity of team structures and labels used to name services that offer community prescribing, including community drug or substance misuse teams and drug dependency units. In this chapter we use the term substance misuse team (SMT) as a generic label to denote these multidisciplinary teams. Recent Department of Health guidelines (Department of Health et al. 1999) have stressed the importance of a shared care approach between primary and secondary care in the management of drug misusers. GPs are encouraged to provide specialist treatment programmes, which may involve them prescribing substitutes. They are also encouraged not to prescribe in isolation but to liaise with other professionals who will help with factors contributing to drug misuse. A multidisciplinary approach to treatment is therefore essential. 75

82 Programme duration Prescribing may be one part of a treatment programme, and such programmes may be of varying length. Detoxification programmes for benzodiazepines (Ghodse 1995a) and opiates (Task Force to Review Services for Drug Misusers 1996) are generally in the order of weeks to months. This document does not support a finite duration for maintenance prescribing. On the contrary, the bulk of evidence shows that length of time spent in methadone maintenance is a good predictor of outcome; the longer the time spent in methadone maintenance, the better the result in terms of reduction of illicit use and psychological adjustment. There is evidence that the duration of treatment is one of the most influential determinant factors in outcome of methadone maintenance; with adequate daily dose levels, longer retention is associated with better outcomes (Strain et al. 1993a, 1993b; Ball and Ross 1991). Similarly, studies show that retention in treatment is an important goal and is the result of successful methadone maintenance, and that premature termination of methadone maintenance is associated with a return to drug use (Gearing and Schiwitzer 1974; Ball 1991; Rosenbaum et al. 1988). Although low-threshold methadone programmes are not new, there is in the UK increasing interest in such programmes. Low-threshold methadone programmes can vary quite significantly. At an international level, some programmes have been criticised because the criteria for entry are applied simply as a replacement for the more rigorous criteria of maintenance programmes. Others have more structured criteria (Perreault and Mercier 2001). The importance of better documenting and describing the ones that exist has been advocated (Perreault and Mercier 2001). Some programmes have been documented (Finch et al. 1995) and some evidence is available on the effectiveness and outcomes of some programmes. For example, a Dutch study suggests that low-threshold programmes reduce overdose mortality, with higher dosage being most protective (Vanameijden et al. 1999). A German study found that low-threshold programmes reached clients who are more advanced in their drug-taking career and less influenced by social pressure to enter treatment (Hoffman et al. 1997) Staffing and Competencies Specialist drug or substance misuse treatment services. Specialist prescribing services are those that deal exclusively with drug users and in some cases, problem drinkers as well. Their target population should be drug misusers whose problem level is mostly moderate to severe. They are staffed by people with special knowledge and expertise in the field of substance misuse and in the field of dependence or addictive behaviour in general. Staff have received some specialist training in the treatment of substance misuse problems. A specialist service has a multidisciplinary team that can include psychiatrists, clinical psychologists, counselling psychologists, general and psychiatric nurses, social workers, drug workers and counsellors with no particular professional affiliation. Other professionals, such as occupational therapists, can also be involved (Raistrick and Heather 1998). Prescribing can only be carried out by a doctor. GP-led prescribing and shared care. General practitioners and primary care play a pivotal role in the treatment of substance misusers. The target population of most GPs should be drug misusers whose severity of problem at contact is mild to moderate, although some GPs can target drug misusers with severe and complex needs. All doctors in the UK are able to prescribe substitutes. 76

83 Department of Health guidelines (Department of Health et al. 1999) emphasise that the range and complexity of the treatment and rehabilitation of problem drug users requires a continuum of medical practice, skills and experience, ranging from the contributions that can be made by all doctors to that made by specialist practitioners. Three levels of expertise have been identified: Level One Generalist: These are medical practitioners who are involved in the treatment of drug misuse, although this is not their main area of work. They should be able to demonstrate relevant competence, usually on a shared care basis. All services provided are normally carried out with support from a shared care scheme with a specialist service, or following advice from more experienced medical practitioners (specialised generalists or specialists). Services provided must include the assessment of drug misuse and the prescribing of substitute medicine, where appropriate. Generalists include general practitioners, physicians, surgeons and obstetricians. Level Two Specialised generalist (now referred to as GPs with Special Clinical Interest): These are medical practitioners whose work is essentially generic, or if they are specialists, their work is not primarily concerned with drug misuse. Specialised generalists have a special interest in the treatment of drug users. They must have the expertise and competence to assess most complex cases. Services provided include the prescription of specialised drug regimens. They can also act as an expert resource in shared care arrangements with medical practitioners at Level One. They should undergo appropriate training to maintain this level of competence. Examples of generalised specialists are general practitioners and prison medical officers. The Royal College of General Practitioners provides a training programme which includes a certificate course in drug misuse (accredited qualification). Other support mechanisms may include Action Learning Sets at local levels (multidisciplinary). Level Three Specialist: These are medical practitioners who provide expertise, training and competence in drug misuse treatment as their main clinical activity. They work in multidisciplinary teams, can carry out an assessment of any case of complex needs and provide a full range of treatments. Services they offer include the prescribing of injectables and other specialised forms of prescribing which involve a Home Office licence. Most, but not all, specialists are consultant psychiatrists who hold a Certificate of Completion of Specialist Training (CCST) in psychiatry. Specialists can also be general practitioners, public health or other physicians, or nurse consultants with the appropriate expertise and training. Specialists are required to maintain their level of expertise by attending appropriate training events (Department of Health et al. 1999) Aims and objectives Aims of treatment The aims of withdrawal prescribing are to: minimise withdrawal symptoms achieve a safe detoxification programme, minimising risks of adverse events, for example seizures (alcohol and benzodiazepine withdrawal) engage users in treatment programmes and ongoing psychosocial therapies. The overall aims of substitute prescribing, as described by Department of Health guidelines (Department of Health et al. 1999), are to: assist the service user to remain healthy, until, with appropriate support, they can achieve a drug-free life stabilise the service user, where appropriate, on substitute medication to alleviate withdrawal 77

84 reduce the use of illicit or non-prescribed drugs deal with problems related to drug misuse reduce the dangers associated with drug misuse, particularly the risks of HIV, hepatitis B and C, and other blood-borne infections reduce the duration of episodes of drug misuse reduce the need for criminal activity to finance drugs reduce the risk of prescribed drugs being diverted on to the illegal drug market; improve the service user s overall personal, social and family functioning (Department of Health et al. 1999) Client groups Service users are individuals who have drug-related problems and meet ICD- 10/DSM-IV dependence criteria. The majority of clients entering prescribing programmes are dependent opioid users who present with additional polydrug use. Concurrent use of benzodiazepines and psycho-stimulants is common. While prescribing programmes are geared to the withdrawal needs of opioid users, they are able to supervise the withdrawal of primary users of other drugs and provide adjunctive prescribing for biomedical complication and conditions (psychological and behavioural). It is widely acknowledged that drug misuse treatment in the UK is opiate-focused and it is often argued that the needs of stimulant and other drug misusers are marginalised Eligibility Dependent drug users or others assessed as requiring symptomatic treatment for drug-related problems are eligible Priority groups Priority groups for prescribing interventions include: those who are HIV symptomatic or who present with other severe physical comorbidity those with mental health co-morbidity pregnant women. In some cases, partners should also be considered a priority, for example, where a couple require treatment and the prescribing for only one of them may compromise treatment young people, especially those identified as vulnerable other locally defined groups, such as where there are child protection implications Exclusion A comprehensive assessment is mandatory prior to any prescribing intervention (see Chapter 1). Research evidence strongly suggests that substance misuse treatment professionals must be alert to the risks of polydrug use, including the combined use of alcohol with illicit drugs. (Gossop et al. 2002). All doctors should be prescribing within their own level of competency, as defined by the clinical guidelines (Department of Health et al. 1999). There are cases where community prescribing may be less appropriate than other options. For example, chaotic pregnant misusers may benefit from inpatient assessment, stabilisation and detoxification where appropriate. Similarly, chaotic homeless misusers may benefit from inpatient assessment and stabilisation. 78

85 Research evidence base Treatment environment and holistic treatment and care Drug misuse is associated with a wide range of personal, social, economic and potential health problems. Individuals may require several different types of support over time (i.e. a continuum of care with, for example, housing support, legal advice, access to vocational agencies, etc), and these are important elements in an effective package of care. There is evidence of the importance of providing support services, especially in first three months of treatment. However, the intensity or comprehensiveness of services, per se, is not consistently associated with improved outcomes services (Simpson et al. 1995). A US study (Ball and Ross 1991) found that the most successful maintenance programmes had the following characteristics. They: did not enforce detoxification after a period of maintenance provided better counselling and medical services achieved a good level of clinic attendance by clients/patients maintained a close long-term relationship with patients had low rates of staff turnover. Research also shows that therapeutic involvement (measured by rapport between a client and a programme counsellor, and the service user s rating of the extent to which they are committed to treatment and believe it to be effective) and counselling session attributes (as measured by the number of sessions attended, the number of health and other topics discussed) have direct positive effects on retention in, among others, outpatient methadone treatment (Joe et al. 1999; Fiorentine and Anglin 1996). There is evidence that it is important to assess the extent to which clients are ready and motivated to make changes in substance-use behaviours. US-based research has shown that treatment readiness is related to early therapeutic engagement and retention for outpatient methadone treatment, among other factors. Treatment readiness was not only a significant predictor of engagement and retention, but was more important than socio-demographic, drug use and other background variables (Simpson et al. 1997). Research on predictors of treatment retention in methadone treatment programmes has also shown that care management was one of the factors associated with a higher probability of retention, particularly in the first 90 days. Other factors include group participation, psychiatric services, contingency-based reinforcers and transportation assistance (Grella et al. 1997). There is evidence of the effectiveness of psychological treatment for people on methadone treatment. In particular, those who suffer from depression can benefit from cognitive therapy and interpersonal therapy. Some of the most needy people (e.g. suicide borderline) can benefit from dialectical behavioural therapy Effectiveness by treatment setting NTORS follow-up data show that overall, significant improvements in drug-related problems, health and social functioning were made among the clients of GPs and primary care services as well as those in specialist services (Gossop et al. 1999a). Other research showed that a positive treatment outcome was equally likely in either setting (Hutchinson et al. 2000b; Lewis and Bellis 2001). Effective specialist services as well as high-quality primary care have retained service users engaged in treatment. 79

86 Prescribing for opiate dependence There is well-established research in the UK and internationally into substitution, especially with oral methadone. A meta-analysis has shown the effectiveness of methadone maintenance, across a variety of contexts, cultural and ethnic groups and study designs (Marsch 1998). For example, methadone maintenance is associated with lower levels of heroin use, reduced levels of crime, improved social functioning and a lower risk of premature mortality. Substitution programmes have also contributed to the prevention and spread of HIV. In the UK, results from NTORS show that, on average, methadone substitution programmes are positive across a broad range of substance use, injecting and sharing behaviours, health and crime (Gossop et al. 1998a). Improvements in drug taking and other problem behaviours were substantially maintained at one- and two-year follow-ups. Data show substantial reduction in rates of criminal behaviour and also show improvements in psychological and physical health. There were substantial reductions in illicit drug use, injecting and sharing injecting equipment. Abstinence from heroin was more than twice that at intake and the number of regular heroin users was considerably reduced. Similar improvements were also noted in the use of stimulants and benzodiazepines (Gossop et al. 2000a, 2000b; Stewart et al. 2000). There is evidence of greater benefit in maintaining individuals on daily methadone doses of between 60mg and 120mg. Larger doses may be required in some instances. There is evidence that under-dosing and poor initial assessment often undermine the success of English methadone programmes (Findings 2001). Research has also shown that higher doses of methadone are associated with a greater likelihood of cessation of injecting (Capelhorn et al. 1993; Lagendam et al. 2000). Most prescribing in the UK is for oral methadone, although a national survey carried out in 1995 showed that 10% of all methadone prescriptions were issued for injectable (Strang et al. 1996b; Strang and Sheridan 1998). No outcome study has been carried out in the UK on injectable methadone prescribing. However, an observational study has been carried out (Metrebian et al. 1998) and there are encouraging reports from clinical audit of this practice (Ford and Ryrie 1999). Injectable methadone maintenance can be suitable for more severely affected heroin addicts (Strang et al. 2000), and most particularly those who have failed to achieve change through oral formulations. There are no simple universal criteria for prescribing injectables; rather, such prescribing requires a complex clinical decision based on the suitability of the individual. Whatever criteria for injectable prescribing are identified at local levels, it is necessary that this is managed by specialists, who may need additional training. Diamorphine is only rarely prescribed in the UK (a licence from the Home Office is needed) as a maintenance regime for a minority of people who have not been stabilised through methadone. It is estimated that 300 to 500 people currently receive a prescription of diamorphine (Sell et al. 1997; Gabbay et al. 2001). The Department of Health and the National Treatment Agency for Substance Misuse (NTA) are currently hosting an expert advisory group on heroin prescribing. The NTA guidance on heroin and other injectable opioid prescribing based on the recommendations of this group, concludes that injectable heroin and injectable methadone maintenance prescribing, in principle, is an appropriate drug treatment for a minority of entrenched injecting heroin misusers who do not respond to optimised oral drug treatment. Injectable heroin (and methadone) maintenance should therefore be part of the range of potentially available drug treatment options in each area, provided it is part of a comprehensive drug treatment system and is in line with eight key principles outlined in the guidance document (NTA 2003). An implementation strategy will be required to achieve this. 80

87 A variety of other substitutes are also used for the treatment of opiate dependence in the community. They include codeine-based substitutes, especially dihydrocodeine, currently not licensed for withdrawal but used by some clinicians and described (Department of Health et al. 1999; Macleaod et al. 1998). Buprenorphine has recently been licensed for substitution, and there is increasing evidence of its effectiveness and relative safety as a partial agonist in comparison with full agonists such as methadone, especially in relation to overdose and drugrelated death (Ling et al. 1998; Barnett et al. 2001; Petitjean et al. 2001; Auriacombe 2001, Eder et al. 1998; Strain et al. 1996). Guidance on the instalment prescribing of buprenorphine was issued by the Department of Health in March 2001 (Department of Health 2001c). Lofexidine is prescribed for community detoxification programmes. It has been suggested that lofexidine is most suitable for patients using up to 50mg methadone or one gram of heroin daily, for those with shorter drug histories, and for nonpolydrug users (Department of Health et al. 1999; also see Gowing et al. 2002). Maintenance treatment with the opiate antagonist naltrexone is available to those who have completed opiate withdrawal and require pharmaceutical assistance to maintain a drug-free state (see also Inpatient substance misuse treatment ) Benzodiazepine prescribing The use of benzodiazepine is common among opiate users (see Inpatient substance misuse treatment ), but benzodiazepine prescribing is recommended only for withdrawal. Guidelines state that longer-term use of benzodiazepines requires adherence to the general principles of management of controlled substances (Department of Health et al. 1999). There is no evidence that the long-term prescribing of benzodiazepine reduces the harm associated with dependence on that drug. In fact, there is increasing evidence that the long-term prescribing of more than 30mg daily causes harm (Department of Health et al. 1999) Prescribing for primary stimulant users (cocaine, crack-cocaine and amphetamine) There is concern over the use of cocaine, crack-cocaine and illegally manufactured amphetamine sulphate in the UK. There is still, however, little accurate information available about the misuse of stimulants in the UK, and especially about the nature of services required or the effectiveness of those provided. The prevalence of cocaine misuse appears to have increased greatly in the last decade, with official notifications of cocaine dependence having more than doubled between 1990 and 1995 (Marsden et al. 1998). It is estimated that the national prevalence of cocaine use is greater than that of heroin (Gossop et al. 1994b). There is also widespread use of amphetamine sulphate (Pates and Mitchell 1996). NTORS data show that drug users who approach treatment services commonly use stimulants: 88% had used stimulants and 59% were current stimulant users. A substantial percentage of the NTORS cohort, although primarily dependent on heroin, were also frequent users of stimulants. For those clients, it is appropriate to target their stimulant use as part of the wider cluster of substance misuse problems that require treatment (Gossop et al. 2000a). Other research has found the use of cocaine by methadone maintenance clients to be associated with higher rates of criminality, health risk behaviour and other problems (Grella et al. 1995; Des Jarlais et al. 1992; Kosten et al. 1988). For 7.5% of the NTORS cohort, stimulants were their main problem drug. Although these clients were mostly polydrug users, they were much less likely than other stimulant users to use heroin or other opiates and less likely to inject. They were, however, more likely to be heavy drinkers. The differences in substance use patterns 81

88 are likely to require different clinical management (Gossop et al. 2000a). There is evidence that dexamphetamine sulphate is currently prescribed in England and Wales for the treatment of primary amphetamine use (Fleming 1998; Bradbeer et al. 1998; White 2000; Klee et al. 2001). The Task Force to Review Services for Drug Misusers (1996) stated that there might be a place for amphetamine substitute prescribing in some cases, but further research is needed as there is little scientific evidence for its efficacy. Department of Health guidelines suggest that such prescribing should be restricted to particular groups (Department of Health et al. 1999). There are dangers associated with stimulant prescribing and the evidence suggests that psycho-social interventions are the management of choice for stimulant misusers (see Stimulant users, in Chapter 3). The Department of Health s clinical guidelines state that there is no indication for the prescribing of cocaine or methylamphetamines in the treatment of stimulant misuse. The guidelines also recommend that methylphenidate or phenternine not be prescribed (Department of Health et al. 1999). Similarly, there is currently no supporting evidence for the clinical use of carbamazepine for cocaine dependence (Lima et al. 2000). Antidepressants, such as Fluoxetine, can be effective in the management of major depressive episodes associated with stimulant use. However, care must be taken if selective serotonin re-uptake inhibitors are prescribed while cocaine or amphetamine is still taken, as toxic reactions have been described (Department of Health et al. 1999). There is some evidence of the efficacy of disulfiram for treatment for cocaine dependence and alcohol dependence or abuse, although the use of alcohol and disulfiram could potentially cause serious physical adverse effects. There is also some evidence that disulfiram may be an effective pharmacotherapy for cocaine misuse among methadone maintained clients, even those without co-morbid alcohol misuse. Disulfiram may work with buprenorphine to reduce cocaine use in opiate users (Carroll et al. 2000; George et al. 2000; McCance-Katz et al. 1998; Petrakis et al. 2000) (see Stimulant users section in Chapter 3). To date, research shows that abstinence-based psychological treatment approaches, linking counselling and social support, have had the greatest impact on cocaine misuse (Department of Health et al. 1999). Complementary therapies, such as acupuncture, are commonly used, despite limited evidence of their effectiveness. Nonetheless, they are capable of attracting drug users to treatment settings and it is suggested that they are explored (Department of Health et al. 1999). However, the main problem remains that drug services in the UK are primarily geared to opiate dependence and there is little information about the outcome of treatment for stimulant users Access Access to the service Access to a community prescribing programme is voluntary (i.e. through self-referral, GP or criminal justice referral, or through other agencies such as social services, GUM clinics, antenatal clinics, etc). Children and young people under 16 must receive treatment in, or in shared care with, child-centred services (see Young people and substance misuse in Chapter 3; also see Health Advisory Service 1996 and 2001b). There is some concern that harm reduction principles, which associate greatest harm with injecting, may be restricting the access of non-injectors to oversubscribed methadone treatment because they are not categorised as a priority. In particular, it 82

89 has been noted that this may be marginalizing South Asian and other minority ethnic users who exhibit trends of heroin smoking Referral pathways and relevant pathways of care There should be clearly described written information about how the referral process is undertaken. This material should cover: how referrals are made the minimum and maximum timescales for response which staff are involved and how the referral will be managed the Care Co-ordination processes and responsibilities how the referral process will be documented how referral outcomes will be monitored and communicated. Within the agency undertaking prescribing, the relevant pathway of care is as follows. All patients are fully assessed by the appropriate team. A decision is made as to eligibility for admission. The category of admission is considered: for example, priority, or routine. The admission of a patient as an emergency may be considered in exceptional circumstances. Admission is in accordance with admission category. For example, emergency admissions would be offered immediate admission, priority admissions would be admitted to the next available slot, and routine admissions would be placed on a waiting list for routine admission. Patients are offered preparation for admission such as information about substitute prescribing and care plans, pre-admission meetings, details of the agency s protocols, including prescribing protocols, and urine testing. The care plan is formulated. A Care Co-ordinator is appointed. Patient is admitted to the programme and assessment undertaken in compliance with clear assessment protocols. Prescribing is initiated (where appropriate) after a period of assessment and in accordance with prescribing protocols. Periodic review of care plan is undertaken. Where appropriate, discharge planning meeting is organised during treatment programme, with attendance from local referring teams, in order to formalise ongoing care plan. Where appropriate, patient is referred for assessment for funding for residential rehabilitation and links with housing. Where appropriate, patient is discharged to follow-up care. Where appropriate, relapse prevention intervention is made. Joint working protocols and agreements with all services required to provide packages of care are recommended, including: toxicology; community pharmacists (re supervision of dispensing); social services re child protection; mental health services etc. Relevant referral pathways with other organisations include referrals to counselling, housing, welfare advice, legal advice, social services, primary care, acute medical services (including liver units, haematology, HIV units), antenatal and maternity, dentistry, GUM clinics, psychiatry and psychology, etc Integrated care pathways See diagrams on pages 87 89: Stabilisation on substitute medication; Community detoxification; and, Community maintenance prescribing for opioid dependence. 83

90 2.5.5 Assessment For details on assessment, see Chapter Management Treatment phases The phases of prescribing treatment are as follows: Decision on type of admission (routine, priority, emergency/crisis). Admission management (e.g. waiting list). Assessment. Risk assessment. Preparation of individual for substitute prescribing (e.g. advice and written information about methadone, risks of overdose, etc). Development of a care plan. Identification of a Care Co-ordinator. Provision of practical social support (e.g. housing, welfare benefits and legal advice). Provision of counselling. Review of treatment and care plan, and ongoing assessment. The Task Force recommends that all clients on a substitution programme are seen regularly (at least fortnightly initially and then at least monthly). The status of clients/patients on methadone maintenance programmes must also be reviewed every three months to review what has been achieved, set new goals where appropriate and review service users requirements (Task Force to Review Services for Drug Misusers 1996). Provision of a health promotion element of treatment. Harm minimisation advice is provided on a range of issues including alcohol use, overdose prevention, safer injecting, contraception and safer sex, nutrition and so forth. HIV and hepatitis testing where appropriate. Hepatitis B immunisation. Assessment should consider tuberculosis, as drug misusers have been identified as a risk group. The interaction between methadone and Rifamcipin should be considered. Relapse prevention is a component part of all treatment programmes. Clients successfully detoxified have access to aftercare programmes. Where appropriate, antagonists such as Naltrexone are prescribed for the prevention of relapse in clients who have achieved abstinence. Psychological methods of relapse prevention and specific, focused behavioural relapse prevention approaches which have proven to be effective should also be available where appropriate (Irvin et al. 1999) Individuals who have achieved abstinence are given appropriate support through further outpatient attendance, community projects or self-help groups such as Narcotics Anonymous (NA). Link to rehabilitation programmes. There must be active co-ordination between detoxification services and subsequent rehabilitative care. Clients who have achieved abstinence are encouraged to be assessed for suitability for rehabilitation. Case closure, where service user has achieved abstinence or left the programme Care co-ordination, planning and review The processes of care co-ordination, planning and review are described in detail in Chapter 1 of this report. There should be a written protocol describing the care coordination, planning and review processes that are followed by a prescribing service. 84

91 Services should seek to actively involve the service user so that their needs are recognised at key stages during the programme Departure planning Departure from the programme and onward referral should be a planned element of the programme, and should include the following stages. successful detoxification personal discharge (stopped coming) removal from programme by service (for contravening service rules/policies) move script to GP (stabilisation) move away from GP to specialist service (include move due to chaos, physical or psychological morbidity) Aftercare and support The development of an appropriate package of aftercare and support should take place in the final phase of the treatment episode for service users aiming to achieve abstinence. Relapse prevention must be a component part of the substitute treatment programme. Where appropriate, there is a change in Care Co-ordination and referral to other services such as residential rehabilitation, specialist housing and so forth. Positive outcomes are also engendered by contact with housing agencies and vocational agencies specifically aimed at substance misusers Standards Core management and commissioning standards QuADS: organisational standards for drug and alcohol treatment services (Alcohol Concern and Standing Conference on Drug Abuse 1999) provide core standards on the management of services prescribing in the community. Standards on the commissioning of services prescribing in the community are available in Commissioning standards for drug and alcohol treatment and care (Substance Misuse Advisory Service 1999) Training and Competencies Relevant competencies are outlined in the Drugs and alcohol national occupational standards (DANOS) (Skills for Health 2002) Clinical management and responsibility Responsibility for prescribing lies with the doctor who signs the prescription. This responsibility cannot be delegated. A decision to prescribe and how much to prescribe depends on: the overall treatment plan of the individual client Department of Health clinical guidelines locally agreed protocols the doctor s experience and level of training discussion with other members of a multidisciplinary team advice, where necessary, from a specialist in drug misuse (Department of Health et al. 1999). It is expected that prescribing will be in line with the Department of Health s clinical guidelines and that it will take into account the recommendations for the reduction of drug-related deaths identified in the report of the Advisory Council on the Misuse of Drugs (ACMD) (2000) and the government s response to that report (Department of Health 2001d). 85

92 Prescriptions must written in accordance with the Misuse of Drugs Regulations (1985), which must also be adhered to by pharmacists. These regulations are mainly concerned with record-keeping and the storage and dispensing of controlled drugs. NHS prescriptions for methadone normally provide a supply for two weeks. UK guidelines recommend that, as a general principle, all prescribing is on a daily dispensing regime. Dispensing intervals can be reduced gradually (e.g. two or three times a week) if the client/patient is making progress on a daily dispensing regime. No more than a week s supply is dispensed at one time, except in exceptional circumstances (Task Force to Review Services for Drug Misusers 1996; Department of Health et al. 1999). It is recognised that prescribing which requires daily attendance may be difficult in some rural areas. Guidelines also state that for some patients, prescribers should arrange supervised consumption with an appropriate health professional, such as the clinic nurse or community pharmacist. Prescriptions are initially taken under daily supervision for a minimum of three months. The ACMD report on reducing drug-related death suggests a period of six months at least. Supervised consumption can be re-initiated at any stage during the prescription if there are doubts about compliance (Task Force to Review Services for Drug Misusers 1996; Department of Health et al. 1999; ACMD 2000). The Task Force also recommends that methadone tablets no longer be prescribed for the treatment of problem drug use, but only for other indications such as pain control (Task Force to Review Services for Drug Misusers 1996). Exceptional circumstances where tablets can be prescribed include where the patient is travelling or where it is recommended for reasons of physical co-morbidity. A Home Office licence is required for the prescribing of diamorphine Performance and outcome monitoring For detailed information about monitoring community prescribing, see Performance and outcome monitoring in Chapter 4. 86

93 Diagram 1 Integrated care pathway: Stabilisation on substitute medication Initial assessment of drug and alcohol misuse problems identifies dependence (or probable dependence) on one or more substances (including alcohol) Refer to appropriate service (for example community drug team) with access to prescribing interventions and inpatient beds Full assessment of drug and alcohol misuse problems, including assessment as to the presence and level of dependence; identification of other medical, social and mental health problems; complications and risk assessment. Includes physical examination and urine testing Dependence syndrome present and eligible for community stabilisation Dependence syndrome or probable dependence syndrome but contraindications to community stabilisation, for example chaotic polydrug use with complications such as withdrawal seizures Care plan formulated with patient (and carer) and relevant members of multidisciplinary team, with identified needs, including targets for outcome. Care plan includes community stabilisation, adjunctive treatments (e.g. psychological therapies) and longerterm care planning, for example community maintenance or detoxification programmes, residential rehabilitation etc. Regular review dates for care programme identified Care plan formulated with patient (and carer) and relevant members of multidisciplinary team, with identified needs, including targets for outcome. Care plan includes inpatient stabilisation and longer-term care planning, for example, community maintenance or detoxification programmes, residential rehabilitation, etc. Regular review dates for care programme identified Community stabilisation programme on substitute medication Admission to inpatient unit for stabilisation programme on substitute medication Unsuccessful completion of stabilisation Successful completion of stabilisation Unsuccessful completion of stabilisation Community maintenance prescribing programme (see relevant care pathway, page 89) Community detoxification prescribing programme (see relevant care pathway, page 88) Detoxification on inpatient unit (see relevant care pathway, page 98) 87

94 Diagram 2 Integrated care pathway: Community detoxification Initial assessment at any venue suggests that prescribing intervention may be appropriate Refer to appropriate prescribing service, for example community drug team, specialist generalist working with support of multidisciplinary team offering adjunctive therapies Full assessment of drug and alcohol misuse problems, including assessment as to the presence and level of dependence; identification of other medical, social and mental health problems; complications and risk assessment. Includes physical examination and urine Indications for admission for inpatient stabilisation and detoxification (see inpatient detoxification care pathway) Care plan formulated with patient (and carer) and relevant members of multidisciplinary team, with identified needs, and including targets for outcome. Care plan includes stabilisation (see relevant care pathway), community detoxification and adjunctive treatment (e.g. psychological therapies). Regular review dates for care programme identified Stabilisation on appropriate substitution medication (see relevant care pathway) Opioid detoxification programmes with substitute opioids (e.g. methadone), or with symptomatic treatment (e.g. lofexidine) Benzodiazepine detoxification with appropriate benzodiazepine Alcohol detoxification with appropriate benzodiazepine (e.g. chlordiazepoxide, diazepam) Polydrug dependence requiring detoxification, for example alcohol and opioids Patient fails to complete detoxification programme (drops out, relapses, discharged due to non-compliance) Patient successfully completes detoxification programmes Aftercare plan (e.g. rehabilitation programme, community-based relapse prevention programmes) 88

95 Diagram 3 Integrated care pathway: Community maintenance prescribing for opioid dependence Initial assessment indicates that prescribing intervention may be appropriate Refer to prescribing service, for example, community drug team, specialist generalist working with support of multidisciplinary team offering adjunctive therapies Full assessment of drug and alcohol misuse problems, including assessment as to the presence and level of dependence; identification of other medical, social and mental health problems; complications and risk assessment. Includes physical examination and urine testing Establish dependence on opioids via history, objective signs of opioid withdrawal, investigations (e.g. urine toxicology) Establish treatment goal of abstinence or maintenance Detoxification programme (see relevant care pathways) Care plan formulated with patient (and carer) and other relevant members of multidisciplinary team, with identified needs and targets for outcome. Care plan includes stabilisation on substitute medication, maintenance prescribing, and adjunctive treatment (e.g. psychological therapies). Regular review dates for care programme identified Stabilisation on appropriate substitution medication (oral methadone mixture). See relevant care pathway Review (initially weekly, fortnightly, then reduced frequency as indicated). Review of needs, and whether treatment programme meeting needs, particularly in areas of risk Continuation of treatment for considerable period of time with regular reviews Detoxification (see relevant care pathways) Non-completion of programme due to drop out, or discharge due to non-compliance Aftercare programme (e.g. rehabilitation, community-based relapse prevention) 89

96 2.6 Inpatient drug (and alcohol) misuse treatment Description Inpatient drug (alcohol) misuse treatment is a Tier 4 service. Inpatient drug and alcohol misuse treatment programmes are specialised units for people with drug and alcohol misuse disorders. They provide medically supervised assessment, stabilisation and withdrawal with 24-hour medical cover and a multidisciplinary team. Programmes also include a range of additional provisions such as relapse prevention work and aftercare referral services Context Inpatient provision for drug treatment is often in designated drug and alcohol misuse beds in psychiatric wards rather than specialist inpatient units. While this may work well in some areas, we are aware that in others there are significant problems. These may be due to factors such as: a lack of suitably trained staff; preferences of drug and alcohol misusers; difficulties in effecting planned admission due to pressure on beds; and, difficulty in maintaining a drug-free environment. All of these factors are likely to undermine the effectiveness of designated beds compared with specialist units, and there is some evidence that the latter result in better outcomes. Consideration should be given in local areas and regions to expanding the provision of specialist drug (and alcohol) misuse beds Philosophy and approach Many people with substance use dependence have difficulty achieving abstinence in the community. Inpatient programmes are therefore intended for those drug misusers whose needs require supervision in a controlled medical environment. Inpatient programmes provide medically supervised withdrawal (detoxification) and most regard this as an induction pathway into a short-term residential programme of psychosocial counselling and support aimed at relapse prevention. This programme can continue in the community as aftercare (with adjunctive prescribing such as naltrexone). Alternatively, clients can be referred to a residential rehabilitation programme (see relevant section in Chapter 2). Inpatient treatment can facilitate the provisions of the following specific prescribing interventions: stabilisation on substitution opioids (e.g. methadone) withdrawal from substitution opioids (e.g. methadone) withdrawal from opioids using non-opioid medication (e.g. lofexidine) stabilisation on benzodiazepines for sedative (including alcohol) withdrawal withdrawal from benzodiazepines for sedative (including alcohol) withdrawal opioid relapse prevention with naltrexone symptomatic treatment for stimulant withdrawal Location Inpatient drug and alcohol misuse treatment services are usually based in hospital general psychiatric units and in general hospitals (general medical beds) or in specialist dedicated inpatient units. There is evidence that drug misusers receiving treatment in dedicated inpatient units achieve better outcomes than those who receive treatment in general wards. Inpatient substance misuse treatment services are also provided by the voluntary/independent sector (Task Force to Review Services for Drug Misusers 1996). 90

97 Programme duration The usual length of stay on a withdrawal programme is between two and seven weeks, with the average being four weeks (Task Force to Review Services for Drug Misusers 1996). In the National Treatment Outcomes Research Study (NTORS), the duration of actual inpatient provision varied from two to five weeks. This variability is attributable to the speed of the withdrawal regimen and the provision of psychosocial counselling in the programme. Research suggests that longer periods in treatment, with some indication of a critical period of 28 days for opioid users, may predict better outcomes (Gossop et al. 1999b) Staffing Inpatient programmes are usually staffed by multidisciplinary teams with an emphasis on medical and nursing staff (Task Force to Review Services for Drug Misusers 1996). Multidisciplinary teams include psychiatrists, nursing staff, psychologists, social workers, occupational therapists, physiotherapists and pharmacists Aims and objectives Treatment aims and objectives The aims of inpatient programmes include the following: to fully assess the psychological, psychiatric, social and physical status of patients, using clearly defined assessment schedules to fully assess the degree of dependence on various classes of drugs, including assessment instruments as indicated, for example opioid and benzodiazepine withdrawal schedules (Ghodse 1995a) or alcohol withdrawal assessment instruments (Stockwell et al. 1979) to define a programme of care, to ensure that a Care Co-ordinator is in place from community services or the inpatient facility, and to develop a care plan to carry out a risk assessment to prescribe medication where indicated, according to clearly defined protocols and as part of a comprehensive programme of care to prescribe medication safely and effectively in order to achieve stabilisation and/or withdrawal from psychoactive substances to prescribe medication appropriately for relapse prevention to prescribe medication for psychiatric and/or physical complications and/or comorbidity as appropriate to identify risk behaviour and offer appropriate counselling to enable minimisation of harm to offer appropriate tests for hepatitis B and C and HIV with informed consent to provide hepatitis B prophylaxis where indicated to refer patients for a community care assessment where indicated to assess the longer-term treatment needs of patients and formulate an appropriate discharge care plan in accordance with the care programme approach to provide a period of drug-free recovery as appropriate to provide effective psychological interventions, such as cognitive behavioural therapy and relapse prevention therapy to assess and refer patients for other treatments as appropriate, for example trauma therapy, family therapy, etc to monitor and evaluate the efficiency and effectiveness of prescribing interventions to monitor and evaluate the efficiency and effectiveness of psychological interventions 91

98 to enable mothers with young babies (i.e. under the age of nine months) to access treatment services with their babies to provide referral to other services as necessary, including medical services (e.g. liver clinic, communicable diseases unit, etc), psychiatric services (e.g. general adult psychiatry, personality disorder units, etc), social and community services (e.g. housing, legal advise centres, children and families social services) Client group served Service users are individuals who have drug-related problems and meet International Classification for Diseases (ICD) 10/Diagnostic and Statistical Manual (DSM) IV dependence criteria. This group comprises individuals who are seeking abstinence from their main problem drug in a controlled medical setting (although occasionally patients may be admitted for stabilisation on substitution medication and discharged to a community prescribing programme such as maintenance opiate prescribing). Here, too, the majority of those entering inpatient programmes are dependent opioid users who present with additional polydrug use. Concurrent use of benzodiazepines and psycho-stimulants is common. While these services are geared to the withdrawal needs of opioid misusers, they are able to supervise the withdrawal of primary users of other drugs and provide adjunctive prescribing for biomedical complication and conditions (psychological and behavioural) Eligibility Admission to inpatient drug and alcohol misuse treatment programmes is voluntary. Most units are adult units, that is, patients must be over the age of 16 years. The target groups for inpatient treatment are: patients physically dependent on one or more classes of drugs patients with physical or psychiatric complications or co-morbidity patients with chaotic polydrug use women who are pregnant patients who have failed to complete outpatient drug treatment programmes patients who are unlikely to cope with outpatient detoxification due to significant personal isolation or lack of support from family or friends Priority groups Priority groups for inpatient detoxification are people with the following characteristics: severe dependence co-morbidity pregnancy/puerperal withdrawal complications, for example seizures. significant personal isolation Exclusions/contraindications serious acute psychiatric morbidity, e.g. acute psychosis, requiring acute psychiatric treatment serious physical morbidity (e.g. life threatening physical illness) admissions may be specially timed, for example where a couple both require inpatient treatment, their admissions may be consecutive, to avoid compromising care. 92

99 2.6.3 Research evidence base Research suggests that a high proportion of patients accessing inpatient treatment can achieve successful withdrawal from opioids. A relatively small number of studies have evaluated the impact of hospital inpatient units and residential rehabilitation programmes. One early English follow-up study of patients who were treated by a specialist inpatient unit found that 51% of patients were drug-free at a six-month follow-up (Gossop et al. 1989). The only controlled study of inpatient versus outpatient treatment of opiate withdrawal in the UK found inpatient withdrawal to be four times more effective in terms of the proportion of patients who completed the withdrawal regime (Gossop et al. 1986). An uncontrolled study found that 74% of patients admitted for opiate detoxification successfully completed treatment and onethird of patients followed up one year after inpatient detoxification had been abstinent from opioids for at least one month prior to follow up (Ghodse et al. 1997). There is evidence that a dedicated substance misuse inpatient unit is associated with better outcomes in terms of completion of opioid withdrawal and abstinence from opioids after seven months than a general psychiatric ward (Strang et al. 1997b). NTORS has shown that those clients participating in the study who were in residential treatment settings (inpatient units and residential rehabilitation units) tended to be older, have longer drug careers, be regularly using a broader range of substances (including alcohol), and have more previous contact with drug treatment services (Gossop et al. 1998c). Those clients in the cohort who were admitted to residential treatment programmes showed substantial improvements in terms of abstinence from opiates, psycho-stimulants and benzodiazepines. At one year, more than a third of all patients admitted to residential treatment programmes were abstinent from all of the target drugs and had been so for the previous three months. There were also improvements in other problem areas (injecting, sharing injecting equipment, heavy drinking and criminal behaviour). It was found that a critical period of 28 days for inpatient and short-stay residential programmes predicted likelihood of achieving abstinence from opiates at one year, although improvements were also seen in patients who were discharged before this critical period (Gossop et al. 1999b). However, a proportion of patients leave inpatient treatment prior to completion, with studies reporting drop-out rates of between 18 46% (Ghodse et al. 1987; Gossop et al. 1987). Severe drug use and severe medical problems were identified as predictors of failure to complete inpatient detoxification in one study (Franken and Hendriks 1999). It is also recognised that most of the research has been conducted on inpatient treatment of opioid and polydrug (including stimulants) misuse, rather than primary stimulant users. Turning to the evidence base for effective withdrawal agents and regimens, a variety of medications have been found to be efficacious in managing withdrawal syndromes in inpatient facilities. These include oral methadone, codeine-based medication such as dihydrocodeine and buprenorphine. Lofexidine may be used for opioid withdrawal and there is evidence that it is as efficacious as methadone in inpatient withdrawal (Bearn et al. 1996). Rapid opioid detoxification under sedation has been described, although properly controlled trials have not been performed (Seoane et al. 1997). Symptomatic relief of mild opioid withdrawal symptoms, for example by use of diphenoxylate, promethazine and propranolol, has also been described (Department of Health et al. 1999). 93

100 It is common for inpatient programmes to manage benzodiazepine withdrawal. The majority of opioid drug users presenting for treatment have a history of benzodiazepine use in the year prior to treatment and nearly half of opioid users in treatment have injected benzodiazepines (Perera et al. 1987; Strang et al. 1994). In one study, 43% of patients admitted to an inpatient unit who reported benzodiazepine misuse were found to be physically dependent on benzodiazepines, and most were successfully stabilised on a mean dose of diazepam 40mg, with a range from 20 80mg (Williams et al. 1996). Sedative withdrawal using substitution benzodiazepines, generally long-acting preparations such as diazepam, is a well-recognised treatment for benzodiazepine and alcohol dependence (Ghodse 1995a). For drug users who are found to be dependent on both sedatives (including alcohol) and opioids, it is recommended that benzodiazepine withdrawal be completed first, while the patient remains on a steady dose of substitution opioid such as oral methadone. Primary stimulant misusers, and polydrug users whose use of drugs includes stimulants, may also be admitted to inpatient substance misuse units. Primary stimulant misusers may be admitted due to severity of withdrawal symptoms, including depressive and suicidal symptoms, or due to physical or psychiatric comorbidity. Most studies have found that a psychosocial abstinence-based approach is most efficacious (Carroll et al. 1995b). There is little research evidence for the use of substitution stimulant prescribing in the inpatient treatment setting. However, there is a role for non-substitution prescribing for stimulant withdrawal in inpatient settings including the relief of symptoms such as anxiety, agitation and psychotic indications. The prescription of antidepressant medication for major depressive episodes associated with stimulant use may also be necessary (see section on stimulant users in Chapter 3). Prescribing interventions for relapse prevention may be commenced during inpatient treatment. Naltrexone, an opiate antagonist, may be prescribed for opioid users following withdrawal and a period of recovery. Disulfiram may be prescribed for patients following alcohol withdrawal and for those with alcohol and cocaine problems (see section on stimulant users in Chapter 3). Most inpatient drug misuse treatment services have a contingency management approach. Clients may be asked to agree to a contract of care which specifies that certain behaviours are not acceptable. These commonly include the use of illicit drugs, racist or sexist behaviour and violent behaviour. At the commencement of treatment these behaviours are clearly outlined as unacceptable, and patients are asked to agree this contract as a condition of accepting treatment in the unit, with the understanding that a breach of this contract will lead to a review of their treatment and possibly to discharge Access Access to the service Information should be made available on criteria for access to the inpatient detoxification programme. This material should describe: who the service is intended for expected waiting times (and these should be subject to target setting, monitoring and regular review) Referral pathways and relevant pathways of care There should be clear written information about how the referral process is undertaken. This material should cover: how referrals are made 94

101 what are the minimum and maximum timescales for response which staff are involved and how the referral will be managed care co-ordination processes and responsibilities how the referral process will be documented and referral outcomes monitored and communicated. Within the inpatient facility, the relevant pathways of care are as follows. All patients are fully assessed by the appropriate team. Decision is made as to eligibility for admission. Category of admission is considered: for example, e.g. priority or routine. The admission of a patient as an emergency may be considered in exceptional circumstances. Admission would be in accordance with admission category. For example, emergency admissions would be offered immediate admission, priority admissions would be admitted to the next available bed, and routine admissions would be placed on a waiting list for routine admission. Patients would be offered preparation for admission, for example, information about the unit, information about care plans, pre-admission meetings, details of unit protocols including prescribing protocols, etc. Formulation of care plan: including care following discharge, community care assessments for rehabilitation placements, day programmes, etc. Patient admitted to the inpatient unit, and assessment undertaken in compliance with clear assessment protocols, which should include observation and recording of symptoms and signs of drug abstinence phenomena. Prescribing initiated (where appropriate) after a period of assessment, and in accordance with prescribing protocols. Discharge planning meeting organised during patient s treatment programme, with attendance from local referring teams, in order to formalise ongoing care plan. Discharge to follow-up care. Except in unusual circumstances, any ongoing prescribing is the responsibility of the agency co-ordinating follow-up care. Relevant referral pathways with other organisations after discharge from the inpatient facility are carried out by the care co-ordinator. In particular, there must be active coordination between detoxification services and subsequent rehabilitative care, and the service user is encouraged to be assessed for suitability for rehabilitation Integrated care pathway See diagram for care pathway concerning inpatient detoxification (page 98) Assessment Patients should have a comprehensive assessment (see Chapter 1) Management 6.1 Treatment phases The treatment phases for inpatient substance misuse treatment include: assessment of patient admission criteria fulfilled decision on type of admission (e.g. emergency, priority, routine) admission management (e.g. example waiting list management) 95

102 preparation for admission (e.g. introductory groups in outpatient facilities, written information) assessment of treatment needs after detoxification (e.g. community care assessment, visits to rehabilitation units) admission to unit assessment of degree of dependency stabilisation withdrawal further aftercare needs assessment institution of pharmacological relapse prevention as appropriate implementation of aftercare and follow-up Care co-ordination The process of care co-ordination is described in detail in Chapter 1. It is recommended that where the stay of the service users in the inpatient facility is short term, the function of care co-ordination remains with the care co-ordinator who has undertaken the referral to the inpatient unit Departure planning: aftercare and support Departure from the programme and onward referral should be a planned element of the programme. In the final phase of the treatment episode, the inpatient provider should prepare for departure and return to the community or for admission to a residential rehabilitation programme. Onward referral may be planned as: discharge to community-based drugs services (e.g. community drug team) discharge to rehabilitation programme (residential or day patient) discharge to other facilities (e.g. psychiatric unit, mother and baby unit) Discharge for reasons of safety Some patients may violate treatment protocols, for example by using drugs or alcohol in the inpatient unit or by violent or other inappropriate behaviour. In some situations this may compromise the safety of other patients or staff, or undermine the therapeutic programme for other patients. In some cases a criminal offence may be committed (e.g. assault, supplying drugs to other patients). Such patients should be assessed for suitability for discharge, if necessary under the Mental Health Act. If patients are fit to be discharged into the community, a clear discharge care plan should be drawn up for the aftercare of the patient. On rare occasions, patients may need to be transferred to a mental health unit if there are concerns about their mental health. Close liaison with mental health services will then be required to formulate ongoing care plans. Where criminal acts have taken place consideration needs to be given to involving the police Discharge against medical advice Some patients may decide to take their own discharge against medical advice. Assessment should occur in order to determine if a patient is fit to be discharged, and if necessary, a mental health assessment may be required. A clear discharge plan should be formulated for patients who are fit for discharge. This includes the notification of the care co-ordinator in the community. In rare cases where patients are detained under the Mental Health Act, liaison with the mental health services will be necessary to formulate ongoing care plans. At the time of discharge it is critical that the clinical staff member co-ordinating the discharge provides information to the client, prior to them leaving the unit, about the 96

103 potential risk of overdose (Advisory Council on the Misuse of Drugs 2000; Department of Health 2001d) Standards Core management and commissioning standards QuADS: organisational standards for alcohol and drug treatment services (Alcohol Concern and Standing Conference on Drug Abuse 1999) provide core standards on the management of inpatient substance misuse treatment. Standards on the commissioning of services providing inpatient substance misuse treatment are available in Commissioning standards for drug and alcohol treatment and care (Substance Misuse Advisory Service 1999) Clinical management and responsibility Clinical monitoring: regular team reviews of patient progress, for example, multidisciplinary ward rounds use of laboratory tests to monitor abstinence, for example urine toxicology, random breath alcohol levels. See also Community prescribing section Performance and outcome monitoring For detailed information see Performance and outcome monitoring in Chapter 4. 97

104 Diagram 4 Integrated care pathways: Inpatient detoxification Initial assessment of drug and alcohol misuse problems identifies dependent (or probably dependent) on one or more substances (including alcohol) Refer to appropriate service (usually community drug teams) with access to prescribing and inpatient beds Full assessment of drug and alcohol misuse problems, including assessment as to the presence and level of dependence; identification of other medical, social and mental health problems; complications and risk assessment. Includes physical examination and urine testing. Assessment of suitability for inpatient and community prescribing programmes Patient does not meet eligibility criteria for inpatient detoxification programme (see community prescribing pathways) Eligible for an inpatient detoxification programme Care plan formulated with patient (and carer) and relevant members of the multidisciplinary team. Care plan identifies needs and targets for outcome. Include support while awaiting detoxification and identification of appropriate aftercare programme. Establish category for admission (e.g. emergency, priority or routine) Admission of emergency and priority cases Preparation for admission (e.g. pre-residential groups, information on programme, including prescribing programmes). Community care assessment for aftercare programmes (e.g. rehabilitation programmes) Admission to inpatient detoxification programme. Assessment, stabilisation and detoxification, assessment of medical, social and mental health problems; complications and risk assessment. Formulation of, or review of, aftercare plan. (Patients admitted as a priority or emergency may require community care assessment during the admission.) Unsuccessful completion of programme Aftercare plan, for example rehabilitation programmes, structured day care, communitybased relapse prevention 98

105 2.7 Residential rehabilitation Description Residential rehabilitation is a Tier 4 service. Tier 4 services are specialist drug and alcohol services offering intensive and structured programmes delivered in controlled residential, hospital inpatient or other controlled environments. Residential rehabilitation programmes aim to engender and maintain abstinence in a residential setting. It is recognised that people with complex problems related to drug misuse may require respite and an intense programme of support and care which cannot realistically be delivered in a community or outpatient setting Context The broad array of drug and alcohol residential rehabilitation services in the UK can be described on various levels: therapeutic orientation and milieu programme structure, intensity and duration. The degree of intensity of therapeutic support also varies quite widely across the residential services sector. Residential rehabilitation services have been pioneered and sustained mainly in the voluntary sector and by independent providers on a not-for-profit basis. Local authority social services departments currently initiate access to residential rehabilitation programmes. Treatment is paid for by community care funding and supplemented by other funding. There are over 100 programmes operating in England (DrugScope 2002). Residential treatment should be seen as a national resource with out-of-area referrals characterising substantial numbers of client episodes. Residential services are usually registered under the Registered Care Homes Act (1984), now the Care Standards Act 2000, as registered nursing or care homes with or without nursing. They must comply with appropriate registration controls imposed by the local authority and by the new Care Standards Commission (see standards below). A few residential services are registered as independent hospitals Philosophy and approach The treatment philosophy, structure and intensity of residential rehabilitation services vary quite widely in the UK. There are three broad types of rehabilitation provision: therapeutic communities 12-step programmes based on the Minnesota Model of addiction recovery treatment faith-based or general houses promoting a less structured programme which favours a more individually tailored package of care for each client different programmes are available, based on cognitive behavioural and motivational interviewing approaches. The majority of residential rehabilitation programmes require their clients to be drug free on entry, although some provide medically supervised withdrawal to facilitate abstinence (see previous section Inpatient substance misuse treatment ). Programmes usually run from the point of client detoxification, or immediately after the completion of detoxification, and last for a period of between six weeks and 12 months. The National Care Standards Commission (NCSC) classify short-term as under six months. Full-time residential care is often phased in intensity, so that the resident may be in a minimum supervision half-way house or in supported housing in the later stages of this care. There is a somewhat patchy network of aftercare houses in the UK. These provide a 99

106 bridging rehabilitation programme for the drug user in recovery. Collectively, these residential services are abstinence based and have relapse prevention as their major service outcome goal. This is accomplished by providing a safe living environment supported by staff and peers and a therapeutic programme comprising groups, lectures, individual counselling, and sometimes, family involvement Location Residential facilities can be purpose-built or refurbished free-standing facilities in rural/semi-rural locations, or converted inner- and outer-city facilities in residential houses. Residential rehabilitation facilities vary in size. Many services receive clients from a wide catchment area for example, clients from urban locations may need to receive treatment away from their usual drug-oriented environment Programme duration A number of types of programme can be identified: short-term residential rehabilitation, long-term residential rehabilitation, and third stage or low intensity half way houses. Short-term residential rehabilitation These services usually include a medically supervised withdrawal programme (see previous section Inpatient substance misuse treatment ) as the first stage of a rehabilitation programme that has a planned duration of six to 12 weeks. The National Treatment Outcomes Research Study (NTORS) project studied four of these services in England, with 88 clients recruited to the study. The median duration of treatment for these clients was six weeks. Long-term residential rehabilitation or second stage These services generally do not provide medically supervised withdrawal services as a first treatment phase. The planned duration of the rehabilitation programme varies quite widely. The 11 long-term residential services in the NTORS reported a planned duration of weeks, and the 108 subjects recruited had a median time in treatment of 10 weeks. Low-intensity residential rehabilitation or third stage and halfway house rehabilitation Low-intensity residential rehabilitation and halfway house rehabilitation services denote forms of continuing residential care for clients who have usually completed a long-term residential therapeutic programme. Third stage and halfway houses are normally residential services linked to the main programme. Clients maintain their drug-free status and live in a semi-independent context preparing for fully independent living in the community. The duration of halfway house care programmes is not currently known. The goals of these services relate to promotion of stable employment, vocation training and education. Low-intensity services may have a low level of staff cover and input to the clients, although a higher level of care may be available if needed Staffing and competency Most residential rehabilitation services (particularly those offering detoxification or longer-term programmes) will be registered as care homes or independent hospitals. As such they must comply with the standards for the category under which they are registered. The majority of residential rehabilitation services are registered under the Registered Care Homes Act (1984), now the Care Standards Act 2000, as registered nursing or care homes with or without nursing. They must comply with appropriate registration controls imposed by the Care Standards Commission. This includes demonstrating competence against national occupational standards in social care 100

107 (and/or health care) for individual staff and managers. The standards require that all managers and staff of residential homes are appropriately trained and working towards a recognised qualification. Residential programmes are usually staffed by a multidisciplinary team, which can comprise: co-ordinator/manager administrator/secretary social workers counsellors drug workers/care workers state-registered nurse/other nurses. Programmes may also have sessional input from consultant psychiatrists and specialist registrar and other medical personnel from primary care and other health services. Other professional groups that may be involved include clinical and counselling psychologists, family therapists, occupational therapists and other professional groups (also see Standards below). From 1 April 2002 all staff working in residential rehabilitation homes must have a criminal records check carried out on them before they are confirmed in post. The NTA has published a toolkit to enable managers of residential rehabilitation services to meet the Care Standards Commission human resource standards. It is available on the NTA website: Aims and objectives Treatment aims and objectives Residential rehabilitation programmes are quite diverse in the way they operate but most provide a structured programme of treatment, which shares the following basic features: maintenance of abstinence from illicit drugs, or prescription drugs that have been abused, in a controlled or semi-controlled therapeutic environment communal living with other drug users in recovery emphasis on shared responsibility by peers and group counselling relapse prevention-oriented counselling and support individual support and promotion of education, training and vocational experience improved skills for activities of daily living housing advocacy and resettlement work aftercare and support Client group served Clients of residential rehabilitation services are individuals who are seeking abstinence from their main problem drug in a controlled setting. They also include drug misusers in recovery or individuals who have achieved a state of abstinence from their main problem drug (or all drugs), usually through successful detoxification. Many individuals who enter rehabilitation units have quite long histories of drug misuse treatment and many have quite severe drug misuse problems at referral. Opioid dependence is the most common problem encountered by staff at these services and higher rates of drug injecting and sharing of injecting equipment may also be encountered, in comparison with clients attending specialist community prescribing services. Residential rehabilitation clients are also more likely to use 101

108 stimulants (amphetamine and cocaine), drink alcohol at risky levels and be involved in criminal behaviour (Gossop et al. 1998c). It is acknowledged that current service provision in England often does not adequately meet the needs of primary stimulant misusers and most particularly the needs of primary crack-cocaine misusers, although US evidence shows that residential rehabilitation can be effective for this group. It is also widely acknowledged that residential rehabilitation services are generally poor at meeting the needs of black and minority ethnic drug misusers (Sangster et al. 2002) Eligibility and priority Admission to residential services is voluntary, but can be part of a community sentence or post-custodial sentence from the courts. To establish eligibility, a community care assessment is carried out to ensure that the client meets admission criteria. Local authorities usually perform this function and pay for these services, although the assessment function may be delegated to another agency such as a community team or a voluntary sector agency. From April 2002, the Residential Allowance for residential rehabilitation has been replaced by a grant to local authorities. Individuals accessing residential rehabilitation must have drug-related problems and meet International Classification for Diseases (ICD) 10/Diagnostic and Statistical Manual (DSM) IV dependence criteria. Eligibility criteria and priority groups are determined at local levels and vary according to the criteria identified by the various social services departments. The target group includes: individuals who fail to achieve and maintain abstinence in a community setting those who express a desire to maintain abstinence and express a preference for admission to rehabilitation programmes or agree to enter this type of programme those who are likely to have substantial problems maintaining abstinence due to the severity of their substance dependence those requiring a programme of support and rehabilitation that is most suitably delivered in a residential environment those who are living in an environment characterised by social deprivation, including housing problems or instability, which represents a threat to relapse those who lack social support those whose social environment contains people (e.g. partners, friends) who are substance misusers and who are likely to hinder resolve or ability to maintain abstinence. Most units are adult units, that is, patients must be over the age of 18 years. Young people must be referred to child-centred programmes (for more information on young people, see Health Advisory Service 2001b and the section on young people in Chapter 3) Exclusions/contraindications These include: serious acute psychiatric morbidity, e.g. acute psychosis, requiring acute psychiatric treatment serious physical morbidity admissions may be specially timed, for example, where a couple both require inpatient treatment their admissions may be consecutive to avoid compromising care. 102

109 2.7.3 Research evidence base The literature on the effectiveness of residential rehabilitation programmes remains sparse, albeit growing. Only a small number of randomised controlled trials have been conducted (see McCusker et al. 1995; 1996; 1997; Nemes et al. 1999). A relatively small number of studies have evaluated the impact of hospital inpatient units and residential rehabilitation programmes. One early English follow-up study of clients who were treated by a specialist inpatient unit found that 51% of patients were drug free at a six-month follow-up (Gossop et al. 1989). The only controlled study of inpatient and outpatient treatment of opiate withdrawal in the UK found inpatient withdrawal to be four times more effective for the proportion of patients who completed the withdrawal regime (Gossop et al. 1986). The National Treatment Outcome Research Study (NTORS) showed that clients entering residential rehabilitation and inpatient programmes made substantial improvements in terms of abstinence from, and reduction of, illicit drug misuse, criminal activity, levels of injecting and psychological health. The study also showed that clients who stayed in treatment for a critical time (more than three months) showed better outcomes than those who left the programme at an earlier stage. It also showed that severely dependent and problematic misusers could achieve positive outcomes as a result of residential rehabilitation programmes (Gossop et al. 1999b and 2001a). US studies have shown that outcome from longer-term residential rehabilitation programmes is related to total time spent in treatment, with episodes of at least three months associated with positive outcome (Simpson 1997). The American Drug Abuse Treatment Outcome Studies (DATOS) provided important information, especially in relation to primary crack misusers. The studies found that long-term residential programmes that retain clients for at least three months are particularly cost beneficial for highly criminal clients with severe problems. In contrast, shorterterm and less-intensive treatments appear to be adequate for most of the less problematic users, even those who have left relatively early (Simpson et al. 1999). The majority of US studies have evaluated therapeutic community (TC) programmes. Programme length varies from short term with aftercare to long-term programmes of more than one year s duration. US data point to the considerable success of these services for the recovering misuser. Studies show that, on average, clients receiving TC treatment have enduring post-discharge reductions in illicit drug use (DeLeon et al. 1979; Gossop et al. 1999b; Simpson and Lloyd 1979). US and UK studies have shown positive psychosocial benefits after treatment (Georgakis 1995; DeLeon and Jainchill 1982; Bennett and Rigby 1990) Access and referral pathways Admission to residential services is voluntary, but is dependent on an assessment for eligibility. Generally, local authority social services departments carry out assessments for eligibility. In a few cases, local specialist drug services have been contracted by social services departments to carry out community care assessments. If eligibility for residential care is supported and funded, the client is referred directly to a suitable programme either within the local authority or DAT boundary or to a provider in another area. Care management is undertaken by the social services departments or contracted agencies. The most common referral pathway involves an initial determination of need for residential rehabilitation by generic or specialist substance misuse services or 103

110 criminal justice agencies that refer clients to social services departments or other organisations contracted by them to carry out a full assessment of eligibility. Referral is also sometimes undertaken by Tier 1 services. It is also possible for clients to be assessed for community care funding by directly contacting their local social services department. There should be clearly described written information about how the referral process is undertaken. This material should cover: how referrals are made/eligibility criteria the minimum and maximum timescales for response which staff are involved and how the referral will be managed how the referral process will be documented and referral outcomes monitored and communicated Integrated care pathways See diagram detailing care pathway for residential care Assessment dimensions Clients who are considered for residential rehabilitation will be assessed on the following six problem areas: acute intoxication and/or withdrawal potential biomedical conditions and complications emotional/behavioural conditions and complications (e.g. psychiatric conditions, psychological or emotional/behavioural complications of known or unknown origin, poor impulse control, changes in mental status, or transient neuropsychiatric complications) treatment acceptance/resistance relapse/continued use potential recovery/living environment. The client is evaluated on the six problem areas above, together with other individual psychological, medical and social factors. At referral, clients may have several biomedical complaints, including: depressed mood nervousness/anxiety insomnia physical complications related to drug use accidents and injuries related to drug use. For more details on assessment see Chapter Management Treatment phases Many residential rehabilitation services organise the delivery of their therapeutic programmes in stages that mark milestones of a client s progress through the organisational programme. The concept of stages is closely, but not exclusively, grounded in the philosophy and practice of therapeutic communities (DeLeon 2000). Generally speaking, the treatment stages are: assessment detoxification: physical withdrawal/psychological monitoring and treatment (where provided) 104

111 ongoing reduction of vulnerability, relapse prevention and health promotion (which includes assistance with housing, career counselling, welfare and financial counselling, etc) Care planning, co-ordination and review The processes of care planning, co-ordination and review are described in detail in Chapter 1. Individuals who are eligible for community care support are allocated a care manager from social services or the organisation contracted by social services Departure planning Departure from the programme and onward referral should be a planned element of the programme. This should normally be overseen by the keyworker, although some providers may have dedicated workers who facilitate onward referral and aftercare support. The importance of housing in the rehabilitation and integration of substance misusers who have achieved abstinence cannot be stressed enough. Supporting People is the new policy framework for supported housing; it provides new opportunities for DATs and commissioners to establish (or review) policies in relation to drugs and homeless drug users. The importance of housing to the rehabilitation and re-integration of substance misusers is discussed in Tackling drugs in rented housing: a good practice guide (Home Office and Department for Transport, Local Government and the Regions 2002). Chapter 4 in particular is relevant and discusses how housing can be used to assist drug users overcome their dependence Aftercare and continued support Aftercare following departure from the programme and onward referral should be a planned element of the programme. Aftercare can maximise the benefits of residential rehabilitation programmes and reduce the risk of relapse and drug-related harm. Service providers (in partnership with community care managers if appropriate) should be planning aftercare from the outset of a treatment episode particularly if the service user has housing needs. In the final phase of the residential treatment episode, intensive work should be undertaken by the provider to prepare the individual for departure and return to the community. This should include liaison and referral to supportive services to sustain and reinforce the rehabilitation programme. Patients may be at particular risk of drug-related death due to overdose if they leave residential rehabilitation and return to previous levels of drug and alcohol misuse. All residential rehabilitation services should educate and work with service users to reduce the risk of harm due to drug-related death particularly those who are discharged or leave programmes prior to completion Standards As previously stated, residential rehabilitation services may register as care homes or independent hospitals. They must comply with the standards for the category under which they are registered. The majority of residential rehabilitation services are registered under the Registered Care Homes Act (1984), now the Care Standards Act 2000, as registered nursing or care homes with or without nursing. They must comply with appropriate registration controls imposed by the Care Standards Commission. Some concessions have been made to elements of the standards to accommodate the special needs of drug treatment services. Any areas of noncompliance must be transparent and have an identified need within the risk assessment. Clients must be informed of these variations. The exemption to the 105

112 standard can be allowed if they can be justified appropriately by the therapeutic needs of the programme. Any exemption to the standard must be specified in the initial contract (for example, restrictions on visitors). Residential rehabilitation programmes must also comply with health and safety legislation, environmental health and fire regulations. Other relevant standards are: The national minimum standards for Residential Homes for Younger Adults and Adult Placements Core standards on the management of residential rehabilitation can be found in QuADS: organisational standards for alcohol and drug treatment services (Alcohol Concern and Standing Conference on Drug Abuse 1999) Standards on the commissioning of residential rehabilitation are available in Commissioning standards for drug and alcohol treatment and care (Substance Misuse Advisory Service 1999) ) Relevant competencies are outlined in the Drugs and alcohol national occupational standards (DANOS) (Skills for Health 2002) Performance indicators For detailed information about monitoring residential rehabilitation, see Performance and outcome monitoring in Chapter

113 Diagram 5 Integrated care pathway: Residential rehabilitation Initial assessment indicates rehabilitation may be appropriate Full assessment of substance misuse problems, including assessment as to the presence and level of dependence; identification of other medical, social and mental health problems; complications and risk assessment. Includes physical examination and urine testing Community care assessment to establish that client meets admission criteria. Usually performed by local authority, but criminal justice agencies may refer and fund rehabilitation programmes or via DAT pooled treatment budget Care plan formulated with patient (and carer) and relevant members of multi-disciplinary team, with identified needs and targets for outcome. Care plan may include stabilisation and detoxification (see relevant pathways), preparation for rehabilitation, a programme of rehabilitation, and after care planning Application and acceptance at an appropriate rehabilitation programme Requires stabilisation and detoxification Does not require stabilisation and detoxification Inpatient or community stabilisation and detoxification in inpatient unit (see relevant care pathways) Arrange admission to rehabilitation unit which provides detoxification Admission to short-term or long- term residential rehabilitation Regular review and formulation of after care plan, may include lowintensity residential rehabilitation and halfway house rehabilitation placements or community based relapse prevention 107

114 108

115 Chapter 3 Special groups This chapter discusses the needs of special groups of drug misusers who are typically under-served by drug misuse services. The chapter highlights the specific needs of these groups and provides guidance as to how services can be improved to meet the needs of these groups. 109

116 3.1 Stimulant users Description of the special group Stimulant users are those drug users who primarily misuse stimulant drugs such as amphetamines and cocaine. While many drug users use a variety of substances, there is a population of drug users who primarily misuse stimulants. Persistent use of stimulants is recognised to be associated with the use of a variety of other substances to reduce withdrawal symptoms or to counteract the over-activity, agitation and other adverse effects of stimulants. Stimulant users often present to services with a complex picture of multiple drug and alcohol use, sometimes with multiple dependencies. Currently in the UK, the most commonly used stimulants are amphetamines (amphetamine sulphate, dexamphetamine, methamphetamine and amphetamine-like slimming tablets) and cocaine (cocaine hydrochloride and crackcocaine). Cocaine hydrochloride is a powder that can be snorted or injected. Crackcocaine can be smoked or injected. Amphetamines are usually swallowed, snorted or injected, although a new, more concentrated form of amphetamine (crystallised methamphetamine, or ice ) may be smoked or injected. Other stimulant drugs include qat (or khat) and caffeine Epidemiology/nature and extent Prevalence The British Crime Survey (Ramsey and Partridge 1999) revealed a significant increase between 1996 and 1998 in the and age groups for all three recall periods for cocaine (consumption of cocaine within the last month, within the last year, and on a lifetime basis). In the year-old age group, 6% reported having tried cocaine. Seizures of cocaine, including crack appear to be rising, and the number of cocaine offenders (excluding crack) rose by 32% (Home Office 2000a). The Department of Health Statistical Bulletin (Department of Health 2000d) summarising information from the Regional Drug Misuse Databases (RDMD) for the six months ending March 2000, shows that cocaine was reported as the main drug of use by 6% of users, and amphetamines by 4% of users. Of patients reporting cocaine as their main drug, 4% were injecting the drug. Of those patients with amphetamines as their main problem drug, 44% were injecting the drug. The British Crime Survey (Ramsey and Partridge 1999) revealed that the group of drugs which includes amphetamines was the second most widely used group of drugs after cannabis in the age group. There are marked regional variations in the proportions of amphetamine users presenting to services (Department of Health 2000d). The proportion of stimulant users who would need treatment is unknown. However, the scale of use and numbers of amphetamine injectors presenting to needle exchanges would suggest that there are many in need of treatment (Stimson et al. 1988). In addition to those drug users who primarily misuse stimulants, a significant number of drug misusers entering treatment use stimulants in the context of multiple drug use. For example, in the National Treatment Outcome Research Study (NTORS), although heroin was the most-used drug prior to entering treatment, more than half 110

117 the subjects had used stimulants in the three months prior to treatment, and stimulants were the second most frequently used category of drugs (Gossop et al. 1998c) Problem drug use and dependence It is well known that stimulants cause psychological dependence, and it has been suggested that withdrawal symptoms of the crash (that is depression, sleepiness and hunger) represent physical withdrawal symptoms. Diagnostically, physical dependence is only one of a number of features of dependence syndrome, and need not necessarily be present for diagnosis (World Health Organization 1992). Other features include subjective compulsion of drug use, difficulties controlling drug use, tolerance to drug effects, neglect of other pursuits, and persistence with drug use despite evidence of overtly harmful consequences. In a non-random sample of stimulant users, Farrell et al. (1998) found that most stimulant users in their study were not dependent on stimulants. Dependence on stimulants was found to be related to the route of administration, for example, smoking crack-cocaine or injecting cocaine or amphetamines. There is a recognised association between stimulant use and the use of a variety of other classes of drugs (Donmall et al. 1995). Farrell et al. (1998) found that the majority of their sample of stimulant users were users of multiple drugs, and 34% of their sample of stimulant users were classified as problem drinkers Morbidity Cocaine and stimulant use may be associated with medical and psychiatric sequelae. Of a sample of cocaine and amphetamine users, many of whom were not in contact with treatment services, 41% reported emotional health problems and 35% reported physical health problems in the previous year (Farrell et al. 1998). There are known associated mental health problems including depression and paranoia (Ghodse 1995a; Gray 1999). There is also a link between cocaine use and suicide, deaths from cocaine overdoses due to cardiac depression, and in relation to accidents fatal hypothermia (Advisory Council on the Misuse of Drugs (ACMD) 2000) Psychiatric co-morbidity (see Psychiatric co-morbidity (dual diagnosis) in Chapter 4) The use of stimulant drugs is associated with psychiatric co-morbidity. Psychiatric symptoms were found to be present in 40% of stimulant users (Farrell et al. 1998), and 20% of cocaine users in one study had past treatment for psychiatric problems (Donmall et al. 1995). Recognised symptoms and syndromes include: anxiety and agitation insomnia persecutory beliefs psychotic illnesses, classically indistinguishable from schizophrenia (Ghodse 1995a) affective disorders such as depression suicidal ideation and para-suicide eating disorders (Jonas and Gold 1986) Physical co-morbidity The use of stimulant drugs is associated with: heart disorders (Ghuran and Nolan 2000) cerebrovascular accidents convulsions and seizures 111

118 effects on the gastro-intestinal system kidney disorders lung disorders (e.g. crack lung pneumonia which fails to respond to standard treatment; pneumothorax; interstitial pneumonitis; subcutaneous emphysema; bronchospasm) Effects of stimulant use on foetus (see Women drug users section in Chapter 3) The use of stimulant drugs is associated with: non-specific effects (e.g. low birth weight, premature birth) some possible evidence of direct teratogenicity (Platt 2000) Blood-borne diseases (see Blood-borne diseases section in Chapter 4) The use of stimulant drugs is associated with: injecting risk behaviours for blood-borne diseases (Hunter et al. 1998) stimulant users may be at increased risk of sexual transmission of HIV and hepatitis B (and other sexually transmitted diseases) due to increased sexual risk behaviours and an association of stimulant use with sex work (see Women drug users section in Chapter 3) Mortality Stimulant use has been associated with: suicide (DeLeon 1993; ACMD 2000) accidents (ACMD 2000) physical morbidity, especially convulsions, cardiac arrhythmia, respiratory failure and heart failure overdoses: Death from cocaine overdose is usually due to cardiac depression (ACMD 2000). Cocaine and amphetamines can lead to an increase in heart rate and blood pressure. Stimulants such as cocaine have a number of serious effects on the heart, including changes in heart rhythms, damage to heart muscle, accelerated coronary atheroma and myocardial infarction (Ghuran and Nolan 2000) fatal hyperthermia (ACMD 2000) Social Stimulant use has been associated with: property and violent crimes (Klee et al. 1998; Miller et al. 1991) breakdown and deterioration in social relationships (Klee 1995; Klee et al. 1998) social crises (Klee 1995; Donmall et al. 1995) homelessness. Racial and ethnic differences among cocaine misusers may be less relevant than socio-cultural differences in understanding cocaine misuse. Lillie-Blanton et al. (1993) found that the proportion of minority groups smoking crack-cocaine was about equal to the representation of these groups in their nationally based stratified sample (see Black and minority ethnic populations in Chapter 3) Evidence base Service accessibility and service utilisation Stimulant users perceive drug services as providing services for opiate users, and evidence suggests that patients seeking help for a stimulant use problem were less likely to have received treatment than those with opiate problems (Farrell et al. 1998). Stimulant users reported that harm reduction advice and 112

119 information services, residential services, ex-user counsellors and support and advice for family members were important components of treatment. One-quarter of this sample rated prescribed substitution stimulants as an important element of treatment (Farrell et al. 1998). Amphetamine users may be more likely to approach general practitioners than specialist drug treatment agencies (Klee 1995). Needle exchange schemes have more difficulty attracting injectors of non-opiate drugs in comparison to opiate injectors (Donoghoe et al. 1992b). Cocaine and crack-cocaine drug misusers often present in acute crisis and require a service response almost immediately if they are to be kept in treatment (Task Force to Review Services for Drug Misusers 1996). Retention in treatment has been noted to be a problem in several cocaine treatment studies. For example, Critschristoph et al. (1999) found high rates of drop-out at all stages of their large cocaine treatment study. Access is a key factor in the provision of treatment to ensure that clients are aware of the services interventions available Haynes et al. (2000). Speed of access to treatment is seen as crucial for cocaine users in surveys contacted with treatment agencies (Haynes et al. 2000). Festinger et al. (1996) noted that where there was an appointment given within 24 hours 83% of cocaine users attended, compared with 55% if the waiting time was longer. In another study where access was accelerated, the differences were 69% and 33% respectively, although Stark et al. (1990) noted that accelerated access increased attrition. Less formal, more open access services for crack-cocaine users providing a broad range of psychological support are considered appropriate for this group. Services with rigid appointment systems and little access to counselling will generally be unattractive to cocaine users (Audit Commission 2002) Barriers to service utilisation perception of services by stimulant drug users and professionals lack of appropriate psychosocial treatments lack of services to provide immediate responses or crisis intervention persecutory beliefs may inhibit stimulant users from engaging with services black and minority ethnic stimulant drug users face barriers to accessing treatment and care services (see Black and minority ethnic populations in Chapter 3) a desire to avoid mixing with, and being identified with, heroin users (Klee et al. 1998) NTA Research into practice briefing The NTA s Research into practice briefings on commissioning services and providing treatment for crack-cocaine (NTA 2002a and 2002b) provide a review of the recent evidence base and outline the implications for commissioners and practitioners Care pathways Care pathways with this client group will include collaboration and joint working with a number of services, based on the individual needs of the client and the presenting problems, and may include a range of professionals and services, including those listed below: mental health services arrest referral schemes prison-based referral schemes antenatal services primary care 113

120 general medical services social services accident and emergency homeless hostels criminal justice agencies crisis intervention agencies Treatment processes/environment Consultation/partnership working The planning and design of services for stimulant drug misusers must include a number of stakeholders, including: stimulant drug users the families of stimulant drug users local communities generic mental health services criminal justice agencies services for homeless stimulant drug users general practitioners Staff skill mix and qualifications The staff involved in delivering these services should be: educated and trained about stimulants, and have developed an understanding of stimulants users motives and lifestyles (Klee et al. 1998) trained in crisis management skilled in specific counselling techniques, for example, cognitive behavioural therapy and individual drug counselling trained in mental health Staff The above range of skills suggest that the following range of professionals should be involved: nursing staff (psychiatric and medical) medical staff (psychiatric and medical) social workers and care managers psychologists and counsellors ex-drug users (Haynes et al. 2000) drug workers Treatment provision Treatment needs to achieve the two primary goals: initiation of abstinence and prevention of relapse (Ghodse 1995a). There is no single treatment package that has been demonstrated to achieve this for cocaine users. In light of this, there are three phases of treatment of cocaine use: initial where the cessation of cocaine use is sought, with a focus on assessment, motivation and the involvement of support networks relapse prevention including the identification of relapse cues maintenance of abstinence and learning the additional skills to achieve this (Platt 2000). 114

121 Access to treatment generally Access to treatment should be rapid (Task Force to Review Services for Drug Misusers 1996). Outreach services should attract stimulant users into treatment services (see Outreach work in Chapter 4). Treatment retention may be enhanced by offering quick access to treatment and personal support to address crises in stimulant users lives (Klee et al. 1998). In areas with high rates of crack-cocaine use, there may be a need for specific workers in drug treatment agencies or for specific specialist crack-cocaine services (Haynes et al. 2000). Flexible boundaries and a user-friendly and relaxing environment appear to be particularly important for cocaine users (Audit Commission 2002) Access to specific treatments Advice and information: Access to these services was rated highly by stimulant users (Farrell et al. 1998). Research suggests that giving early appointments and an empathetic, encouraging early experience in treatment, may be important in treatment retention and outcomes (Witton and Ashton 2002). See Advice and information section in Chapter 2. Needle and syringe facilities (see Needle exchange facilities in Chapter 2): Stimulant users are usually under-represented in needle exchange programmes, although there is plenty of evidence of stimulant injecting. Services must be aware of the high rate of injecting and provide advice and information to their clients about the risks associated with injecting stimulants. Psychological therapies: Large-scale studies in the US suggest that psychosocial treatment programmes are effective in the treatment of problem cocaine users (Simpson et al. 1999) and that effects of treatment last (Gossop et al. in press). Drug-focused counselling may be effective for many, and group therapy may be a cost-effective option (Witton and Ashton 2002). Cognitive behavioural therapy (CBT) has been shown to be significantly better than interpersonal psychotherapy for cocaine users with higher severity of problem cocaine use (Carroll et al. 1991). One year after receiving CBT treatment, cocaine users continued to reduce their use of cocaine, whereas cocaine users who had received clinical management (a non-specific psychotherapy) remained stable in their use of cocaine. CBT has also been shown to be more effective than clinical management in retaining depressed cocaine users in treatment (Carroll et al. 1995a). CBT may be the treatment of choice for the more severely dependent cocaine users (Carroll 1998). Research from the US has shown that four programmes of psychological therapies were effective in reducing cocaine use. However, one type of therapy produced a greater reduction in cocaine use and a more rapid reduction in cocaine use than the other treatments; it comprised individual drug counselling (based on the 12-step approach) offered twice weekly for three months, then once weekly for three months, with concurrent weekly group therapy (Critschristoph et al. 1999) (see Care-planned counselling in Chapter 2). Behavioural interventions: these have shown some promising results in the US (Platt 2000), but there has been no research into these interventions in the UK. Structured day programmes (SDPs): Some evidence from Project Star and the US suggests that SDPs may be helpful. These programmes may be particularly suited to patients with stable accommodation and less complications (Witton and Ashton 2002). SDPs have components of psychological therapies outlined above, 115

122 as well as productive activities and peer support. They are also able to offer a higher level of support than traditional outpatient treatment (see Structured day programmes in Chapter 2). Inpatient services: While many stimulant users may not require prescribing interventions for detoxification, some may require inpatient admission for the withdrawal period, particularly if they experience severe depression or suicidal ideation on withdrawal. Inpatient detoxification may be required for co-morbid substance use (e.g. alcohol or sedative withdrawal symptoms) (see Inpatient substance misuse treatment in Chapter 2). Community prescribing: Although prescribing of substitution medication has been described for amphetamine users (Department of Health et al. 1999), there is little evidence for its efficacy, and amphetamines are not licensed for this indication (see Community prescribing in Chapter 2). Prescribing for symptomatic relief may be indicated, for example, antidepressants for major depressive episodes or anti-psychotic medication for psychotic symptoms (Ghodse 1995a). Many drugs have been the subject of experimental studies to determine if they are able to aid with cocaine withdrawal and relapse prevention, but there is no clear evidence of efficacy (Platt 2000; Soares et al. 2002; Lima M. S. et al. 2002; Lima A. R. et al. 2002). There is some evidence for the efficacy of disulfiram for patients with cocaine dependence and alcohol dependence or abuse, although the use of alcohol and cocaine with disulfiram could potentially cause serious physical adverse effects (Carroll et al. 2000). Also the mechanisms of effect are currently unclear. Residential rehabilitation: These services were found to take clients with more severe and multiple problems and achieved reductions in drug use and crime (Simpson et al. 1999) (see Residential rehabilitation in Chapter 2). Criminal justice: Criminal justice agencies may provide an important pathway into treatment (e.g. via arrest referral or prison based workers), and stimulant users may benefit from Drug Treatment and Testing Orders (see Criminal justice in Chapter 4). Consideration of alternative therapies: Such therapies are used already in some treatment services, although evaluation has been limited. There has been some indication that auricular acupuncture may have some efficacy in relation to a reduction in cocaine use, although further work is needed (Avants et al. 2000). It is possible that patients who value this treatment may be attracted into treatment and retained longer (Witton and Ashton 2002). Self-help groups (e.g. Cocaine Anonymous): There is an emerging evidence base from the USA that the regular use of self-help groups can be beneficial to client outcome from drug treatment (see section 4.6). 116

123 3.2 Women drug users Description of the special group This special group is defined as women experiencing problematic drug use involving a range of substances. It should be remembered, however, that women do not constitute a heterogeneous group and differ in terms of characteristics such as race, ethnicity, sexuality, age, physical or mental ability. Women drug misusers also differ along the dimensions of the nature of their misuse of drugs (e.g. drug of choice, route of use, frequency of use, etc) Epidemiology/nature and extent Prevalence The Department of Health statistical bulletin, based on the statistics of the Regional Drug Misuse Database (RDMD) consistently reports a ratio of 3:1 male:female (Department of Health 2000d). This figure is not indicative of prevalence, but offers a description of women s uptake of drug services and is believed to be an underrepresentation. Although this ratio of 3:1 has remained consistent over a number of years, there are instances elsewhere where other ratios have been reported. For example, a survey of drug agencies in Scotland revealed a male to female service user ratio of 1.5:1 (Ditton and Taylor 1990). The RDMD statistics demonstrate that patterns of drug use are similar for men and women. For example, figures for the six months ending March 2000 show 63% of both men and women reporting heroin as their main drug of misuse. This pattern remains true across most categories of drug, with the exception of cannabis, which is more likely to be reported as a main drug of misuse by men (12%) compared to use by women (6%) (Department of Health 2000d). The RDMD statistics report that women are less likely to have injected in the last four weeks than their male counterparts (42% compared to 47%) (Department of Health 2000d). However, women report higher incidences of having shared injecting equipment in the last four weeks than men (25% compared to 19% in the figures to March 2000) (Department of Health 2000d). There is limited reliable prevalence data for drug-using women, usually attributed to women s status as a hidden drug-using population. Population studies such as those made of the prison population and the British Crime Survey offer useful sources of data on women s drug misuse. These studies provide data on women drug misusers as follows. The Office for National Statistics (ONS) survey of substance misuse among prisoners in England and Wales found that women roughly approximate men in drug consumption and dependence. However, more women reported opiate dependence than did men. Women prisoners also reported less cannabis use than the men (ONS 1999b). This finding is consistent with that reported by the RDMD statistical bulletin. Women in the prison population were more likely than men to report dependence. The ONS survey reported that almost 50% of women on remand were dependent on opiates compared with just over 25% of the men on remand. The report of the 1998 British Crime Survey suggests a male:female ratio of 1.4:1 for use ever and 2:1 for use in last year or month (Mirlees-Black et al. 1998). 117

124 The ONS shows comparable rates of use of drugs in the last year between young women and young men (12% and 13% respectively). Broadly similar rates of use can be found in each age group, that is, 11 through to 15 years (ONS 1999a). Some research has shown that women are over-represented in cases of HIV, although more men than women inject. For example, studies have shown that in % of Glasgow s injectors identified as seropositive were women (ANSWER 1992; Barnard 1993). Similarly, in the US a study of drug users in Florida found that the seropositivity rate was 26.5% for women drug users compared to a rate of 19.5% for male drug users. Reasons posited for this included a range of social factors including homelessness and working as sex workers. Crack-smoking women were twice as likely to be HIV-positive than non-crack smokers, and those who smoked crack and were injecting drug users were five times more likely to be HIV-positive. Those who were injecting drugs but not smoking crack were six times as likely to be HIV-positive (McCoy et al. 1999). Substance misuse is often linked to specific behaviours and lifestyles (e.g. commercial sex work) that place women at the risk of HIV infection (Wambach et al. 1992) Nature and extent (particular needs) Physiological and psychological responses Research into the nature of women s drug use has included investigations into the differential effects of drugs and experiences of drug misuse, between men and women. This includes research that points to differentiation between men and women in their susceptibility to the ill-effects of alcohol and other drugs (Swift et al. 1996). This is due to physiological differences between the genders such as weight, body composition and hormones, as well as in metabolism of alcohol and other drugs. For example, due to their higher body fat and lower body water content than men, women have a higher blood alcohol concentration than men after an equivalent dose (Deal and Gavaler 1994; Jarvis 1992). Women are reported as experiencing adverse physical and psychological reactions to their drug use in a shorter period of time than do their male counterparts. This phenomenon is sometimes termed telescoping. Women s use of drugs often begins at a later age than is commonly found in men, but despite this shorter drug career, women enter treatment at much the same age as men due to greater vulnerability to the adverse effects of drug misuse (Finkelstein et al. 1997; White et al. 1996; Hser et al. 1987) However, observance of this phenomenon is limited to studies of women who have accessed treatment. In addition, women who have accessed treatment report a number of recurrent physical and mental health problems including hepatitis, eating disorders, selfmutilation, suicide attempts and low self-esteem. There are high rates of a history of physical or sexual violence. Other studies have suggested that the presence of such factors can also be predictive of relapse (Swift et al. 1996). Social factors Women s lack of uptake of drug services has often been attributed to two factors: childcare concerns and the stigmatisation experienced by women drug misusers. Although each of these factors can result in different rationales for not approaching or utilising services, they are fundamentally interconnected. Childcare responsibilities provide contrasting responses among women drug users. Many women are concerned that approaching drug services may have the consequence of their children being taken into care (Thom and Green 1996). 118

125 However, childcare responsibilities can act as an important motivator to women wanting to modify their drug misuse (Taylor 1993). Many women will prioritise the needs of their children above their own needs and seek to modify their behaviour accordingly. However, women often have to undertake this in isolation from drug service provision because of their childcare concerns. If women do approach services, it is often the case that they will not find them to be child-friendly. Few services, with some notable exceptions, can treat women effectively and at the same time offer a safe, child-friendly atmosphere. Pregnant drug misusing women require support during the pregnancy and delivery of the baby. Although drug misusing women can experience secondary amenorrhoea, this does not mean that ovulation has ceased. The absence of menstruation can lead women to believe their fertility is reduced, often resulting in the woman ceasing the use of contraception. As result, women may not be aware of a pregnancy until the second or third trimester. It is important for the health of both the child and the mother that drug misusing women present to antenatal services as early in a pregnancy as possible. Misuse of drugs can lead to pregnancy complications as well as low birth weight and premature birth. Careful management of withdrawal or stabilisation is required. This should only be undertaken by, or in partnership with, experienced drug service specialists, as too rapid a withdrawal can have harmful effects on the foetus. Management of labour should also be undertaken to ensure adequate pain relief. Issues of stigmatisation from both others and the woman herself can become particularly acute during pregnancy. Added to this, pregnant drug misusing women can be extremely fearful of losing their child post-partum. These factors can lead to delayed presentation to antenatal services. However, pregnancy can also be an important determinant in initiating help-seeking in drug misusing women. Pregnancy is therefore a crucial moment when specific and timely interventions are required. Women drug misusers experience high levels of stigmatisation from both society and themselves. Drug misusing women can feel that they have deviated from the traditional societal norms expected of women, including expectations about their suitability as mothers and carers (Broom and Stevens 1991). Research has shown that despite their lifestyle, many women drug users hold traditional values (Cuskey et al. 1982; Polit et al. 1976; Rosenbaum 1981; Suffet and Brotman 1976). Research has also shown that the conflict between their attitudes and their lifestyles leads women to experience low self-esteem (Griffin-Shelley 1986; Reed 1985). The career of women drug users has been analysed as one of narrowing options in which the practices of traditional ways of living become increasingly closed off. The differential impact of drug misuse and the resultant stigmatisation of drug misusing women encroaches on their experiences of sexual relationships. A number of researchers have reported that drug misusing women are more likely to have a drug misuser as a sexual partner than are male drug misusers (Gossop et al. 1994a; McKeganey and Barnard 1992). Traditionally research has looked at drug using women as having been introduced to drug use by men, and has determined that they rely on men for their drug supply. This view has been challenged by other research which argues that women are becoming more assertive and are as independent in maintaining their habits as men are (Anglin et al. 1987; Taylor 1993). Women obtain their own drugs, and sometimes do so for their male partners. Women often finance their drugs habit themselves and run the same risks as their male counterparts (Taylor 1993). 119

126 The link between drug use and commercial sex work has been noted by research (Anglin et al. 1987; Cushman 1972; Datesman and Inciardi 1979; Plant 1990) but there is disagreement over the importance of commercial sex work in supporting women s substance misuse. Some suggest that it is the most common means of funding drug misuse (Cushman 1972) while others have found that it is not the most widely used method (Taylor 1993) Evidence base Service accessibility and service utilisation Anecdotally, women drug misusers are believed to find drug services inaccessible. This is thought to result in their under-representation in statistics gathered from services. Underpinning this supposition is a belief that women drug misusers are generally a hidden population and that actual figures for women s drug misuse are higher than current statistics would suggest. This premise is partly borne out by higher ratios of female to male drug misuse found in population studies. Research has demonstrated that women are also under-represented in the uptake of services offered by needle exchanges (Gaughwin et al. 1990; Stimson et al. 1989). Women drug misusers are at risk of HIV infection and may be more vulnerable than their male counterparts. Women working in the sex industry may have particular needs in relation to blood-borne diseases (see Chapter 4). They also have particular needs in relation to flexibility of access around their working hours. In some situations it may be necessary to provide outreach service to these women where appropriate (see Outreach work in Chapter 4). Primary care services offer self-referred, easy-access provision to drug misusing women provided in their own community. Many women will be accessing primary care to meet their, or their dependants, healthcare needs. The current development of shared care provision offers increased accessibility to women drug misusers. This is particularly pertinent where women are pregnant and require management of their pregnancy. Women in rural areas experience further barriers to accessibility due to elements such as poor public transport infrastructure and lack of access to private transport, lack of local primary care facilities, lack of childcare provision, and general isolation from drug services and other services that are women-specific Barriers to service utilisation Women are often reported as experiencing barriers to entry to service provision. These barriers to entry are partly due to women drug users stigmatisation drug misusing women are unlikely to approach services which they feel may exhibit the same attitudes as they experience elsewhere. Other, more practical, difficulties exist. These include factors such as: a lack of economic resources fear of childcare proceedings lack of trust in confidentiality procedures poor referral networks poor advertising of women-specific services lack of women-oriented services lack of services able to meet the full range of women drug misusers treatment needs conflicting child-related responsibilities (Coupe 1991; Ettore 1992; Hunter and Powis ; Taylor 1993; Addiction 120

127 Research Foundation 1995; Babcock 1996; Hodgins et al. 1997; Kandall and Petrillo 1996; National Institute on Drug Abuse 1996; Paone and Alperen 1998; Perry 1978; Swift et al. 1996; Thom and Green 1996). Drug services are often perceived to be provided for the majority population who access them that is, white, opiate-misusing men under the age of 35. For many women, the type of service provided for this population does not meet their specific needs. There are also institutionalised barriers to service use. The high levels of drug misuse found among women prisoners (remand and sentenced) suggests that points at which women come into contact with the criminal justice system may offer opportunities to provide treatment. However, women do not currently experience equality of experience in the criminal justice system. Home Office research reports that women are less likely than men to receive a custodial sentence for a first drug offence. However, repeat offenders of either gender were equally as likely to receive a custodial sentence (Home Office 1999). This suggests the importance of appropriate community sentencing options for women first-time offenders. However, community sentencing has limited options for women offenders. An Inspectorate of Probation report (HM Inspectorate of Probation 1996) found that: only a minority of probation areas had strategies, action plans or practice guidelines to ensure that women had equal access to community sentences only a minority of areas provided women-only group work and community service tasks the needs of women were not a priority when developing local partnership arrangements to deal with the misuse of drugs and alcohol and the effect of unemployment there was a lack of consideration of all the issues involved when preparing presentence reports on women offenders. Lack of knowledge of childcare provision meant that some women were excluded from consideration for a community sentence provision of safe and secure accommodation pre- and post-trial was patchy. The impact of new community sentencing orders, such as Drug Treatment and Testing Orders, on the sentencing and provision of appropriate and effective treatment for women has yet to be assessed Professional guidance and legal framework In relation to service provision for women who have children, there will need to be a locally determined, legally sound and widely disseminated child protection and drug use policy, agreed by the local Area Child Protection Committee. Other relevant legislation includes: The Sex Discrimination Act 1975 The Equal Pay Act 1970 The Children Act 1989 Mental Health Act 1983 National Health Service and Community Care Act Care pathways Care pathways with this client group will include collaboration and joint working with a number of services, based on the individual needs of the client and the presenting 121

128 problems, and may include a range of professionals and services, including those listed below Other collaborators and onward referral Drug services will need to establish protocols for collaborative work and referral with other services that focus on issues such as physical and sexual abuse, eating disorders, self-mutilation and parenting skills, for example: mental health services (health and local authority) comprehensive healthcare social services women s refuges (where they will work with drug-using women) women s projects antenatal care (where appropriate) childcare provision education, training and employment services parenting support housing welfare benefit advice residential rehabilitation. The high prevalence of drug misuse problems among women prisoners necessitates consideration of effective treatment within the prison system, including the planning of throughcare and aftercare post release. Planned care must include provision of services outlined above as necessary Treatment processes/environment Consultation/partnership working The planning and design of services for women drug misusers must include a number of stakeholders, including: women drug misusers and their dependants local communities providers of generic services to women (and children). The high levels of concomitant mental and physical health problems, alongside histories of physical and sexual abuse, require a co-ordinated and planned approach to treatment across a number of services, including those that do not specialise in working with drug misusers Staff skill mix and qualifications Staff require relevant skills to: work effectively with issues of child sexual abuse, physical abuse, eating disorders, other mental health problems address the specific needs of black and lesbian women liaise effectively with other professionals (e.g. midwives, social workers) provide a comprehensive range of healthcare. To provide effective services to drug misusing women, team structures should offer: a relevant ratio of women staff members for the service user population an appropriate mix of staff based on factors such as ethnicity and sexuality male members of staff who are able to recognise and deal with the specific nature of women s drug use (as not all women will want to see only women staff members). 122

129 Staff should be appropriately qualified in: health (physical and mental) counselling (specifically competent in dealing with substance misuse, eating disorders and sexual abuse) social work criminal justice childcare provision Staff This range of qualifications suggests that the following range of professionals should be involved: nursing staff, including midwives medical staff probation officers social workers counsellors childcare workers Treatment provision Evidence suggests that effective women-specific treatment provision should include the following features: services for children (e.g. daycare, play therapy, child developmental monitoring and parental training) comprehensive healthcare (e.g. antenatal, family planning and HIV prevention) appropriate staffing (e.g. female staff and culturally/racially sensitive) shared care treatment programmes, particularly pregnancy liaison projects which can be effective in retaining and treating pregnant drug misusers (Clark and Formby 2000) advocacy (e.g. contact with child protection services, welfare) (Paone and Alperen 1998) access to education and training, housing support, support with co-morbid mental health problems such as depression and eating disorders, and aftercare following treatment (Hodgins et al. 1997; Finkelstein et al. 1997; National Institute on Drug Abuse 1996; Oppenheimer 1989; Paone and Alperen 1998) treatment that takes account of factors concomitant to women s drug use (e.g. physical/sexual abuse, eating disorders, self-mutilation) group/therapy counselling: Several studies point to better treatment outcomes and lower rates of relapse for drug-using women who have access to group/therapy counselling, especially single sex provision, as many women do not feel able to discuss personal issues with men present, and may have issues to do with past sexual or physical abuse (Hodgins et al. 1997) women counsellors, women-only sessions (drop-in or group therapy), and telephone lines staffed by women (DAWN 1994; Ettore and Waterson 1989; Hackland 1998) extended treatment: Women are reported to benefit less from brief interventions and more from extended treatment (Thom and Green 1996) outpatient behavioural programmes accurate assessment of the needs of drug misusing women and their dependants, and the provision of a menu of drug services (Hodgins et al. 1997). 123

130 3.2.6 Outcome monitoring/procedures For detailed information on monitoring, see Performance and outcome monitoring in Chapter Special issues for this special group under the treatment modalities Local, child and parent-friendly residential placements are made available (see Residential rehabilitation, in Chapter 2). Integrated local childcare policies and protocols are developed with antenatal services and child protection agencies (see Substance misusing parents in Chapter 3). There is a need for integrated service provision with a number of specialist mental health, social care and criminal justice providers (see Criminal justice and Psychiatric morbidity (dual diagnosis) in Chapter 4) The issues surrounding single sex versus mixed sex service provision, including group therapy/counselling (see Care-planned counselling in Chapter 2) are considered. The needs of all groups of women, including black and minority ethnic women, lesbian women, women with impaired physical ability, and women who are carers (see Black and minority ethnic populations in Chapter 3) are considered. The relative merits and impact of brief versus extended interventions (see Careplanned counselling in Chapter 2) are considered. The high level of HIV infection among drug-misusing women relative to their injecting practice are considered (see Blood-borne diseases in Chapter 4 and Needle exchange facilities in Chapter 2). 124

131 3.3 Black and minority ethnic populations Description of the special group This special group is defined as individuals from black and minority ethnic groups experiencing drug and alcohol misuse problems. The term minority ethnic refers to groups of people who share certain characteristics (common history, language, religion or family or social values), that distinguish them from the majority ethnic population. The term visible minorities is also sometimes used. Black and minority ethnic populations are heterogeneous, with differences both within and between groups. According to the 1991 Census, black and minority ethnic people form approximately 6% of the total population. The majority live in urban areas, with nearly half concentrated in the greater London area, and the rest concentrated in the West Midlands, Manchester, Liverpool, Leeds and Bradford. In London, one in four people is from a black and minority ethnic group, and it is estimated that by 2011, over 50% of the population of two London boroughs will be from black and minority ethnic groups. Although there are few areas in the country where there are no minority ethnic groups, the majority of local authority districts have a population with less than 2% (Department of Health Social Care Group SSI 1998). The largest minority ethnic groups in Britain have their origins in the Indian subcontinent and the Caribbean, with smaller numbers of Africans, Chinese and others. Although half of the non-white minority ethnic people living in Britain were born in this country, research shows that they are significantly disadvantaged in many respects, including obtaining health, housing and social services. Compared to the general population, black and minority ethnic people are more likely to be unemployed or on a low income. They are also more likely to live in sub-standard or overcrowded housing and suffer stress-related mental illness. Despite these factors, minority ethnic people have been found to be less likely to receive acute and community healthcare, to use domiciliary, day and residential services, and to seek public housing (Commission for Racial Equality et al. 1997; also see Rawaf and Bahl 1998) Epidemiology/nature and extent (particular needs) Prevalence The Department of Health statistical bulletin on drug treatment, based on the statistics of the Regional Drug Misuse Databases, does not provide national statistics by ethnicity, although this information is collected at local levels. These data are not well supplied by local agencies and a large proportion is missing; it was therefore felt that any analysis of this data would be misleading (Department of Health 2000c). It is recommended that commissioners of drug services require, through service specifications, that treatment agencies improve the collection of this data for the National Drug Treatment Monitoring System (NDTMS) and other monitoring systems. This is now required by the Race Relations (Amendment) Act The paucity of data on drug treatment and ethnicity mirrors a situation in healthcare in general. Despite guidelines for collecting data on ethnicity (NHS Executive 1994), not all NHS organisations have done so uniformly (De Cock and Low 1977). It is argued that the quality of data by ethnicity is improving, but the public health benefits of collecting this surveillance data needs to be maximised (Nicoll et al. 1997). 125

132 Existing data and anecdotal evidence show that drug use is evident in black and minority ethnic communities, and that a range of drugs is used. The most reliable source of information on ethnicity and drug use is self-reported data for the British Crime Survey (BCS). Data indicate that overall drug use is more widespread among whites than any other ethnic groups. There are differences, however, among the various minority ethnic groups. Low levels of use are found among South Asians and black Africans. The level of use among African-Caribbeans is similar to that of the white majority population, although this similar level is primarily driven by cannabis. These differences are amplified when analysis is restricted to those aged years (Ramsey and Spiller 1997). Existing data and anecdotal evidence suggest problematic use among individuals from minority ethnic populations. Drug use exists among women as well as men, even among South Asian groups where it often remains hidden. Studies also suggest important differences by ethnicity in patterns of problematic use. Problematic drug use among African-Caribbeans often centres on crack-cocaine use and cannabis use to some extent. This does not mean that heroin use does not exist. It has been noted that prison poses a particular risk of introducing crack users to opiates. Problematic heroin use has been noted among South Asian groups, notably Bangladeshis, Indians and Pakistanis, and among Vietnamese (Awaih et al. 1992; Chaudry et al. 1997; Sherlock et al. 1997; Patel 2000a, 2000b; Sangster et al. 2002; White 2001). The use of Qat (or Khat) among Somalis has also been documented (Griffiths 1998). Black and minority ethnic heroin users appear to be less likely to inject than their white peers and more likely to smoke. Nonetheless, there is evidence of injecting in South Asian, African-Caribbean, Turkish, Middle Eastern, North African and other communities that share a stigma on injecting (Abdulrahim et al. 1994; Sherlock et al. 1997; Pearson and Patel 1998; Patel 2000a, 2000b). It is believed that these injectors are under-represented in needle exchanges and are thus not accessing harm reduction initiatives (see Needle exchange facilities in Chapter 2) Evidence base Service accessibility and service utilisation Drug use among black and minority ethnic users must be located within a wider context of social exclusion, deprivation and discrimination. Although the issue has not been systematically investigated, there is a widely held belief and some research evidence that black and minority ethnic drug users find treatment services less accessible than do the rest of the population. It is also widely believed that black and minority ethnic drug users are under-represented in treatment services in the majority of the country (Advisory Council on the Misuse of Drugs 1998; Mirza et al. 1991; UKADCU 1998a; Task Force to Review Services for Drug Misusers 1996; Patel 1993; Sangster et al. 2002). Evidence suggests that under-representation may be particularly marked in relation to South Asian communities (Sangster et al. 2002). This may not be the case everywhere. Regional Drug Misuse Database (now the National Drug Treatment Monitoring System) figures from London show that in the capital over the last decade the ethnic profile of users attending drug services is broadly similar to that of the general population (Daniel 1992; Sondhi 1999; Sangster et al. 2002). However, this does not necessarily mean that the needs of black and minority ethnic users in London are adequately met. Nor does it mean that the needs of all black and minority ethnic groups are addressed. Little is known about the needs of refugees and asylum seekers and other more established groups from the Middle East, for example. 126

133 Anecdotal evidence indicates that drug treatment services often fail to retain black and minority ethnic clients in treatment, and that treatment attrition rates are high. There is evidence that this is the case in the US (see, for example, Hser et al. 1990). Future research should investigate rates of retention in treatment among minority ethnic service users in England and the impact of attrition from treatment on treatment outcomes. There is some evidence that black women substance users are reluctant to approach their GP with personal problems and anxieties at an early stage, and that contact is established only when they have reached crisis point (DAWN 1991). They may therefore miss out on harm minimisation interventions aimed at reducing drug-related risk. Research data suggests that African-Caribbean users tend to present to voluntary sector treatment agencies, although this reflects, to some extent, the scarcity of crack services in the statutory sector. Asians, on the other hand, do use statutory sector services that cater for opiate users (Sangster et al. 2002). Although it is recognised that GPs could be a valuable source of care (Chaudry et al. 1997; Patel 2000a, 2000b), research carried out in London suggests low levels of uptake of drug treatment with GPs and primary care services by Asians and African-Caribbeans (Sangster et al. 2002) Barriers to service utilisation The mental health National Service Framework states that the stigma attached to mental illness can be compounded by racial discrimination, with access to appropriate assessment, treatment and care inhibited (Department of Health 1999a). This statement is equally applicable to drug treatment and care services. Studies on drug treatment and ethnicity have suggested a range of obstacles or barriers to the utilisation of services by minority ethnic users. The opiate focus of drug treatment services at the expense of other substances, most particularly stimulants (crack-cocaine), and even cannabis, has been noted (Tippell et al. 1990). There is a perception that drug treatment services are run for and by white people (Awaih et al. 1992; Mirza et al. 1991; Perera et al. 1993), that there is little empathy and understanding by staff, and that there is a lack of black and minority ethnic staff (Perera et al. 1993). Studies have also noted the view of black and minority ethnic drug users that services do not provide practical support; for example, a study has shown that black users tend to see drugs in the broad context of social disadvantage, unemployment and racism (Perera et al. 1993). Studies have also indicated that drug users experience of racism in other services and in the wider context of everyday life creates an expectation that approaching drug services would be unrewarding and possibly unpleasant (Perera et al. 1993; Khan 1999). Studies have also identified the fear of breach of confidentiality and suspicion of drug services, especially in relation to confidentiality, as major obstacles to accessing services (Abdulrahim et al. 1994; Perera et al. 1993; Awaih et al. 1992; Klee and Owaolabi 1993). For example, research among Asian users showed fear that agencies will inform the police and their families about drug use (Butt 1992). The shame and honour ideology held by some groups also works against the access of black and minority groups to services, and especially (but not exclusively) the access of women. Studies have shown that the social risks of disclosing drug use may be seen by some Greek and Turkish Cypriots and South Asians as more significant than the personal health risks associated with continued drug use (Abdulrahim et al. 1994; Khan et al. 1995). The under-utilisation of services by women should not be read as reflecting the absence of substance misuse among women. 127

134 Black and minority ethnic groups may also be less aware of local services (Task Force to Review Services for Drug Misusers 1996). Evidence from outside the drugs treatment field show that those with poor English experience particular difficulty in gaining access to care: their knowledge of services is limited, as is their ability to make contact by telephone or communicate with doctors and nurses (see for example Free and McKee 1998; Naish 1994; Smaje 1995; Free et al. 1996; Carr-Hill et al. 1996). There is some anecdotal evidence that refugees and asylum seekers often seek treatment in non-drug-specific services. This should be investigated at local levels, the appropriate training should be given, and care pathways should be developed. Refugee-specific barriers to service utilisation include fears that exposing drug use may jeopardise applications for refugee status. Also, previous experience of oppression or torture in home countries may have led to a distrust of any organisation viewed as official, including statutory health services Service appropriateness There is evidence that, in general, healthcare services planned for the majority population are not always appropriate to black and minority ethnic groups (Smaje 1995). In the mental health field, the National Service Framework (NSF) points out that combined evidence suggests that services are not adequately meeting mental health needs, and that black and minority ethnic communities lack confidence in mental health services (Department of Health 1999a, p. 51). There is evidence that black people tend to be more critical of mental health services. Mental health service users from black and minority ethnic groups commonly report that mental health assessments are undertaken from a perspective that may not be sympathetic to their own ethnicity (Department of Health 1999a, p. 44). These conclusions can safely be applied to the drug treatment field. Research on issues of drugs and ethnicity has shows an institutional failing of existing drug provision in relation to: the image of services and their isolation from the communities an inability to identify and respond to the distinct patterns of drug use among minority ethnic communities a more general inability to respond to diverse needs (Sangster et al. 2002). There is a tendency by treatment agencies to adopt simplistic views of black and minority ethnic communities, and of ways of addressing their needs (Abdulrahim et al. 1994; Task Force to Review Services for Drug Misusers 1996). The mental health NSF states that mental health services need to develop and demonstrate cultural competence, with staff having the knowledge and skills to work effectively with diverse communities (Department of Health 1999a). This call for cultural competence was echoed by research among black and minority ethnic drug treatment professionals (Sangster et al. 2002). Studies have shown the predominance of Euro-centric counselling and support by treatment staff. They have also shown staff ignorance of cultural factors that impact on drug use and drug treatment (Abdulrahim et al. 1994). Research in other areas of mental health has shown how ethnocentrism among professionals shapes the experience of mental health services by black and minority ethnic users (Littlewood and Lipsedge 1989). Overall, research on black and minority ethnic drug users suggests a number of institutional failings in meeting needs. This is especially true for residential rehabilitation facilities, but also of the whole treatment system. There is no doubt that patterns of commissioning and service delivery, as well as treatment philosophy, sometimes work against meeting the treatment needs of black and minority ethnic 128

135 users. The most obvious example is the dearth of services that have the skills and expertise to work with crack users. Services that can meet the needs of African- Caribbeans are therefore often non-existent. Marginalisation from services can also take more subtle forms. Harm reduction, for example, which views the greatest harm to be associated with injecting, works against the access of South Asian and other non-injecting opiate users to services. As non-injectors, these users are often categorised by treatment services as low priority for methadone treatment. Moreover, as harm reduction initiatives focus on injecting, interventions simply do not address the needs of non-injectors. Interventions to prevent transition to injecting are particularly important and must be developed, especially among young South Asian heroin smokers (see Needle exchange facilities in Chapter 2) Professional guidance and legal framework The Race Relations (Amendment) Act 2000 (hereinafter referred to as the Act) is an amendment of the 1976 Race Relations Act and therefore continues to place public and voluntary sector organisations under the legal obligation not to discriminate on the grounds of race in functions such as service delivery, employment and policies. The Act defines the government s expectation for public organisations to pursue race equality in outcome and process. It places a general duty on all public sector organisations to promote racial equality and good race relations. The general duty requires due regard to the following three factors: the elimination of unlawful racial discrimination (direct as well as indirect or unintentional discrimination) the promotion of equality of opportunity the promotion of good relations between persons of different racial groups. In addition to the general duty, public sector organisations listed by the Act also have a number of specific duties, including the publication of a race equality scheme. This sets out how the authority intends to achieve its general duty, including arrangements for consultation with black and minority ethnic communities and the assessment of the impact of policies and functions on the three areas of the general duty. The scheme will also identify the action that will be taken to remedy problems that are identified, including those relating to access to information and services, and to staff training. The scheme is also required to identify information on how these and future policies and functions will be monitored. Race relations schemes must include partnerships or contracting arrangements with voluntary or private sector organisations. The other specific duties of the Act are for public organisations to publish on a yearly basis the ethnic monitoring of staff, recruitment, promotion and training. The specific duties of the Act fall to health authorities, primary care trusts and local government. However, DATs, commissioners and providers of substance misuse treatment play an important role in the process. It is good practice for organisations to develop their own race equality schemes. Commissioners can also explicitly identify action on race equality in contracts, service level agreements and service specifications. Race equality can also be explicitly identified in the strategic plan of the DAT and in service providers policies and protocols. The duty to promote race equality is enforceable by the judicial review process, and the Act gives the Commission for Racial Equality (CRE) enforcement powers. The general duty to promote race equality will be audited through monitoring the performance of the authority, as its other public duties are (Centre for Ethnicity and Health 2002; Alcohol Concern and DrugScope forthcoming). Other relevant legislation and guidance includes: The Sex Discrimination Act

136 Mental Health Act 1983 National Health Service and Community Care Act 1991 The Equal Pay Act 1970 The Disability Discrimination Act 1995 Scarman Report (Scarman, Lord (1981) The Brixton Disorders April 1981, Cmnd. 8427) Macpherson Report (Macpherson, Lord (1999) The Stephen Lawrence Inquiry, Cmnd 4262-I) Commissioning standards: drug and alcohol treatment and care (Substance Misuse Advisory Service 1999) QuADS: organisational standards for alcohol and drug treatment services (Alcohol Concern and Standing Conference on Drug Abuse 1999) Care pathways Other collaborators and onward referral In addition to collaborators already identified for all drug users (including gender and youth-specific ones), the following services or agencies may be necessary for onward referrals for minority ethnic drug misusers. Mental health services: - post-traumatic stress syndrome: Refugees and asylum seekers are particularly vulnerable, post-traumatic stress disorder is a common problem, and the risk of suicide is raised in the long term. The development of care pathways should account for evidence of co-morbidity of traumatic stress symptoms and substance misuse (Jacobsen et al. 2001). The risk of misdiagnosis and inappropriate treatment is also present in relation to traumatic stress and resulting from presentations of depression, psychosis, schizophrenia and personality disorder. Mental distress in refugees may well be responsive to early intervention, and severe and enduring mental distress may often be averted, or at least better managed - trans-cultural psychotherapies/counselling: Mental health services need to develop and demonstrate cultural competence, with staff having the knowledge and the skills to work effectively with diverse communities (Department of Health 1999a, p. 44). The Royal College of Psychiatrists have recently developed a register of all psychiatrists in the UK with an interest of special expertise in trans-cultural psychiatry (Royal College of Psychiatrists 1999) - depression among African-Caribbeans, Asians, refugees and asylum seekers is frequently overlooked, although rates have been found to be 60% higher than in the white population; depression among men from these groups is particularly high. People from black and minority ethnic populations are less likely to be referred to psychological therapies (Department of Health 1999a, p. 30; Sashidharan and Commander 1998) advocacy and interpretation services: Research show that doctors in general may not be unaware of interpreting services (Hicks and Hayes 1991) haematology departments (abnormal haemoglobinopathies such as sickle cell and thalassaemia) race-specific drugs projects community organisations local race relations councils or similar agencies link with GUM clinics. There has been a recent substantial increase in gonorrhoea, and black people in some areas are at greatly increased risk (Fenton et al. 1997). 130

137 3.3.5 Treatment processes/environment Needs assessment A needs assessment exercise must consider in detail patterns of substance use in black and minority ethnic communities, considering in particular the diversity of cultures that may require services (Abdulrahim et al. 1999). The particular service needs of black and minority ethnic problem alcohol and drug users must be reflected in service agreements, service specification and broader purchasing agreements and monitoring requirements (Abdulrahim et al. 1999). In the drugs field, as well as in other areas of health and social care, even though needs assessments of various black and minority ethnic communities have been carried out, the findings of these studies are often not acted upon. It is often argued that the undertaking of a needs assessment exercise among a particular group of people raises expectations that some practical work will be carried out. The fact that this is often not the case leads to the distrust that many people hold of needs assessment or research on the needs of black and minority ethnic communities. It is also acknowledged that needs assessment exercises only rarely actively involve the communities studied and do not lead to the engagement of the communities in substance misuse-related work. These problems have been acknowledged by the Department of Health, which funded the Centre of Ethnicity and Health (University of Central Lancashire) to develop the Black and Minority Ethnic Drug Misuse Needs Assessment Project. The project aims were two-fold: to produce a number of needs assessments across the country to highlight the drug-related needs of a range of black and minority ethnic communities to develop a process which would be based on the direct involvement of the various communities in undertaking the needs assessment and which would benefit them. The Centre provided intensive training to recruited volunteers, a support worker to facilitate the process and encouragement to engage local drug misuse organisations to ensure that the work was fed into the local drug misuse strategy (for more information see Strategy development The D(A)AT and all agencies within it must give detailed consideration to racial and ethnic equality, accessibility and anti-discriminatory practice as follows: the D(A)AT and each of its constituent agencies have developed strategies to tackle issues of racial/ethnic equality. The strategy: identifies gaps and priorities are identified identifies clear objectives and measurable targets are identified includes timescales funding or other resources are available to tackle issues of racial/ethnic equality (SMAS 1999). 131

138 Consultation and partnership working The mental health NSF states that all services must be planned and implemented in partnership with local communities and must involve service users and carers. If services are to match the needs of black and minority ethnic communities and reduce the present inequities, this principle is especially important (Department of Health 1999a). This is equally true for the field of substance misuse. Consultation of minority ethnic communities is therefore essential. However, it is not enough on its own. The consultation of the various communities is often carried out by health and social care organisations, but the findings of these exercises are only rarely acted upon. Consultation is therefore often tokenistic, and it is now acknowledged that a type of consultation fatigue exists among black and minority ethnic people who feel that consultation exercises are a waste of time. Consultation must be linked to action. The notion of community engagement or participation has been on the policy agenda for a long time, but initiatives truly based on partnership working remain few and far between. The model of community engagement developed by the Centre for Ethnicity and Health at the University of Central Lancaster has proven to be successful and is a model of good practice that can be replicated at local levels Staff skill mix and qualifications There is a dearth of drug practitioners from black and minority ethnic backgrounds, especially at management level and among commissioners and DAT co-ordinators. Anti-discriminatory employment practice must be adopted. The Race Relations (Amendment) Act 2000 now requires the monitoring of employment practice. Recruitment of staff from local communities is the most effective longer-term strategy for building cultural competence (Department of Health 1999a, p. 44). Relevant competencies are outlined in the Drugs and Alcohol National Occupational Standards (DANOS). All staff must be aware of and sensitive to cultural difference and racial discrimination. This has training implications. Services need to develop and demonstrate cultural competence, with staff having the knowledge and skills to work effectively with diverse communities (Department of Health 1999a, p. 44) Treatment provision Johnson and Carroll s review of UK and US literature and the Home Office Drug Prevention Initiative Team s work identified successful strategies and some key elements of good practice (Johnson and Carroll 1995). They recommend that: Direct action must be targeted at black and minority ethnic groups to meet their specific needs. At the same time, all activity must take into account diversity in the general population. The resource needs of black and minority ethnic community and drug service providers must be met if work is to be relevant and effective. Raistrick and Heather (1998) have identified criteria for commissioning targeted services alongside generic services. These criteria can be applied to race-specific projects and include: the sub-group is under-represented in cases seen by generic services there is a need for sub-group specification modification of standard treatments standard treatments can be enhanced by sub-group specific modifications 132

139 the speciality service is cost-effective within local expectations Outcome monitoring/procedures The improvement of the collection of data cannot be stressed enough and is now a statutory requirement. The CRE recommends that services set up systems to monitor workforce and service provision to assess and change practice, where needed. Tools such as the Racial Equality Means Quality (REMQ) developed by the CRE can be used. It is recommended that monitoring by ethnicity is embedded in contracts, service level agreements and service specifications. Commissioners at local levels should also ensure that the data collected provides information relating to the range of local black and minority ethnic groups. It is argued that the use of the optimal detailed codes by ethnicity as defined by the Department of Health (Department of Health 2001a) provides a better picture of local needs. In particular, the detailed codes provide information on the needs of refugees and asylum seekers and other groups who may disappear where broader ethnic coding is used. See Performance and outcome monitoring in Chapter Special issues for this special group under the treatment modalities Drug treatment and care providers must take into account the experience of black and minority ethnic users in relation to other areas of healthcare. For example, large numbers of young African-Caribbean men are admitted to hospital under the Mental Health Act, treated by physical rather than talking therapies, and admitted to secure units. Young African-Caribbean men are also more likely than young white men to be referred to mental health services by the criminal justice system than by GPs or social services (Department of Health 1999a). Furthermore, there are high numbers of compulsory admissions and admissions to secure beds from the African- Caribbean population (Department of Health 1999a). Black and minority ethnic people s experiences of the criminal justice system must also be taken into account. It is now widely acknowledged that there are significant differences in the experiences and perceptions of the criminal justice system between members of black and minority ethnic groups and the majority ethnic population. Refugees and asylum seekers also present particular needs which often remain undetected. These could include co-morbidity of post-traumatic stress disorder and drug and alcohol misuse (Jacobsen et al. 2001). 133

140 3.4 Young people and substance misuse Models of care focuses on commissioning and provision of drug treatment for adults, that is those aged 18 years and older. The provision of drug and alcohol treatment for adolescents and young people is extensively covered elsewhere (Health Advisory Service 1996, 2001b). Commissioning these services should be within the existing frameworks for commissioning health and social care for young people, to provide adequate links to generic services for children and families. There should be explicit links to DATs and commissioning processes for adult drug and alcohol treatment, with particular reference to commissioning interface services for those in transition from adolescence to adulthood (for those aged 16 to 21) Description The term children refers to all those individuals who are under the age of 18, in accordance with the United Nations (UN) Convention on the Rights of the Child There are, however, certain sections and statements in this document where young people or children are defined as those under the age of 16, and these will be clearly specified as such. Lower age distinctions between definitions of children and adolescents and young people can be hard to draw clearly, as they vary widely between departments and services. It must also be noted that local authorities acting under certain provisions in the Children Act 1989, courts and the Prison Service may also use the term young people to refer to those up to the age of 21. The Young people s substance misuse plans: DAT guidance (UKADCU 2001) refers to young people as those under 19 years of age. This differentiation is to ensure that adequate transition arrangements are put in place for drug treatment service users, aged 18, as they move to adult service provision Professional guidance and legal framework The Children Act 1989 and government guidance on its implementation forms the overarching framework for most interventions and arrangements for addressing the needs of young people in England and Wales. It details the responsibilities of local authorities in ensuring that young people s needs are met through appropriate services (section 17 of the Act), and that their safety and well-being are protected by appropriate investigation and intervention where a child is thought to be at risk of coming to significant harm (section 47 of the Act). Many aspects of the Act address themselves to appropriate means of responding to young people when they are involved in court proceedings, whether for reasons of accommodation and welfare decisions, or in relation to statutory responses to offending behaviour. This Act has a number of underlying concepts which should be applicable to all interventions with young people. In reaching decisions relating to the child: the welfare of the child is paramount the child s wishes and views should be sought and taken into account statutory intervention should be the minimum necessary to meet the needs of the child there should be interagency co-operation and partnership (Department of Health 1999d). 134

141 Philosophy and approach Approaches to young people should reflect the intrinsic differences that exist between adults and children, and between children of different ages. In all substance-related interactions and interventions with young people under the age of 18, consideration will need to be given to: differences in legal competence, age appropriateness, parental responsibility, confidentiality, and exposure to, as well as protection from, risk and harm. Young people s drug use should not be considered in isolation from alcohol and volatile substance use. It is important that strategies and services are developed that can address all substance misuse by young people. Most professionals working with young people will encounter those who have tried, or who take, alcohol or illegal drugs. All professionals need to be able to respond appropriately to the needs of young substance users and their families. Working with young substance users can pose challenges for professionals, including the need to consider the degree of autonomy children should be given to decide their own treatment, and the extent to which services can and should involve parents and other professionals Aims and objectives All young people should have access to drug and alcohol education. All young substance users should have access to advice and information about their substance use, including how to reduce associated harm. All young substance misusers should have access to treatment that meets their identified needs Epidemiology Research from a range of sources indicates that over the last ten years there has been a significant increase in drug use among young people under 18: a fivefold increase among year-olds and eightfold among year-olds since 1987 (Balding 1996). However, this increase appears to have reached a plateau in 1997 (Balding 1999). A small minority of primary school children will have tried alcohol, volatile substances, and/or an illegal drug. One in every two or three young people has tried an illegal drug by the age of 15 (Balding 1997). This figure rises to almost half of males (48%) and over a third of females (42%) between the ages of 16 and 19 (Ramsey and Spiller 1997). Trends in young people s drug use indicate that: the vast majority of drug use by young people is cannabis use a range of drugs are used by young people, often in combination with alcohol most drug use is one-off and experimental some experimental drug use can be dangerous (e.g. cocktails of drugs and alcohol) regular drug use is less frequent among young people there are regional differences and local variations in patterns and preferences in drug use, which may change rapidly drug use varies across age groupings and within and between different groups of the same age young women are using drugs at almost the same rate as young men more young people start to experiment with drugs at younger ages in each local authority in England there is evidence of small but significant numbers of young people with serious drug problems there are hotspots around the country where young people are using heroin 135

142 and/or injecting drugs the use and methods of use of some drugs is associated with more harm than others (e.g. solvent misuse, combinations of drugs and alcohol, crack use, heroin use and injecting drug use) levels of drug and alcohol use by young people in the UK are among the highest in the European Union (EMCDDA 2000) for some young people, leisure activities and socialising may be virtually synonymous with drug and alcohol use of one form or another (Boys et al. 2000) adolescent substance misuse is associated with behavioural, physical, mental health, social and legal problems (Audit Commission 1999; Gilvarry 2000) a Europe-wide survey of year-olds found that nearly all of those in the UK had drunk alcohol, with nearly half drinking within the past month (Miller and Plant 1996) 12% of male and 7% of female year-olds show signs of alcohol dependence (Alcohol Concern 2000) the majority of young people who try drugs will eventually grow out of it without experiencing harm, but some will not (Swadi 2000) (Alcohol Concern 2000; Audit Commission 1999; Balding 1996, 1997; Boys et al. 2000; EMCDDA 2000; Gilvarry 2000; Miller and Plant 1996; Parker et al. 1998; Ramsey and Spiller 1997; Social Services Inspectorate 1997; Swadi 2000) Evidence base Barriers to utilisation There is evidence that drug treatment services for young people are not fully developed in every area. A Health Advisory Service report (1996) documented that local responses to substance misuse problems among children and adolescents are often ad hoc. Services and interventions, where they exist, have developed in an isolated, uneven, patchy and idiosyncratic manner. A 1997 Social Services Inspectorate report (1997) on whether social services departments Children s Services Plans addressed the issue of substance misuse, concluded that: a third of authorities were actively addressing the needs of young people in their care in relation to substance misuse and have formulated strategies for the further development and prioritisation of targeted services a third of policies and provision were poor or ad hoc. However, departments were aware of the need to establish services specific to young people and reported being in the process of developing strategies through drug action teams (DATs) a third appeared to be paying little or no attention to the needs of young people in their area in relation to substance misuse and showed little evidence of having any intention to do so. In a service-mapping report (DrugScope 1999) of two surveys, one of 134 drug services targeting young people under the age of 17 and one of 102 DATs, it was found that: only 25 services were actually offering a dedicated service for young people, in line with Standing Conference on Drug Abuse and the Children s Legal Centre (1999) policy guidance over a quarter of services reported employing one or less dedicated young person s worker only a third of DATs reported that health services, social services and criminal 136

143 justice agencies had policies for working with young drug takers. A review of DAT plans for 2000/1 found: a lack of baseline data on current need and level of provision insufficient monitoring and evidence of service quality/effectiveness inadequate or absent drug service provision for young people in some areas too few young people s drugs workers too few childcare professionals with drugs training lack of a shared agency or professional approach to substance misuse wide variations in children's service planning/dat links. The review revealed that only 4% of DATs had full joint planning or commissioning systems with children s services and a further 52% had some joint planning or commissioning, but 44% were making little or no attempt to engage children s service planning (Lawrence 2001) Professional and statutory guidance There are a number of key documents that will impact on providing drug treatment to young people: United Nations Convention on the Rights of the Child 1989 Children Act 1989 Health Advisory Service (1996) Children and young people: substance misuse services the substance of young need Department of Health (1999d) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children Standing Conference on Drug Abuse and the Children s Legal Centre (1999) Young people and drugs: policy guidance for drug interventions Drugs Prevention Advisory Service and Standing Conference on Drug Abuse (1999) Young offenders and drugs: guidance for DATs and YOTs Department of Health (1998) Quality Protects: framework for action (updated annually) Department of Health (2000a) Framework for the assessment of children in need and their families Standing Conference on Drug Abuse (2000) Assessing young people s drug taking: guidance for drug services United Kingdom Anti-Drugs Co-ordination Unit (UKADCU) (2001) Young people s substance misuse plans: DAT guidance DrugScope/Drugs Prevention Advisory Service (2002) Assessing local need: planning services for young people Care pathways All young people s drug treatment services should be developed in line with the Standing Conference on Drug Abuse and the Children s Legal Centre (1999) ten key policy principles, as outlined below. As a matter of good practice these should inform and underpin the development of drug services for young people. A child or young person is not an adult. The overall welfare of the individual child or young person is of paramount importance. The overarching principle in this document, in accordance with the Children Act 1989 and the UN Convention on the Rights of the Child 1989, is that of the welfare of the child. Each young person is unique and should be worked with on 137

144 an individual basis. The views of the young person are of central importance, and should always be sought and considered. Article 12 of the UN Convention on the Rights of the Child 1989 and the Children Act 1989 place emphasis on the need for those taking decisions in relation to a child to ascertain the child s views and wishes. The child s views should be listened to and given weight according to the child s age and maturity. Services need to respect parental responsibility when working with a young person. Providers of services should remember that there will be an adult with parental responsibility for virtually every young client. The education, involvement and support of parents or carers may be beneficial to successful work with young drug users, and parental consent may be required before intervening. Services should recognise the role of, and co-operate with, the local authority in carrying out its responsibilities towards children and young people. Local authorities have a responsibility to ensure that appropriate services are provided for children in their area who are in need, and to investigate and protect children at risk of significant harm. A holistic approach is vital at all levels, as young people s problems do not respect professional boundaries. Multi-agency co-ordination and consistent policies need to be achieved at commissioning, planning and contracting levels, linking with DATs, Area Child Protection Committees, youth offending teams and Integrated Children s Services Planning structures as key strategic and policy-making bodies. All clients of youth offending teams (YOTs) should have access to a named drug worker. YOTs can access budgets to purchase services which will contribute to a treatment programme for young offenders. Services must be child-centred. Interactions and interventions must be appropriate to the age, maturity and level of development of the individual child or young person. Their drug taking should be looked at within their wider personal, social and cultural background or circumstances. A comprehensive range of services needs to be provided. Service provision in any local area must be able to respond to different patterns of drug and alcohol use and misuse by young people, by providing access to a wide range of drug and alcohol-related interventions, as appropriate to each individual case. The range of interventions available should include: drug education, prevention programmes, advice, counselling, prescription and detoxification, rehabilitation, needle exchange services, as well as information, advice and support for parents. Services must be competent to respond to the needs of the young person. Staff in a young people s drug service should be competent to work with children, adolescents and families, and with substance misuse. 138

145 Services should aim to operate, in all cases, according to the principles of good practice. Services must operate within the current legal framework, respect the underlying philosophy of the Children Act 1989 and the UN Convention on the Rights of the Child They should also reflect accepted, evidence-based effectiveness. Services are responsible for being aware of the latest locally and/or nationally established policy and guidance on working with young people who take drugs. Planning services for young people in any local area should be based on the HAS Four Tier approach (Health Advisory Service 1996) see below. The HAS Four Tiers (Health Advisory Service 1996) Tier 1 generic and primary services The front line of service delivery to which children, young people and their families have direct access and which provide the first response to the needs of children and adolescents. These services are best placed to recognise and screen, and to provide some simple interventions with young people and their families. Tier 2 first line of specialist services Front line young people s specialist services are critical to the identification of vulnerable children and early identification. Their roles should be concerned with the reduction of risks and vulnerabilities to substance misuse, and the reintegration and maintenance of young people in mainstream services. Tier 3 services provided by specialist teams A multidisciplinary team demonstrating a threshold of expertise and competence that is capable of comprehensive assessment and formulation of an overall plan for substance use and various other problems, including outcome domains. The team will deal with the complex and often multiple needs of the child or young person, including substance problems. The aim is to reintegrate and include the child or young person into his/her family, community and school, training or work. Tier 4 very specialised services Very specialised children and young people s services used for particular interventions or focused work and/or short/temporary periods. This might consist of inpatient adolescent services or forensic units complemented by specialist young people s addiction teams, paediatric beds or intensive day centres for detoxification, crisis placements, specialist housing or fostering. The aim would be to provide specialist interventions and a setting for a particular period of time, and for a specific function, as an adjunct to and a backstop for the services for other tiers. Continuity of care pre, during, and post admission is important. A pathway intervention model is shown on the following page (Standing Conference on Drug Abuse and the Children s Legal Centre 1999). 139

146 Diagram 6 (Standing Conference on Drug Abuse and the Children s Legal Centre 1999) 140

147 Strategic development and consultation partnerships DATs were required to develop local plans for young people s services based on the four tiers by April These plans should be based on guidance to DATs advising them on how to undertake a local needs assessment for young people (DrugScope/Drugs Prevention Advisory Service 2002). Commissioners also need to consider the strategic and practical dovetailing of new statutory arrangements and other targeted initiatives, such as: Local Children s Strategic Partnerships Children s Service Plans DAT Young People s Substance Misuse Plans Area Child Protection Committee Crime and Disorder Act (1998) structures and measures measures to address social exclusion Educational Action Zones Health Action Zones Single Regeneration Programmes Operational requirement Staff working with under-18s should know and be able to demonstrate these skills: communication and engagement skills with young people, especially with young people who may be hard to engage an awareness of local children s specialist services, including those with child protection responsibilities, and when and how to refer an understanding of when to inform parents and/or the local authority knowledge of the law relating to the principles of confidentiality and the need to disclose information in certain circumstances the ability to contribute to the development of young people s drug services in-depth knowledge of child and adolescent development; understanding of the implications of major events such as abuse, bereavement and other traumatic incidents in the lives of children and young people the ability to conduct assessments based on the guidance in Framework for the assessment of children in need and their families (Department of Health 2000a) an understanding of the issues of confidentiality and consent to treatment that involve the rights of children and the responsibilities of parents and professionals ability to assess the severity and risks of substance misuse, the complexity of a planned intervention and the competence of a young person to consent to treatment the ability to manage and work within the Area Child Protection Committee s child protection guidelines and to understand the relationship between substance misuse and the vulnerability of children and young people Outcome monitoring For more details see Performance and outcome monitoring in Chapter 4. The UKADCU (2001) issued local operational outputs to be achieved by 2004, covering the full range of provision for young people who use drugs, and for their families. Young people s drug treatment services should ensure that their outcome monitoring reflects these operational outputs and fulfils the data collection requirements of drug action teams. All young people to receive substance misuse education in line with DfES guidance. All parents/carers to receive information on substance misuse and on local services. 141

148 All young people identified as being vulnerable will receive appropriate education, advice, information and support on substance misuse both in and out of school settings. All young people identified as having problems with substance misuse will receive an appropriate intervention or care package, with support for parents /carers. All young people assessed as being in need will be referred to appropriate treatment programmes and facilities. Special issues for this special group under the treatment modalities It is important to ensure that the full range of services described in the four tiers (Health Advisory Service 1996) are accessible in all local areas. Integrated local childcare policies and protocols are developed with the Area Child Protection Committee. Service provision is integrated with child and adolescent mental health services, social services and youth offending teams. Issues in relation to providing young people-specific services that are not located within adult services are considered. The needs of all groups of young people, including their wider personal, social and cultural background are considered. A young person s individual needs, lifestyle, gender, ethnicity, sexuality, culture and beliefs are respected. The relative merits and impact of brief versus extended interventions are considered. 142

149 3.5 Substance misusing parents Description A large proportion of drug and alcohol misusers entering treatment have responsibility for the care of children. Drug and alcohol misuse does not necessarily lead to problems in childcare or the neglect or abuse of children. However, it is important to consider the impact of parents substance misuse on the welfare of children in their care. One of the principles of the Children Act 1989 is that the local authority and parents should work in partnership to promote the welfare of children. Joint working arrangements should be agreed, implemented and reviewed through the mechanism of the Area Child Protection Committees (Department of Health 1999d) Epidemiology The National Treatment Outcome Research Study (Gossop et al. 1998b) found that 47% of drug misusers entering treatment were responsible for children aged 18 or under. Over 90% of females presenting for treatment are of childbearing age (15 39 years). Parental substance misuse is associated with a higher risk of involvement of families in care proceedings, particularly in relation to alcohol and cocaine misusing parents (Coleman and Cassell 1995). Furthermore, children of substance misusers are more vulnerable to substance misuse than children of non-substance misusers (Health Advisory Service 1996) Potential sources of harm While many children of drug and alcohol misusing parents will not be adversely affected, some may, and therefore it is essential that the impact of parental substance misuse on childcare and child well-being is assessed (Standing Conference on Drug Abuse and Local Government Drugs Forum 1997). Impact of parental behaviour Different drugs and alcohol have different effects on the behaviour of the user that may in turn impact on childcare (Drummond and Fitzpatrick 2000). Some drugs (e.g. alcohol) can cause impairment in judgement, co-ordination and consciousness that may have a negative impact on the care and supervision of particularly young children. Disinhibition due to alcohol or other drugs can lead to aggressive behaviour, such as domestic violence, that children may witness. Withdrawal from certain drugs and alcohol can also lead to irritability and mood disturbance, which may impact on child care. Impact of family lifestyle Drug and alcohol misuse can lead to impairment of family functioning by a variety of means: for example, domestic violence, poverty, unemployment, and criminality. In some cases drug use becomes a higher priority for the parent than buying basic essentials for the family. There may be reduced parental vigilance as a result of drug and alcohol misuse, leaving children vulnerable to abuse by visitors to the home. Drugs and/or injecting equipment in the home can pose risks for children. Impact on children s physical and emotional health The foetus is at risk of harm due to: direct effects of drugs or alcohol; infection; lack of adequate antenatal care; and, poor maternal health and nutrition. Foetal alcohol syndrome is estimated to occur in 1 to 3 per 1,000 live births. Opiates and cocaine cause an increased risk of obstetric complications including low birth weight, stillbirth, 143

150 prematurity, and neonatal withdrawal. After birth, children can suffer from inadequate stimulation, an increased risk of Sudden Infant Death Syndrome, poor care and nutrition, and exposure to domestic violence. School-aged children have an increased risk of: developing behavioural problems including truancy; adjustment problems; poor academic achievement; and school exclusion. Some children may develop a role as a carer for a substance misusing parent or other siblings. In later life, children of substance misusing parents have an increased risk of developing mental health problems (West and Prinz 1987) and substance misuse (Pandina and Johnson 1990). Co-morbid psychiatric disorders that are a consequence of, or are worsened by substance misuse, can also have a negative impact on parenting (e.g. psychosis, depression), often making the parent emotionally unavailable to the child. Parental ill health and premature death due to substance misuse will also clearly affect children of substance misusing parents Professional guidance and legal framework Under section 17 of the Children Act 1989, it is the duty of the local authority to safeguard and protect the welfare of children in their area who are in need, and so far as is consistent with that duty, to promote the upbringing of such children by their families, by providing a range of services appropriate to those children s needs. Under the Act, local authority social services departments have a duty to safeguard and promote the welfare of children. In many cases, children s welfare can be safeguarded by appropriate health and social care without recourse to formal child protection measures. This includes all agencies working together to safeguard children (Department of Health 1999d). In some cases more formal steps need to be taken. Under section 47 of the Children Act the local authority is obliged to make appropriate enquiries and take action to protect children where they have reasonable cause to suspect they are suffering or likely to suffer significant harm. Usually the local authority will convene a child protection case conference to determine the facts and decide on further action, unless action needs to be taken immediately. The child s name may be placed on the child protection register or proceedings may be instituted for a care or supervision order if the case warrants such intervention. Each local authority has an Area Child Protection Committee (ACPC) responsible for developing and promoting local child protection arrangements and effective multi-agency working and information sharing. While the local authority has the prime responsibility for child protection, all agencies in contact with parents and children must consider the risks to children and share information with the appropriate agencies where significant concerns exist. To this end, all agencies working with drug and alcohol misusers should have written confidentiality policies that are shared with clients, preferably agreed with the ACPC and DAT Assessment of drug and alcohol misusing parents Assessment is required to establish the impact of drug and alcohol misuse on parenting capacity, and any risks to children, and to guide the most appropriate intervention. Questions about childcare and parenting issues are clearly sensitive and can have important implications for drug and alcohol misusing parents. The need to gain information must be balanced against deterring substance misusers from accessing appropriate treatment. While parents have the right to confidentiality in most circumstances, society has a duty to protect children, particularly as they can often not advocate for themselves. While a professional s primary relationship is with the parent, where there is cause for concern, information needs to be shared on a need to know basis to protect children. This should be conducted within a confidentiality protocol under the Department of Health guidance (Department of Health 1999d). The emphasis should be on working collaboratively with parents to maximise the care of children and 144

151 protect them from harm. Assessment should be considered under the following headings (adapted from Swadi 1994; Standing Conference on Drug Abuse and Local Government Drugs Forum 1997): Parental drug and alcohol misuse The extent of the parent s drug and alcohol misuse and degree of dependence, and its impact on parental behaviour need to be assessed. This includes the presence of physical and psychological adverse effects that might impact on parenting (e.g. overdoses, psychosis, infections). The presence of a drug-free adult in the home can mitigate against some of the adverse effects. Accommodation and the home environment The parent s drug and alcohol misuse can have an adverse effect on the home environment, including: rent arrears and eviction; the extent to which children witness drug use or violence; the presence of other substance users in the home; exposure to criminal activity. Provision of basic needs This includes: provision of adequate food, clothing, warmth for children; ensuring school attendance; meeting emotional needs; providing age-appropriate activity; ensuring children are not inappropriately acting as carers for the parents or other siblings. Procurement of drugs Drug procurement can become a central daily activity for dependent drug misusers. It is important to determine the extent to which children are affected by this in terms of: being left alone while the parent procures drugs; the cost of drugs and whether drugs are obtained by acquisitive crime; children being taken to drug dealers or involved in criminal acts; whether the home is used for drug dealing. Health risks The extent to which the parent protects children from the health risks of substance misuse should be assessed. This includes whether drugs, alcohol, and injecting equipment are kept out of the reach of children. Social networks of support The extent to which support networks exist to mitigate against the adverse effects of parental substance misuse should be assessed. This includes the availability of relatives and non-drug or alcohol misusers, professional or non-statutory agency support, and the degree of social isolation. Parents perception of the situation The extent to which the parent is aware of the potential impact of their drug and alcohol misuse on the children, the extent to which the parent is able to prioritise the needs of the children, and finally, the parent s awareness of legal procedures and responsibilities relating to childcare can all have an impact on the welfare of children. Pregnancy Particular issues need special attention in relation to pregnant drug and alcohol misusers. The aim should be to encourage early engagement in adequate antenatal care and with a local drug and alcohol treatment service that can advise on treatment during and after pregnancy. Injecting drug misuse poses particular risks to the foetus because of poor maternal health and the risk of transmission of infection. 145

152 Assessment of children Assessment of children is important to establish the child s safety and well-being (Department of Health 2000a). This includes assessment of the child s physical safety, psychological trauma due to the parent s behaviour, the impact on children s health and development (through liaison with health visitors, GPs, school nurses), problems with schooling such as truancy, behavioural problems (through liaison with schools), and in older children, their perceptions and concerns about the parent s substance misuse. Most often a specialist family social worker, or someone with appropriate training and expertise, carries out such an assessment Treatment The main principle of treatment should be to develop, where possible, a collaborative therapeutic relationship with the parent in order to maximise engagement with treatment. This needs to be balanced with the need to ensure the safety and welfare of the children of drug and alcohol misusing parents Childcare facilities Where it is possible for children to remain in the care of the parent during treatment, adequate facilities need to be made available to meet children s needs and leave the parent available to attend treatment. This should include the provision of daycare or crèche facilities for children. Sometimes it is necessary to provide foster care for children (e.g. when the parent enters residential treatment) Community-based drug treatment programmes It is often not appropriate for children to attend adult drug treatment facilities with the parent. Therefore, adequate alternative childcare facilities need to be available. For parents with school-aged children, organising appointments within school hours can enable parents to be more compliant with the programme. Some parents will need additional help with parenting skills, which may be provided in some specialist family centres or specialised programmes within drug and alcohol treatment centres Residential drug and alcohol treatment programmes Parents who require residential drug and alcohol treatment and rehabilitation will most often do so without the children being present with them. Units that admit children with drug and alcohol misusing parents tend to take only younger children (under school age), although exceptions to this do exist. Where a parent is admitted to a residential unit without their children, consideration needs to be given to providing continued contact with the children, as long as this does not conflict with the child protection plan. Children who enter residential placement with the parent need a separate care plan and key worker. Children placed with their parents in residential rehabilitation usually require separate funding from the local authority During pregnancy It is clearly important to maximise the drug and alcohol misusing parent s engagement in antenatal care and appropriate substance misuse treatment during pregnancy. Areas that have services specialised in managing pregnant drug and alcohol misusers are more effective in engaging women, and probably have better outcomes (although little research has been conducted on this). Substitute prescribing for pregnant opiate misusers can be an effective method of enhancing engagement with a reduced risk of harm to the foetus than uncontrolled drug misuse. Drug or alcohol detoxification during pregnancy is best conducted with obstetric supervision. Multi-agency planning meetings should be held regularly to review and co-ordinate care. An appropriate antenatal care plan is required with all appropriate agencies working together (Standing Conference 146

153 on Drug Abuse and Local Government Drugs Forum 1997). It is not necessary to hold a child protection case conference for all pregnant drug and alcohol misusers, but it is likely to be necessary where particular concerns exist over concurrent health or social problems, poor compliance with antenatal care, or lack of engagement with drug services Care pathways See attached care pathways for the management of substance misusing parents and pregnant substance misusers Outcome monitoring For more information see Performance and outcome monitoring section in Chapter

154 Diagram 7 Integrated care pathway: Drug and alcohol misusing parents Routine drug and alcohol misuse assessment establishes client as a parent Assessment to determine if the child is in need The child is in need or there are concerns that the child may be at risk ; refer to child protection agency, social services, police or NSPCC, preferably with parental knowledge and consent The child is not in need ; treatment as usual with watching brief Social services will conduct a detailed assessment of the child s needs Social services will convene a child protection case conference Multi-agency care plan agreed Regular review of the child s needs by social services with input from agencies in contact with parents and/or child Parent continues to attend drug and alcohol treatment programme 148

155 Diagram 8 Integrated care pathway: Pregnant drug and alcohol misusers Suspected pregnancy disclosed to drug service Screening for drug and alcohol misuse at antenatal booking Confirmatory testing as required; fast track refer to antenatal services or GP Fast track referral to drug and alcohol misuse services Immediate provision of drug and/or alcohol service to manage substance misuse put in place (including care coordinator/care plan) Multi-agency case conference to plan management of antenatal care and substance misuse Planned management and/or detoxification from drugs and/or alcohol in a specialist substance misuse or obstetric unit Aftercare programme to prevent relapse to drug/alcohol misuse or unmanaged drug or alcohol use before birth Multi-agency conference at 32 weeks to plan birth 149

156 3.6 Alcohol and alcohol misuse in drug misusers Description Alcohol consumption of more than 21 units of alcohol per week by men and more than 14 units by women is associated with an increased risk of harm (Royal College of Psychiatrists 1986). Furthermore, in people with co-morbid physical or psychiatric illness (e.g. depression, liver damage), the very young and the elderly, these limits cannot be assumed to be safe. Drinking above 50 units in men and 35 units in women is associated with a considerably increased risk of harm. The government has recently made an additional recommendation of a safe daily limit of four units for men and three units for women (Department of Health 1995). However, even these limits may be unsafe in some circumstances, for example, during pregnancy or while operating machinery or driving. For drug misusers with hepatitis C and other forms of liver disease, complete abstinence from alcohol is recommended to prevent progression of liver disease. Furthermore, alcohol misuse can interfere with effective engagement in methadone treatment and psychotherapy if it is not adequately addressed (see also sections on blood-borne disease and overdose in Chapter 4) Epidemiology/nature and extent Alcohol misuse is a common problem in opiate misusers attending methadone maintenance treatment. In some cases the alcohol misuse is present prior to entry into methadone maintenance. In other cases alcohol misuse emerges after a patient enters methadone treatment and stops illicit drug misuse. However, alcohol misuse is often overlooked as a problem to be addressed in drug treatment programmes. The National Treatment Outcome Research Study (NTORS) (Gossop et al. 1998b) found that 33% of drug misusers were drinking above the safe weekly limits at the point of intake. The average daily alcohol consumption was 18 units in drug misusers entering residential treatment and 11 units in community methadone programmes. NTORS also found that at one-year follow-up, a substantial proportion continued to drink above safe levels. Some drug dependent patients are also alcohol dependent. Alcohol dependence includes the cluster of features including withdrawal symptoms (such as sweating, shaking, anxiety, insomnia), craving, salience of alcohol-seeking behaviour, tolerance, narrowing of drinking repertoire, and reinstatement after a period of abstinence. In severe alcohol dependence, withdrawal symptoms may require medical treatment (including detoxification), and if untreated they can lead to withdrawal-related fits and delirium tremens Evidence base There is little research that specifically assesses the effectiveness of alcohol interventions in drug misusing populations. There is, however, a large body of evidence in support of the effectiveness of opportunistic screening and brief interventions for alcohol misusers in a wide variety of clinical settings (e.g. primary care, general hospitals, outpatient medical care). Recent reviews point to sustained reductions in drinking (10 30%) at one-year follow-up (Bien et al. 1993; Effective Health Care Team 1993; Miller et al. 1995). Some studies have shown cost savings associated with the interventions (e.g. Fleming et al. 1997). It is likely that brief alcohol interventions would 150

157 be effective in the drug misusing population, but research needs to be conducted in this group. In more severe alcohol dependence, the evidence is less clear cut. Motivational interviewing appears to be the most cost-effective treatment for alcohol dependence (Holder et al. 2000). However, alcohol dependence is often accompanied by psychiatric co-morbidity for which cognitive behavioural therapy can be more effective. There is also some evidence for the effectiveness of certain drug therapies for alcohol dependence (Garbutt et al. 1999). Antabuse (disulfiram), which is an alcohol sensitising deterrent drug, has some effectiveness in alcohol dependent patients who are socially stable and who can have compliance monitored. There is some evidence in the benefit of acamprosate, possibly through its effect on alcohol craving, but the precise mechanism is unknown. Also, naltrexone, the long-acting opioid antagonist, has some benefits for both alcohol and opioid dependence Treatment Assessment of alcohol misuse Assessment is required to guide the most appropriate interventions. Ideally, all staff in drug programmes should be trained to carry out alcohol assessment. Primary care personnel should also be able to screen for and identify alcohol misuse. There are various methods of assessing alcohol misuse. Careful enquiry about daily and weekly alcohol consumption is the most straightforward approach. This should be supplemented by enquiry about the presence or absence of alcohol-related problems and dependence symptoms. This can be difficult with patients who are primarily presenting with a drug problem and may not see the relevance of this enquiry. However, given the high prevalence of alcohol misuse and dependence in this patient group and the potential health risks, particularly in those patients with physical and psychiatric co-morbidity, this is clearly important to include in assessment. It is useful when calculating units to have a unit conversion table and to enquire closely about the type and strength of alcoholic drinks consumed. If a unit conversion table is not available it is possible to calculate units from the volume of alcohol consumed and the percentage alcohol by volume (ABV) of the drink. For example, one litre of 40% ABV vodka contains 40 units of alcohol. Another simple method of screening for the presence of an alcohol problem is the CAGE questionnaire, which consists of four questions. If the patient answers positively to two or more of these questions they are likely to have a problem with alcohol. This can be confirmed by further enquiry. Another useful screening tool is the AUDIT questionnaire, which is a 12-item questionnaire developed by the World Health Organization. It includes questions about alcohol consumption, alcohol-related problems and alcohol dependence. A score of eight or more on the AUDIT indicates alcohol misuse (Saunders et al. 1993). More severe alcohol dependence can be assessed using the Severity of Alcohol Dependence Questionnaire (SADQ) (Stockwell et al. 1979). The questionnaire is scored out of a total possible 60, with a score of 30 or more indicating severe alcohol dependence. Patients with a score of 20 or more are likely to need assisted alcohol withdrawal. The Alcohol Problems Questionnaire (APQ) (Drummond 1990) is used to assess alcohol-related problems. The common score has a total possible score of 23, and a score of 12 or more indicates a significant level of alcohol problems (see also the section on assessment in Chapter 1). 151

158 Brief interventions In patients with minimal alcohol dependence but who are nevertheless drinking above safe limits, brief interventions have been demonstrated to have lasting beneficial effects. The most effective method of brief intervention is motivational interviewing. A follow-up interview can help to reinforce change or prompt the investigation of alternative interventions if no progress has been made since the initial intervention Assisted alcohol withdrawal Patients with significant alcohol dependence and who score more than 20 on the SADQ will be likely to require assisted alcohol withdrawal and should probably have a goal of abstinence from alcohol, at least in the first instance. The drug of choice is chlordiazepoxide in a dose matched to the individual s degree of alcohol dependence Psychological treatments Motivational interviewing and cognitive behaviour therapy are both effective in reducing alcohol consumption and preventing relapse. The principles of these interventions and the techniques used are essentially the same as for drug misuse and dependence Help for relatives and carers Often relatives and carers are adversely affected by the alcohol misuser s drinking. Help is available through Alanon, which is a self-help organisation allied to, but separate from, AA Outcome monitoring For more information see Performance and outcome monitoring in Chapter

159 Diagram 9 Integrated care pathway: Brief alcohol interventions Screening (e.g. units, CAGE, AUDIT) Brief motivational intervention Review 2/52 Referral for not improved Specialist alcohol assessment Intensive outpatient alcohol intervention Review 2/52 153

160 154

161 Chapter 4 Cross-cutting issues This chapter aims to identify important issues relevant to the treatment of drug misusers that cut across other sections and chapters. It is beyond the scope of Models of care to consider the full complexity of these issues, or to provide a comprehensive appraisal, but the important connections are considered. 155

162 4.1 Overdose Description For the purposes of Models of care, we refer to overdose as an event in which a person intentionally or accidentally ingests one or more psychoactive substances at unsafe levels, leading to physical trauma, which may require immediate medical care to reverse and manage symptoms and other complications. Cause of death in cases of overdose may be complex and involve several body systems. In cases of fatal opioid overdose, death usually follows from respiratory depression (either through the direct action of certain substances such as the opioids, or indirectly due to airway blockage or reduced respiratory capacity, caused by vomit, mucus or saliva), which disrupts oxygen supply to the brain and causes cardiac arrest. Fatal overdose of stimulant drugs is usually linked with cardiac depression and arrest (with acute and chronic effects of stimulants implicated) Epidemiology and evidence base Overdoses may be non-fatal or fatal. In Australia, there is evidence that some twothirds of heroin users have experienced an overdose (Darke and Zador 1996; Darke et al. 1996). Loxley and colleagues found that 53% of illicit drug users interviewed had experienced a non-fatal overdose, and of this group some 81% had a lifetime overdose experience with heroin (Loxley et al. 1995). The recent ACMD report notes that in 1998 there were some 2,300 drug-related deaths recorded for England and Wales attributed to accidental or intentional overdose. The likelihood of overdose is increased when drugs are taken by injection and fatal overdose (immediate death) is particularly associated with injecting opioid users. There is also recognition of the increased risk of fatal overdose among some segments of the illicit drug using prison population, particularly during the first few weeks following release. Overdose trends are still rising and the risk of death for a young person injecting heroin is 14 times higher than their heroin smoking peers (Advisory Council on the Misuse of Drugs (ACMD) 2000). It is important to note that the potential for overdose is increased substantially when two or more drugs are consumed and the effects of these interact. This is most commonly observed for concurrent consumption of opioids, alcohol and benzodiazepines (or other sedatives) (Gossop et al. 1996; Powis et al. 1999; Strang et al. 1999). Oyefeso and colleagues found a heightened risk of fatality among drug misusers who were also taking antidepressants. Fatal antidepressant overdoses were twice as likely to occur among cases aged 45 years and over than in younger cases (Oyefeso et al. 2000). Research has linked overdose cases to several personal and demographic characteristics. Adult fatal overdoses are more prevalent among males (ACMD 2000), are substantially higher among people in their twenties and thirties (Ghodse et al. 1985; Bently and Busutill 1996); and among those who are unemployed (Ghodse et al. 1985; ACMD 2000). Moreover, substance misusers are at higher risk of suicide than the general population, and prescribed drugs, notably anti-depressants and methadone, heighten that risk. Drug overdose is the most common method of suicide (Oyefeso et al. 1999). 156

163 4.1.3 Management and care pathways Access to antagonists Acute intoxication is a discrete event, although an individual s needs may advance to those associated with dependence, co-morbidity and withdrawal management and support. Most services provided to the intoxicated drug user will be found outside specialist drug or mental health services (e.g. accident and emergency departments; police custody). All services that have contact with opiate users should have prompt access to the injectable opiate antagonist naloxone, which may be administered intravenously, intramuscularly or subcutaneously, and can be life-saving in the event of an opiate overdose (Strang et al. 1996a; Strang 1999). Ambulance services should carry naloxone as standard. Services should refer to the Department of Health clinical guidelines (Department of Health et al. 1999) on the use of supervised consumption of prescribed drugs for the treatment of addiction. This can increase safety of drug prescribing, particularly during the early stages of treatment and drug dose stabilisation Assessment of risk In terms of practice issues, all drug services including abstinence-based programmes should discuss the risks of overdose, especially when there is reduced tolerance with their clients. All services should establish agreed policies on the response to overdose (ACMD 2000, p. 78). All service users in contact with specialist services in all tiers should have a risk assessment (ACMD 2000, p.74). Service users, doctors, pharmacists and agency workers need to be more aware of the dangers of overdose in relation to methadone (ACMD 2000, p. 64). All services should routinely provide verbal and written advice to clients/patients on the risks and hazards of methadone, particularly at the commencement of prescribing. Further reminders should be provided at treatment review. Mortality in specified clinical populations has often been regarded as a measure of treatment effectiveness (Ghodse et al. 1998). The government s response to the ACMD report on drug-related deaths has been to develop an action plan to tackle accidental overdose involving illegal drugs in the community and among the on-release prison population (Department of Health 2001d). The reduction of drugrelated deaths has also been established as a key performance indicator in the UK national plan and guidance information is being prepared aimed at DATs, drug users attending A&E and drug misuse treatment services, and the prison population Advice and information Drug services should provide advice and information about overdose prevention and response in multi-media format to drug users. This could include the teaching of first aid to service users, their friends and family (DrugScope and Department of Health 2001b). Service users should be informed about the risks and dangers associated with methadone and its interaction with other drugs and alcohol (ACMD 2000). They should be advised about the safe storage of medicines, including methadone Protocols Protocols should be established with local police and ambulance services to adopt a policy of police attending overdose scenes only in exceptional circumstances, such as where there are: child protection concerns concerns for a dependent adult of the drug user concerns for the safety of the paramedics (i.e. violence anticipated) (ACMD 2000). 157

164 It is beyond the scope of this resource to describe the overdose management procedures for all types of drugs and their combinations. The interested reader is encouraged to consult a overdose management text (e.g. Olson 1990). 158

165 4.2 Blood-borne diseases Description Preventing the spread of blood-borne diseases is a major goal of drug treatment services and a major contribution to individual and public health. Helping drug misusers who are already infected to become aware of their condition, to reduce harm and maintain their health is an essential part of drug treatment services Aims and objectives Drug treatment agencies should develop services to: provide health screening for blood-borne diseases for all clients attending substance misuse services in order to identify health needs and problems enable clients to explore issues relating to their health as a result of substance use/misuse and identify ways of achieving a healthier lifestyle assess risk behaviours associated with drug and alcohol use and provide interventions that will help prevent further harms and consequences, for example, advice, information and education on the transmission of hepatitis B and C and HIV provide access to testing for hepatitis B and C and HIV provide access to hepatitis B vaccination provide a comprehensive pathway of care for those who require healthcare relating to blood-borne diseases Research evidence base Injecting drug use is an important risk factor for a number of infectious diseases, including hepatitis B and C, HIV, as well bacterial infections (including life-threatening septicaemia) and fungal infections. The role of needle and syringe exchanges, access to advice and information, and appropriate treatment programmes which can reduce the risk of injecting practices (such as substitution methadone treatment) is explored in the relevant chapters. Advice, information and counselling in relation to sexual risk behaviours and mother-to-baby transmission is also important. National hepatitis B vaccination programmes have been identified as vital public health responses to the global epidemic of hepatitis B (Department of Health 1997a). The World Health Organization (WHO) identified the need to integrate universal hepatitis B vaccination into national immunisations programmes by 1997 (Kane 1995; Van Damme et al. 1997). Although many western European countries remain unconvinced that the burden of disease warrants the expense of universal vaccination, epidemiological data and economic evaluation provide evidence that hepatitis B vaccination is cost effective in countries with low endemicity, reinforcing the necessity for action (Van Damme et al. 1997). Immunisation against hepatitis A virus infection is currently promoted for those with severe liver disease (Department of Health 2001b), but should only be given on the advice of a liver specialist. Injecting drug users who have not been protected by hepatitis B vaccine are at a high risk of acquiring and subsequently transmitting hepatitis B and for this reason, this group has been targeted for vaccination in the UK since 1985 (Heptonstall 1999). Injecting drug users, who acquire hepatitis B virus (HBV) infection are often difficult to reach with healthcare services and are often infected before they present to any health setting, where immunisation could be offered. 159

166 Over a third of injecting drug users attending specialist services have evidence of hepatitis C infection, and some studies suggest that prevalence may be even higher (Department of Health 2001b). Clients with hepatitis C are at further risk of infection from hepatitis B. Co-infection with hepatitis B may accelerate hepatitis C-related liver damage (Esteban 1993), as may alcohol use (Department of Health 2001b). It is, therefore, important to ensure that clients with hepatitis C who have not been infected with hepatitis B are offered hepatitis B vaccination. The risk of liver disease for those who have hepatitis C is increased substantially with heavy drinking, and even small amounts of alcohol can for some be harmful (Department of Health 2001b). Drug misusers may move from one healthcare setting to another, or to another area, and therefore do not necessarily maintain regular contact with healthcare services. This causes difficulties in tracking healthcare provision for clients who require interventions relating to blood-borne diseases (Wong et al. 1996; Heptonstall 1999). It is, therefore, necessary to ensure that all clients have equality of access to provision of: advice and information on blood-borne diseases testing for hepatitis B and C hepatitis B vaccinations (as appropriate) pre- and post-test HIV counselling. It is recognised that not all substance misuse services provide on-site interventions for health screening and testing for blood-borne diseases. It is therefore necessary for services to review local service provision to establish a comprehensive approach in order to ensure equality of access to such services. In some areas, such interventions will be provided within the substance misuse services. In other areas, clients will be referred to other services such as GPs and sexual health services. All testing should be preceded by careful information and advice so that the implications of testing are understood by the individual being tested (Department of Health 2001b). Transmission of hepatitis C and hepatitis B infection through injecting drug use is a major problem. There has been an increase in sharing of injecting equipment, although prevalence of HIV infection remains low. One-third of injecting drug users attending specialist agencies in England and Wales had antibodies to hepatitis C, as had 1 in 11 of those who began injecting in the past three years. Nearly 25% of those who began injecting drugs after 1996 in Glasgow were hepatitis C antibody positive when tested in Since 1992 reports of acute hepatitis B in England and Wales have risen four-fold among injecting drug users, while in 1999 only 29% reported having been vaccinated against hepatitis B (Department of Health 2000b) Care pathways Referral pathways All substance misuse services should have a local protocol for referring clients for health screening and testing for blood-borne diseases. Services should also have jointworking protocols for referral between other services (e.g. genito-urinary medicine, hepatologist, communicable diseases unit, liver unit, GP) for the continued care, support and management of clients with blood-borne diseases. Liaison between specialist services, primary care and local specialists in the treatment of hepatitis C is particularly important (Department of Health 2001b). Within any local area, the organisation of services for access to assessment, treatment and management of blood-borne diseases will vary. It is therefore important to have a clear local protocol about the provision of such services and the referral pathways to ensure that all services across all tiers are providing a consistent message to service users about 160

167 access to and management of hepatitis B, C and HIV (Department of Health 2001b, 2001d). It is important for the client s GP to be involved in the overall care package to facilitate completion of vaccination courses/follow-up of testing. However, many clients do not have a GP and efforts should be made to facilitate clients registering with a GP. For clients who do not wish their GP to be involved it is recommended that the benefits of doing so are emphasised. However, it is recognised that persuading clients to involve the GP is not always possible Assessment As part of risk assessment procedures, all clients should be assessed on their risk behaviours associated with substance misuse. This should include a full assessment of the following: age at first injecting history of sharing injecting equipment (using other people s equipment, passing on equipment to others) history of sexual risk behaviours history of previous testing for hepatitis B and C and HIV client s understanding about contracting or transmitting blood-borne viruses client s concerns about contracting or passing on blood-borne viruses to others previous contact with other healthcare professionals relating to screening for hepatitis B and C and HIV alcohol use. All Tier 1 services should be involved with the provision of relevant advice leaflets and entering into brief discussions about access to further advice and counselling relating to blood-borne diseases Treatment Risk reduction The Department of Health (2001b) recommends the ideal goal of a local risk reduction programme is that drug users: do not start injecting stop any current injecting avoid initiating others do not share injecting equipment or paraphernalia with others pass on safer injecting advice to others Routine health screening All services across all tiers, should provide information and advice to individuals about access to routine health screening for hepatitis B, C and HIV. All services across all tiers should be able to talk to the drug users with whom they come into contact about raising awareness of risks associated with blood-borne diseases (Department of Health 2001b). All substance misuse services should have a policy and agreed procedures for the provision of health screening (Department of Addictive Behaviour 1998) which should include agreed information-sharing policies. All clients should receive an assessment of all their health needs, including blood-borne viruses (British Medical Association 1993, 1997). They should also have relevant tests 161

168 for determining health problems, for example, liver function tests (British Medical Association 1997) and routine blood counts. It is good practice to undertake counselling prior to any screening procedures and explain to clients the possible consequences of the result, whether this is for hepatitis, HIV or tuberculosis (British Medical Association 1993, 1997; Department of Health 1996). All information and issues should be documented in the patient s notes. It is good practice to ensure that all clients are provided with additional written information on the relevant issues. Arrangements should be in place with appropriate services (genito-urinary medicine (GUM), family planning (Miller 1995, 1996), dietician or dental services (Task Force to Review Services for Drug Misusers 1996) for onward referral for further screening and testing if this is not available within the substance misuse service. The substance misuse service should develop a monitoring form for recording and evaluating health screening. Brief health screening and counselling should be included in all client contacts. Health education is useful at all opportunities (Department of Health 1999c) Hepatitis and HIV testing The advent of HIV has required an expansion of our definition of problem drug use to include any form of drug misuse which involves, or may lead to, the sharing of injecting equipment. This in turn means that services must now make efforts to make contact with the hidden population of drug misusers (Advisory Council on the Misuse of Drugs (ACMD) 1988). The 1988 ACMD report states that it is essential for all GPs to provide care and advice for drug misusing patients to help them move away from behaviour which may result in their acquiring and spreading the virus. Primary care trusts should ensure that appropriate support is available and that GPs are made aware of, and are able to access, advice information and training. As such, clinical attachments by GPs to local specialist drug misuse services should be actively encouraged. Short-term sessional contracts should be available to help build a pool of GPs with experience. Additionally, further training for GPs should be provided at postgraduate level both during the threeyear vocational training period and for established practitioners on a regular basis. All services in contact with drug misusers should inform their clients of the risks of HIV and how they can avoid and reduce these risks both in sexual behaviour and in injecting. All services for drug misusers, including GPs, should have the facility to provide free condoms (ACMD 1988). Monitoring of needle exchange schemes should continue so that their success in reaching drug misusers and changing their behaviour can be assessed. Ultimately it will be long-term changes and not short-term results, which are important (ACMD 1988). Services providing HIV counselling and testing should have polices and procedures on pre- and post-test counselling and the arrangements for testing (Department of Health 1996; Miller 1997). Services that come into contact with those with drug and alcohol problems should have access to screening and testing for hepatitis and HIV. 162

169 Substance misuse services should have policies and protocols for the provision of hepatitis and HIV testing (Department of Health 1996, 1997a). Those individuals infected with hepatitis B and/or C should be referred to a hepatologist for advice about further management and treatment (Department of Health 2001d) Hepatitis B immunisations All services should promote hepatitis B vaccination to those with hepatitis C (Department of Health 2001b). All substance misuse services should have a policy and procedures for the provision of hepatitis B vaccinations. Each primary care trust should introduce protocols to increase the uptake of hepatitis B vaccinations by the end of 1999/2000 (UKADCU 1999, p. 18). Clear verbal and written information should be provided to clients about the benefits of immunisation (Heptonstall 1999) and the need for at least three doses of vaccine should be provided (Pallecaros and Robinson 1996). Commissioners should ensure there are suitably trained staff available within the services to advise clients about blood-borne viruses and hepatitis B vaccinations (Department of Health 1997a; NHS Executive 1999b), and to enable the implementation of immunisation programmes. Hepatitis B vaccination is important for those with chronic hepatitis C infection as a combination of two viruses worsens the prognosis (British Medical Association 1997). The British Medical Association (1993, 1997) recommends that patients undergoing investigation into hepatitis B and C should also receive pre- and post-test counselling regarding the implications of a negative or positive test result, similar to that provided with HIV testing (Department of Health 1996). All substance misuse services should refer to the British Medical Association code of practice for the safe use and disposal of sharps (British Medical Association 1995a) to prevent sharps injuries. Substance misuse services should ensure that staff who come into contact with substance misusers who are receiving hepatitis B vaccinations refer to the guidelines for the protection of patients and staff (British Medical Association 1995b) Development of a hepatitis B vaccination policy The service should ensure that the policy sets out inclusion criteria for those eligible for the service (Department of Addictive Behaviour 1998; NHS Executive 1999b); for example: patients whose past or present drug use includes parenteral routes of administration patients who are using potentially injectable drugs, even if there is no history of parenteral use patients who have had a sexual partner who is a drug user patients who are or who have been involved in prostitution, and bisexual or homosexual males other patients who request vaccination but who are not included in the above groups should be considered on an individual basis. 163

170 Hepatitis B immune status should normally be ascertained before commencement of a vaccination course. Patients who have no acquired immunity from previous infection will be hepatitis B antigen and core antibody negative, and should be offered vaccination (British Medical Association 1997; Department of Addictive Behaviour 1998). (NB Patients who have recovered from past infection will be antigen negative but core antibody positive. It is insufficient to establish negative antigen status alone. In this situation a blood test should be requested for Hepatitis B caps = Hepatitis B Core Antibody.) However, when necessary (e.g. when there has been high risk of exposure to infection) vaccination can be started simultaneously with obtaining a blood sample and before the result is known. If immunity is found to exist already, the vaccination course can be terminated and the initial dose considered as a booster. The vaccination course comprises three doses of vaccine administered over a sixmonth period. The second dose is administered one month after the first dose and the third dose is administered five months later (over six months in total). The preferred site of injection (intramuscularly) is the deltoid muscle, and the side should be alternated for the first two doses. Two months after completion of the course of three immunisations, post-vaccination serology should be undertaken to measure the immune response. (NB Vaccination does not stimulate hepatitis B core antibody, which will remain negative. The immune response is measured by the level of hepatitis B surface antibody or anti-hbs, which should be specifically requested.) A booster dose should be offered if there is a low immune response, which will be reported by the Virology Laboratory. All details of care provided should be recorded in the patient s notes. The patient s GP should be informed of progress in the vaccination course. If the patient drops out of contact with the substance misuse service, the GP or other relevant service(s) should be advised of the date when the next dose is due. The substance misuse service should develop an appropriate system for maintaining records and for ensuring the follow-up of patients for the vaccination programme. All vaccination programmes should be monitored and evaluated to establish the rate of uptake and the change in injecting and sharing behaviour (UKADCU 1999; NHS Executive 1999b). For further information see Department of Health memorandum on immunisation against infectious disease (Department of Health et al. 1992) HIV pre-test counselling The aim of pre-test HIV counselling is to provide the client with the opportunity to understand the implications of HIV testing (both a negative and positive test result). It provides the opportunity to discuss the risks of substance use (sexual and injecting behaviour) and enable the client to make an informed choice about undertaking testing. All staff undertaking pre- and post-test counselling should have the necessary skills, knowledge and experience of this work (Miller 1997). Pre-test counselling may require 164

171 more than one counselling session and the time taken to provide the counselling will vary according to the individual needs of the patient. It is important that patients make informed choices about whether to have an HIV test or not. It is good practice to record in patients notes that they gave verbal consent to have the test. Pre-test counselling should include: discussion about reasons for wishing to have a test fears and concerns discussion about the advantages and disadvantages of having a test education on transmission, the manifestations of the HIV virus, the nature of the test and the difference between HIV and AIDS assessment of perceived and actual risk behaviours and education on risk reduction discussion on the implication of a negative or positive test result, including seroconversion, the impact on family and partner(s), pregnancy, the limitations of the test (i.e. it does not identify time of transmission or predict the future course of events), psychological impact, life insurance, mortgages and employment, positive aspects of opting for a test, in that early treatment can improve prognosis information about the confidentiality policy. All services offering a testing facility need to have confidentiality policies regarding the disclosure, recording and storage of test results. This is particularly important when clients records are held centrally in an organisation and are accessible to other services (e.g. mental health teams). Patients need to be aware that within statutory services, information may be shared with other members of the team, including the patient s GP. It is important to explore any concerns regarding confidentiality with the client and explain the importance of the GP as a primary carer with knowledge of treatment and tests undertaken by specialist services. If clients do not want their GP to be informed, they should be advised of the sexually transmitted diseases (STD) Act and told they have the option to attend an STD clinic information regarding timescale for receiving the results and how they will be given patients should be advised about cleaning blood spillage, be warned about the risks of sharing toothbrushes and razors (which may come into contact with blood) and also be informed about preventive measures against hepatitis B and C the patient must be given the opportunity to have time to think about the issues before making a decision (Department of Addictive Behaviour 1998; Department of Health 1996; Miller 1997) HIV post-test counselling There are two aims of post-test counselling. The first is to address the immediate concerns of the individual receiving the positive test result. The second is to provide the necessary support and information. It is necessary that the client is as fully prepared as possible by the staff member. Post-test counselling may require more than one counselling session and the time taken to provide the counselling will vary according to individual needs. The result of the HIV test should be given to the client face-to-face, whether the test result is negative or positive and ideally should be done by the pre-test counsellor (Miller 1997; Department of Addictive Behaviour 1998). It is not advisable to give test results over the telephone or by writing as responses are difficult to assess. More importantly, if there is a lack of a consistent approach across a service or services, a client may wrongly assume a positive test result, when invited to attend for a face-toface consultation, when they have previously experienced results being given over the telephone (Miller 1997). Staff should avoid arranging appointments to give test results 165

172 at the end of the day, last day of the working week or the day before the staff member is due to take leave, so that they will be available over the following few days to provide ongoing support to the client (Miller 1997). This is particularly important when giving a positive test result. Post-test counselling should include: addressing the client s immediate concerns and anxieties and provide the necessary support time for the client to vent their fears/concerns re-emphasising the information on HIV prevention and refer back to the discussions of the pre-test counselling advising about when a further test is necessary (where appropriate) If the test result is positive Allow time for the client to express their feelings. The client may not wish to discuss any concerns immediately as it may take time for the shock to be accepted. However, the client may need time to consider immediate feelings and what they are going to do next. This may include issues raised in pre-test counselling which are now a reality, such as who do they tell, what does it really mean. It is important to: discuss actions/plans for the next few days reiterate the points raised in the pre test counselling offer to facilitate informing the patient s partner and/or family explore the implications the result will have for the patient s personal relationships discuss counselling and testing for patient s partner and others (as appropriate) ensure the patient has ready access to support from the key worker or other members of staff inform the patient about the various agencies and help available. It may be useful to give written information to support verbal discussion (Department of Addictive Behaviour 1998; Department of Health 1996; Miller 1997) Performance and outcome measurement For guidance on the measurement of blood-borne disease prevention and treatment services see Performance and outcome monitoring in Chapter

173 4.3 Psychiatric co-morbidity (dual diagnosis) Description There is no agreed definition of the term dual diagnosis, which refers to two concurrent disorders. Therefore, to avoid misinterpretation, for the purposes of Models of care, the term will be referred to as psychiatric co-morbidity, meaning a combination of mental illness and substance misuse. It is recognised that co-morbidity covers a broad spectrum of mental health and substance misuse problems that an individual might experience concurrently (Department of Health 2002). Krausz (1996) suggests that there are four categories of dual diagnosis: a primary diagnosis of a major mental illness with a subsequent (secondary diagnosis) of substance misuse which adversely affects mental health a primary diagnosis of drug dependence with psychiatric complications leading to mental illness a concurrent substance misuse and psychiatric disorder an underlying traumatic experience resulting in both substance misuse and mood disorders e.g. post-traumatic stress disorder. Identification of the primary diagnosis may be problematic. This is because of the mimicking effect of signs and symptoms of mental illness by signs of intoxication and withdrawal of substance use, which can lead to misdiagnosis. It is necessary, therefore, to assess symptoms and syndromes to identify a disorder as characterised by a particular classification system (Wittchen et al. 1996), such as Diagnostic and Statistical Manual (DSM) IV or International Classification for Diseases (ICD) 10. The nature of the relationships between mental disorders and substance misuse use are complex for the following reasons: substance use (even one dose) and withdrawal from substances may lead to psychiatric syndromes or symptoms intoxication and dependence may produce psychological symptoms substance use may exacerbate or alter the course of a pre-existing mental disorder primary mental disorder may precipitate substance use disorder which in itself may lead to psychiatric syndromes (Crome 1996) Epidemiology Prevalence Psychiatric co-morbidity (dual diagnosis) is recognised as a complex area of health and social care. It requires further research in the UK, since the evidence base to date is primarily based on studies in the USA (Ley et al. 2000). The available evidence base provides a framework for further UK studies. Baigent et al. (1994), in a study carried out in Australia, found that among 53 psychiatric hospital inpatients with a diagnosis of substance abuse and schizophrenia, 40% abused mainly alcohol, 40% abused cannabis, 8% amphetamines and 20% abused more than one substance. Of these 80% reported substance use for the relief of anxiety and dysphoria. In the USA, Reiger et al. (1990) found that 47% of schizophrenic patients, and 61% bipolar (manic depressive) patients, had a substance-related disorder. Lifetime prevalence rates of anti-social personality disorder in drug abuse categories in untreated populations ranged between 14.7% for cannabis to 42.7% for 167

174 cocaine (Reiger et al. 1990). Kessler et al. (1996) found that between 1% and 65.5% of those with an addictive disorder also had at least one mental disorder and 51% of those with mental disorder had at least one addictive disorder. In Canada, Russell et al. (1994) found that lifetime prevalence rates of anti-social personality disorder in drug abuse categories in untreated populations ranged between 10.4% (barbiturates) to 78.5% (cannabis). In the UK, Glass and Jackson (1988) found that 10% of psychiatric inpatients had an alcohol problem and 40% of those with alcohol problems had a dual diagnosis. Ghodse (1995b) reported that co-morbidity of substance misuse and personality disorder account for the majority of co-morbid patients. Crawford (1996) found that individuals with schizophrenia have a three-fold risk of developing alcohol dependence compared with individuals without a mental illness. In 1998, Oyefeso et al. found that the prevalence rate of personality disorder among drug-dependent inpatients was 86%, and the rates for histrionic, dependent and avoidant borderline personality disorder was 44%, 36%, and 76% respectively. Overall prevalence of substance use disorder in mental health patients in the UK was 36.3% (Menezes et al. 1996) Research evidence base Effectiveness of treatment and interventions Lehman (1995 as cited in Ley et al. 2000) found that abuse of alcohol or drugs is associated with increased rates of violence and suicide, poor compliance with treatment, early psychotic breakdown, homelessness, criminal behaviour and increased rates of hospitalisation among the severely mentally ill. In a prospective study of integrated outpatient treatment for substance-abusing schizophrenic patients in New York, USA, Hellerstein (1995) found there was no clear difference between the integrated and non-integrated treatment programmes. Although the result was approaching statistical significance in favour of the integrated programme in terms of lost to treatment, 64% of people in the trial did not continue their treatment. There was no statistical significance between integrated and nonintegrated treatment programmes for mental state outcomes. In New Hampshire, USA, Drake (1995 as cited in Ley et al. 2000) undertook a review of integrated mental health and substance abuse treatment for patients with dual disorders. There was no difference between assertive community treatment (ACT) and the other programme on the number of people lost to treatment. There were seven deaths in the two groups across the three years of the study. There was no difference in mental state between the two groups or in the use of substance between the two groups and there was no clear difference between the two groups on life satisfaction. Burnam et al. (1995) undertook an experimental evaluation of residential and nonresidential treatment for dually diagnosed homeless adults in Los Angeles, California. The study found a significant difference between the two groups for lost to treatment in favour of residential treatment, and no clear difference in substance use at nine months (scores likely to be skewed) Service utilisation Studies in the USA found that individuals with dual diagnosis seek treatment more frequently than those with one disorder (Narrow et al. 1993) and more than 40% of those with three or more disorders have never received any treatment (Kessler et al. 1996). In the UK, 26% of suicides (nationally) with a recent history of non-contact with services had a history of drug misuse; 26% of suicides (nationally) with a recent history 168

175 of disengagement from services had a history of drug misuse; 38% of suicides (nationally) with a recent history of non-contact with services had a history of alcohol misuse; and 38% of suicides (nationally) with a recent history of disengagement with services had a history of alcohol misuse (Department of Health 1999b) Treatment There is no one model of service provision which has been found to be the most effective for managing this client group. Service provision must be based on local needs assessment of the prevalence of those clients accessing both mental health and substance misuse services. The table below describes four themes of service delivery and suggests potential problems and difficulties of each model. Table 2: Models of treatment and potential difficulties Model of treatment Description Problems/difficulties Consecutive treatment (Franey and Quirk 1996) Treatment programmes are provided consecutively by the mental health services Limited communication between the services Health problems treated as separate entities also known as Serial and substance misuse Patients are shunted treatment model services depending on between the two services Parallel treatment (Franey and Quirk 1996) Integrated treatment (Minkoff and Drake 1991) Joint liaison/ collaborative approach the presenting problem The care of the patient is provided by both services concurrently, facilitated by communication between the two services The care of the patient is jointly managed by both services (designated service) The care of the patient is jointly managed by both services Patients are shunted between the two services Health problems are treated as separate entities Medical responsibility not clearly defined Isolated from mainstream services Views dual diagnosis as a static condition Expensive service provision Joint working between mental health and substance misuse services Joint responsibility Ensures the skills and expertise of both spheres of healthcare is utilised The model of collaborative working facilitates capitalising on the skills and expertise of the general mental health services and the specialist substance misuse services. While assertive community outreach programmes are favoured in the USA (Weaver et al. 1999) as a model of management, there is limited supportive evidence for effectiveness of this approach in the UK. There is no clear evidence supporting the advantage of any model as a preference over others (Health Advisory Service 2001a; Ley et al. 2001), each local area needs to identify the appropriate approach according to local needs and service configurations. 169

176 Irrespective of the model adopted, services need to have close collaboration with other providers involved in the care of the patient and carers. Those involved in the care of the patient need to identify a named care co-ordinator with responsibility for coordinating care and a lead medical officer with responsibility for the care of the patient. Treatment approaches will need to be as varied as the individuals presenting with comorbid mental health and substance misuse problems. There is therefore no specific treatment approach, as each person will need to be assessed individually and the treatment approach will need to be tailored to the individual needs of each client. Key elements in treatment will include: engagement of clients into services retaining clients in active treatment providing interventions which facilitate motivation to change addressing the relapsing nature of a chronic condition through relapse prevention work facilitating re-integration into the community with appropriate support (adapted from Department of Health 2002) Assessment of dual diagnosis The aims of assessment are: to ensure that patient needs are accurately identified, thus preventing inappropriate treatment responses to obtain a comprehensive picture of needs and problems through an ongoing process which is multi-professional and multi-agency in approach. The key issues in assessment are: Patients are more likely to disclose substance use, if asked. Substance misuse is a predictor of poor treatment outcome. Neglecting substance use/disorder or mental disorder(s) in the course of treatment can lead to mental destabilisation and/or relapse to harmful substance use. A period of abstinence from substances of at least three to six weeks (but often longer) is necessary to enable an accurate diagnosis of the primary problem. It is necessary to conduct a detailed psychiatric and substance use history with corroborative information from relatives, carers, other staff/professionals, previous record/notes and supported by urine toxicology results. Dual diagnosis requires assessment and observation over a period of time. Accurate assessment is necessary to prevent inappropriate treatment responses. Patients with mental health problems self-medicate with substances such as cocaine and amphetamines to counteract distressing extra-pyramidal side effects. Patients with substance misuse problems may self-medicate in an effort to treat psychiatric symptoms, such as depression. Substance misuse and mental health problems are associated with worsening of psychological and psychiatric symptoms and increased involvement in criminal behaviour. (Sources: Schneider and Siris 1987; Dixon et al. 1990; Crome 1996) The Health Advisory Service (2001a) recommends that: the assessment of all individuals with mental health problems in general psychiatry actively considers the potential role of substance misuse specialist substance misuse treatment providers identify and respond to problems of combined psychiatric illness and substance misuse Risk assessment and management 170

177 Risk assessment is a crucial and integral element of assessment among those with comorbidity. Risk assessment with this client group is particularly important due to a number of reasons, including difficulties in engaging clients into services, disengagement form services, high suicide rates, accidental and intentional drug overdose and harm/violence to others (Department of Health 1999b; ACMD 2000; Alcohol Concern and DrugScope 2002; Department of Health 2002). Mental health professionals should be trained to recognise, assess and manage risk of substance misuse, and risk management should incorporate harm reduction advice (Health Advisory Services 2001a) Care and management Care and management of this client group need to respond to the individual needs and presenting problems identified at the initial assessment and during ongoing contact with the services and ongoing assessment. Clients may present with a number of different problems and needs, such as: self-medication using drugs and/or alcohol to treat psychiatric symptoms (Dixon et al. 1990; Schneider and Siris 1987) depression and suicidal ideation as a result of substance misuse and the associated complications. It is important to recognise that intoxication and dependence may produce psychological symptoms (Crome 1996) and that substance use/misuse may exacerbate or alter the course of a pre-existing mental disorder (Crome 1996). The service response will depend on the presenting features, but it is important to recognise that patterns of dual diagnosis will vary in different individuals over time, and that chronic, complex needs do not remain the same. Clients have a complex clinical presentation which may change over time and hence services need to ensure that ongoing assessment and care plans change according to need. The treatment of alcohol and drug misuse, including substitute medication, is in line with the Department of Health guidelines (1999b) and research evidence (Health Advisory Service 2001a). There are a number of common features that need to be acknowledged when working with this client group. They are as follows: poor medication compliance (Pristach and Smith 1990; Lehman 1995 as cited in Ley et al. 2000) poor compliance with treatment regimes (Ridgely et al. 1990; Lehman 1995 as cited in Ley et al. 2000) higher susceptibility to high-risk behaviours such as sharing injecting equipment and unsafe sexual practices (Brooner et al. 1992) higher rates of hostility, aggression and violence (Ridgely et al. 1990; Wilen et al. 1993) in the case of homelessness people with substance misuse problems, increased vulnerability to substance misuse (Ridgely et al. 1990; Mamodeally et al. 1999; Lehman 1995) increased rates of suicidal behaviour (Ridgely et al. 1990; Wilen et al. 1993; Lehman 1995 as cited in Ley et al. 2000). The Health Advisory Service (2001a) recommends a number of key standards for dual diagnosis, these include the following for the organisation of care for those with substance misuse and mental health co-morbidity. Provision should be made for patients with mental illness and drug and alcohol misuse co-morbidity as part of mainstream mental health service. 171

178 Service users with co-morbidity in all commissioning areas should have access to the full range of specialist substance misuse services, as well as mental health services. It is a requirement that the remit of all assertive outreach services should include working with people with co-morbidity. Mental health professionals should address issues of patient motivation to seek treatment for their misuse of substances. There should be specific and explicit management procedures in place to care for and support clients with substance misuse problems. Service users, carers and families are involved in service delivery Drug use in psychiatric units The use and misuse of drugs is a growing problem for mental health services. Sandford (1995) found that 68% of 187 nurses reported illicit drug use in psychiatric units. The use of substances in the psychiatric ward can have a detrimental and potential harmful effect on the patient and can have an unsettling effect on the ward regime. In some circumstances, where the effects of intoxication or psychiatric symptoms are worsened by illicit drug use, there is a potential risk to the safety of staff, other patients and the community (The Mental Health Act Commission 1999). It is best practice to instigate prevention strategies to avoid the problems associated with drug use and mental illness. It is therefore recommended that all psychiatric units introduce a treatment contract for patients to accept as part of the admission process, by which the patient agrees not to use/misuse or hold in their possession any other drugs licit or illicit unless prescribed as part of their treatment programme. This arrangement relies on the co-operation of the patient, as such policies do not have any powers of legal enforcement. A search of a patient or their possessions and also urine toxicology without consent and without lawful authority would constitute a trespass to the person. A search would be lawful if there were reasonable grounds for suspecting that a patient was in possession of substances or articles that could be used to harm themself or others or was in possession of a controlled drug in contravention of the Misuse of Drugs Act If it is suspected that a patient may be under the influence of illicit drugs, the obvious dangers of such substances reacting with prescribed medication or other consequences of the drug use would justify the responsible medical officer under the common law duty of care to the patient, to carry out some investigation, such as urine toxicology. The Health Advisory Service (2001a) recommends the following in relation to drug and alcohol on hospital premises: There should be protocols in place to deal with responding to substance misuse on hospital premises. Protocols and procedures to control substance misuse on hospital premises should be combined with therapeutic approaches and support. Mental health staff and other employees with substance misuse problems should have access to help and support Legal framework: Mental Health Act The Act defines mental disorder as mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind (The Mental Health Act Commission 1999, pp ). Diagnosis of substance misuse disorder is not specified under the categories and therefore patients cannot be subject to detention for treatment under the Mental Health Act. 172

179 However, the management difficulties associated with this patient group who have psychiatric co-morbidity is often associated with increased violence, non-compliance with treatment and disengagement from services. Due to the nature of psychiatric comorbidity and the relative uncertainty, these patients should be subject to the care programme approach (CPA). Some patients who pose a risk to themselves and others may need to be considered for the Supervision Register under Section Care pathways A number of organisations and agencies will be faced with the issues of dual diagnosis, including health and social services, voluntary organisations, probation services, housing departments and police. The care and management of patients with comorbidity therefore needs to be multidisciplinary in approach. The pathways of care will be determined by the model of care approach in a particular area, which in turn will be determined by the need. While there is some evidence on the various models of treatment, the complex nature of this patient group would suggest the need to work towards an integrated approach of all the relevant services, with one lead service co-ordinating the comprehensive care package. It is important that the care pathway addresses the key role and contribution of each local provider agency concerned. This may typically include some or all of the following, depending on the particular individual: specialist mental health provider; drug and alcohol services (statutory and non-statutory); primary care; more generic organisations such as homeless services or youth organisations; and prisons (Department of Health 2002). It is crucial that community psychiatrists work collaboratively with substance misuse services to identify the most appropriate systems for the referral, care and management of those with mental health and substance misuse co-morbidity. The arrangements may vary from area to area, but all clients should have access to a specialist mental health assessment by a suitably qualified medical practitioner. This should be guided by good practice guidelines (Department of Health 2002) Treatment processes/ environment Steps/stages/processes All services involved in the treatment of those with dual diagnosis need to: adopt a common language operate a common referral criteria and process be in a position to provide a comprehensive multidisciplinary assessment procedure have equal access to a range of treatment modalities, including access to outreach, community treatment, home visits, outpatient treatment, inpatient treatment, and day care provision, including therapeutic interventions involve the general practitioner in the care and management of the patient and be included in all correspondence on all aspects of care. The Health Advisory Service (2001a) recommends the following: Mental health services should have treatment protocols for those with alcohol and drug problems. Clients with co-morbidity should have access to the range of Tiers 1 to 4 substance misuse treatment interventions. Combined pharmacological and psychological treatments should be provided to clients (where appropriate) including those who are receiving shared care between mental health services and substance misuse services. 173

180 Clients with co-morbidity should be given help in developing better support systems within the community. There should be clear policies for the follow-up of clients who are discharged, either planned or unplanned, from inpatient psychiatric care. Clients with co-morbidity should have access to residential and community rehabilitation services that are able to meet their complex needs Special populations The Health Advisory Service (2001a) recommends that attention is given to special populations in relation to co-morbidity. Mental health services for older people should explicitly tackle the misuse of alcohol and tranquillisers. The needs of young people with co-morbidity must be addressed by child-centred services. Strategies should be in place to work with homeless people in the care and management of those with mental health and substance misuse co-morbidity. Commissioners and providers should ensure that all local services are able to meet the diverse needs of the local populations and that the services are accessible to black and minority ethnic groups and effective at meeting their needs. Mental health professionals should consider post-traumatic stress among clients with co-morbidity and among refugees and asylum seekers in particular. The assessment and care of women should take into account gender-specific issues. The care of parents with co-morbidity needs to focus on the needs of their children, assessing the need for support and interventions to prevent harm Staff skill mix and qualifications Training and ongoing professional development is important in ensuring that staff are adequately trained to work with clients with co-morbid mental health and substance misuse problems. Each local area should develop a training strategy to identify the training needs of all staff and professional groups working in statutory and non-statutory organisations (Health Advisory Service 2001a; Department of Health, 2002). Mental health services should appoint staff who have formal training in mental health and substance misuse co-morbidity, or ensure that staff have access to substance misuse training once they are in post. Mental health services should have a substance misuse training strategy that pertains to all staff and professional groups and which is monitored and evaluated (Health Advisory Service 2001a). For staff working within substance misuse services, training should be provided which includes the recognition and care of service users with mental illness and collaborative working with mental health services. Key elements of staffing issues: Substance misuse and mental health service staff need to be adequately trained to assess psychiatric co-morbidity. Services need to ensure they have access to all professionals in medicine, psychology, nursing and social work to work with psychiatric co-morbidity. All staff need to have training in risk assessment. All services providing care and management to those with psychiatric co-morbidity need to have a lead medical officer with experience in substance misuse and psychiatry. All nurses within the services need to be qualified registered mental nurses (RMN). 174

181 All staff in general psychiatric services should have some training in substance misuse. Staff involved in providing the care and management of patients with psychiatric comorbidity should have at least 12 months post-qualification experience. The services involved should agree which consultant psychiatrist will act as the lead medical practitioner responsible for the care of a particular patient. Training of staff should incorporate three main elements: inter-agency collaboration and information exchange through inter-agency training; theoretical and skills-based training; and practice development and supervision (Department of Health 2002) Outcome monitoring/procedures See Performance and outcome monitoring section in Chapter

182 Diagram 10 Assessment care pathway Patient assessed by an agency to have substance misuse and mental health problem Contact other professionals and carers for information on the client/patient to assist in the assessment Obtain formal psychiatric assessment Arrange network meeting to discuss the care package with other professionals and care providers and identify a lead agency to co-ordinate care Liaison with local psychiatric and or substance misuse services for formal assessment Allocate a care co-ordinator and set up a list of all care providers involved with the client/patient for a communication network Agree a care package and identify the role of each care provider Agree monitoring system between all agencies involved Set up arrangements for care programme approach (CPA) 176

183 4.4 Outreach work Description Outreach work is a method of delivering interventions in settings external to a service's usual site. Outreach is not an intervention in and of itself. Outreach interventions can be focused on changing the behaviour of individuals or supporting communities to develop strategies to minimise collective harm (Rhodes 1997) Aims and objectives The aims of outreach work are: to provide services to those unable or unwilling to access site-based services, including hard to reach groups such as young people, black and minority ethnic communities, women, the housebound (e.g. because of physical or psychological illness) and those living at some distance from services (e.g. in rural areas). Services can include the provision of advice and information, brief interventions, sterile injecting equipment and, in some instances, care-planned counselling to provide health education opportunities for drug misusers not currently accessing site-based services to provide harm minimisation/risk reduction services to drug misusers not currently accessing site-based services (e.g. needle exchange, provision of condoms) to make initial contact with drug misusers to facilitate referral to site-based services Research evidence base Outreach interventions in the field of substance misuse treatment can trace their history in the UK to the public health agenda raised by the advent of HIV infection in the 1980s. The harm minimisation/risk reduction health agenda required the development of interventions which could reach drug misusers who were not accessing drug services. Outreach interventions provided these groups with health education and with services such as needle exchange and access to condoms, which led to reduced-risk health behaviour. At community level, outreach interventions can be peer-support initiatives or they can support community development initiatives (Rhodes 1997) Outreach to individuals A number of evaluations show that this form of outreach is effective in making contact with drug misusers not accessing site-based services (Verster et al. 1996; Rhodes et al. 1991). The provision of harm minimisation/risk reduction services including needle exchange and condom distribution have been effective in reducing levels of risky behaviour in those contacted (Verster et al. 1996; Stephens et al. 1991). However, in some cases, while referrals had been made to site-based services, this has not been effective. This is partly due to lack of interest on the part of those contacted in accessing other services and partly due to factors in the site-based services such as waiting lists and admission criteria (Rhodes et al. 1991). Contact can be made with individuals in a number of settings: 177

184 peripatetic (in the premises of another organisation) detached (streets, pubs, cafes, clubs, squats, etc) domiciliary (in the service user s home) (Alcohol Concern and Standing Conference on Drug Abuse 1999). Particularly important target groups include: people with co-morbid mental health and substance misuse problems sex workers street homeless refugees people with learning disabilities older people clients who disengage from services young people black and minority ethnic groups not engaged in services stimulant misusers Peer outreach models Peer outreach is a method less usually employed in the UK, but the model has been used and evaluated in the USA and is used in some developing countries. It has primarily been used as a method for imparting health education and HIV prevention interventions. Evaluation demonstrates that peer outreach workers are better able to make contacts with hard-to-reach drug misusers than their non-peer counterparts (Broadhead et al. 1995; Friedmann et al. 1992) Assertive outreach Assertive outreach is a different model of care for people with severe and enduring mental illness. Assertive outreach services have been proposed by some as a potential model for working with people with a substance misuse and mental health co-morbidity Professional guidance and legal framework The Task Force to Review Services for Drug Misusers (1996) identifies outreach work as a well-established model for delivering advice and harm minimisation interventions to drug misusers not in contact with services. The Review states that much of the evidence supporting the efficacy of outreach work is based on expert opinion. However, evidence does affirm that outreach work is effective in reaching those not in contact with services and in providing effective risk reduction/harm minimisation interventions. The Task Force concludes that there is little evidence of the cost effectiveness of outreach work and that further research should be undertaken in this area. It recommends that Better management, monitoring and support systems should be introduced. Outreach services should clearly identify their aims and objectives and collect data on number of contacts made, the effect of contact, costs per contact and on turnover of clients (Task Force to Review Services for Drug Misusers 1996) Issues of management The Task Force to Review Services for Drug Misusers states that the peripatetic nature of outreach makes supervision, monitoring and evaluation difficult (Task Force to Review Services for Drug Misusers 1996). These factors raise specific issues of management structure, functioning and accountability, and strategic responses to address these issues should include consideration of the following: 178

185 managers ability to provide clinical supervision and monitor working practices and situations the need for appropriate and accessible management and clinical supervision, including when staff are working out of office hours safety issues agreed working protocols with the police clear confidentiality protocols with all partners appropriate insurance cover held by the employer. Clear protocols and guidelines, including the setting of criteria to aid assessing eligibility for domiciliary outreach (e.g. women with children or those with mobility problems), are required. Managers will often make judgements about a worker's performance based on interfaces with that worker, including observation of the worker delivering a service. This is not always possible with outreach workers. Managers therefore have to rely on other forms of performance assessment based on more than workers self-reports. These might be reviews of the workers client notes or links with services which host peripatetic outreach sessions. It is also essential that job descriptions for outreach workers accurately reflect the range of tasks required. Accurate job descriptions will ensure that evaluation and monitoring of work can be structured around an explicit and clear set of tasks. Outreach workers should also be fully involved in site-based management structures such as team meetings. The isolated nature of much outreach work means that those providing management supervision need to be able to reflect on clinical practice and also on the specific nature of outreach work (Rhodes et al. 1991). This means that the employing organisation may have to consider providing outreach workers with access to external supervisors with appropriate experience. Outreach services can be used to improve accessibility to a range of interventions in rural areas. However, consideration needs to be given to a number of issues when planning this type of service: the resource implications of providing such a service, e.g. staff travel costs and opportunity costs of staff time lost in travelling between sites or home visits the appropriateness of providing some services either in a peripatetic of homebased setting, including consideration of issues such as access to equipment and client and worker safety the potential isolation of the worker from management and colleagues, as more time is spent travelling between peripatetic sites or home visits subsequent difficulties in providing management and supervision to staff. Organisations providing outreach services must have appropriate safety policies and protocols in place to ensure worker safety. As stated in the QuADS organisational standards (Alcohol Concern and Standing Conference on Drug Abuse 1999), these should include: details of risk assessment and management procedures in terms of outreach services provided, including risk assessment of service users receiving services in their own home the stipulation that for safety reasons detached work is always undertaken by a minimum of two staff and that staff are provided with a mobile phone details of agreed check-in/check-out systems including staff check-in after completing a specific task and a diary where staff note where they will be working. 179

186 4.4.5 Referral pathways The nature of outreach work means that this service is often a point of referral to other services. Research has demonstrated that this may be problematic if referral protocols are not developed and implemented (Verster et al. 1996). Many of those contacted through outreach express needs relating more to their social conditions, for example, housing, benefits advice, basic nutrition and legal advice (Rhodes et al. 1991). These needs are often given higher priority by the drug misuser than those related to their drug misuse. Referral protocols to services that can meet these needs must therefore also be established Assessment Due to the low threshold nature of much outreach work, little or no assessment is required to access the service. However, it is necessary to assess: the nature of the service user s drug misuse and their drug using behaviour in order to provide appropriate risk reduction/harm minimisation advice risk associated with providing services in the service users own homes in order to ensure the safety of outreach workers Performance and outcome measurement See Performance and outcome monitoring section in Chapter

187 4.5 Criminal justice Definition This section describes the criminal justice interventions and contingencies that have been designed to access substance misusers into drug treatment Epidemiology Breaking the link between drugs and crime has been a key feature of government antidrug strategies since the mid-1990s (CDCU 1995; UKADCU 2000). Recent studies estimate the cost of drug offences to the criminal justice system as 1.2 billion (Brand and Price 2000) and the social costs of class A drugs have been estimated to be nearly 12 billion (Godfrey et al. 2002). Research on offender populations in the UK reveal that acquisitive crime (particularly shoplifting, burglary and fraud) are the primary means of funding drug consumption (Bennett 2000; Coid et al. 2000; Edmunds et al. 1998, 1999). The evidence points to users of heroin and cocaine (particularly crack) as the most likely to be prolific offenders (Bennett 2000; Stewart et al. 2000). The NEW-ADAM research programme has found that those who report using heroin, crack or cocaine commit between five and ten times as many offences as offenders who do not report using drugs. Although users of heroin and cocaine/crack represent only a quarter of offenders, they are responsible for more than half (by value) of acquisitive crime (Bennett et al. 2001). Links between problematic drug use and crime are complex. Edmunds et al. (1999) suggest that experimental drug use can pre-date contact with the criminal justice system and become problematic after extensive criminal activity. For those engaged in crime prior to drug use, their offending behaviour can increase sharply Evidence base The National Treatment Outcome Research Study (NTORS) has shown that clear reductions in levels of drug use and acquisitive crime one year after treatment were maintained after five years (Gossop et al. 2001a). In cost-effectiveness terms, NTORS estimates that for every 1 spent on treatment there is a saving of 3 on criminal justice costs. This translates to an estimated annual criminal justice saving of 5.2 million. Separate research based in an inner-london outpatient clinic found that of 81 opiate users who entered methadone based treatment, over half reduced their heroin use and drug-related offending after six months (Coid et al. 2000) Interventions/treatment Although there is strong evidence of the efficacy of drug treatment services, evidence (Audit Commission 2002; Hough 1996) points to a number of specific issues that need to be addressed if treatment is to work effectively among drug-using offenders entering the criminal justice system: 181

188 Drug-misusing offenders should have quick access and entry into drug treatment. They should be retained in continuous drug treatment for at least three months. They should have the option of methadone maintenance (and not rely on detoxification alone). Comprehensive care management techniques are needed to deal with an individual s multiple needs. There needs to be close co-ordination between specialist and generic services across a range of interventions Criminal justice drug interventions The following diagram illustrates the current range of criminal justice-based drug interventions and how they relate to each other. The criminal justice system provides three key opportunities for intervention: at the arrest stage (police station); at court (through bail and sentencing options); and while in custody (either on remand or sentenced). Some interventions are primarily designed to identify drug misusing offenders and refer them into treatment, i.e. arrest referral schemes, drug abstinence orders/requirements and prison based CARAT schemes. Other interventions like Drug Treatment and Testing Orders and prison-based treatment programmes involve the delivery of treatment within a criminal justice context. 182

189 Diagram 11 Criminal justice interventions and their relationships Drug treatment Drug testing Arrest Referral Scheme Drug Abstinence Order Drug Abstinence Req ment Police station Court Custody CARAT Treatment Point of intervention Identify/refer Integral treatment DTTO Detox Drug progs Voluntary Testing Unit 183

190 Arrest referral schemes In 1998, encouraged by the evidence emerging from evaluations of early arrest referral pilot schemes (Edmunds et al. 1998; Turnbull et al. 1996), the government set a performance target under the communities aim of the 10-year anti-drugs strategy for all police forces in England to operate proactive arrest referral schemes by March To accelerate the expansion of arrest referral schemes, the Home Office launched the Joint Finance Initiative, which provided 20 million matched funding to police services for this purpose. By the end of April 2002 all police forces were operating arrest referral schemes employing 374 workers. Arrest referral schemes operate on an entirely voluntary basis. All arrestees are made aware of the scheme when received into custody and asked whether they want to see an independent drug worker. If they accept the offer, they are seen and assessed by the worker who will then make arrangements for them to be referred to an appropriate treatment agency. Agreeing to see a worker will have no bearing on how the police deal with the arrestee in terms of whether their case is proceeded with. Arrest referral schemes are not alternatives to prosecution or due process but provide a direct route from the custody suite to drug treatment or other programmes of help. Once contact is made with an arrest referral worker, the arrestee s substance misuse needs will be assessed. Arrest referral workers must be competent to assess. Standard assessment forms are used in many areas for monitoring purposes. Onward referral is then made. Arrest referral workers must therefore have a good understanding of local service provision, which should reflect the service framework presented in this document. Appropriate protocols that support speedy referral and the transfer of information between arrest referral schemes and local drug service providers should be developed in partnership, agreed at DAT level, and put in place locally Monitoring The monitoring programme for arrest referral schemes was set up to collect information about the characteristics, drug use and offending behaviour of those interviewed by arrest referral workers in England and Wales. The latest Arrest Referral Monitoring Statistical Update (Son+), which provides statistics from the Arrest Referral Monitoring Programme for October 2000 to September 2001, was published on 12 June 2002 and is available on the government s drugs website at The research identifies significant reductions in offending and in the proportions of offenders using heroin and/or crack-cocaine. There were also significant improvements in physical and psychological health. Arrest referral workers screened about 49,000 individuals in England and Wales between October 2000 and September More than half of them were voluntarily referred to a specialist drug treatment service. Of those referred, a quarter (5,500 individuals) entered treatment. The study showed that arrest referral schemes effectively targeted prolific problem drug using offenders and significantly reduced their level of re-offending. Two-thirds of heroin and crack-cocaine users were arrested less often in the six months after seeing an arrest referral worker than in the six months before. Self-reported follow-up interviews also identified significant reductions in offending and in the proportions using heroin and/or crack-cocaine. There were also significant 184

191 improvements in physical and psychological health. Problem drug-using offenders who were referred by an arrest referral scheme were more likely to drop out of treatment compared to self or GP referred drug users. Some key groups did not engage fully with treatment services, including black and Asian problem drug-using offenders, older heroin and crack users, young, male crackusing street robbers and female crack-using sex workers Drug testing pilot programme The Criminal Justice and Court Services Act 2000 (CJCS) gave the police new powers to drug test detainees in police custody and courts the power to order drug testing of offenders under the supervision of the probation service. These new powers are being piloted in nine sites across England and Wales between 2001 and The Home Office has commissioned a comprehensive evaluation of the pilot programme. Section 57 CJCS allows the police to test detainees aged 18 or over who have been charged with a trigger offence (these include theft, burglary, robbery and possession and supply of Class A drugs). The only drugs that are currently tested for are cocaine and heroin. The test result is then made available to the court to assist with bail and sentencing decisions. If a detainee submits a positive test they will be encouraged to see the arrest referral worker based at the police station to ensure that appropriate advice regarding treatment is made available. Failure to provide a sample is a criminal offence that carries a three-month prison sentence and/or a fine of 2,500. NB There are proposals in the current Criminal Justice White Paper, Justice for All, to extend testing to detainees under the age of 18 and extend the number of trigger offences. CJCS also gives the court power to order a pre-sentence drug test (Section 58) if it is considering passing a community sentence. Section 47 CJCS introduced a new community sentence, the Drug Abstinence Order (DAO) that can be made for a period of six months to three years and requires the offender to abstain from using Class A drugs and to be tested for cocaine and heroin by the probation service. The DAO combines the dual function of monitoring and deterrence and although there is no formal link between DAOs and treatment, testing could help identify those who would benefit from treatment and act as a referral route. Section 49 CJCS allows the court to attach a Drug Abstinence Requirement (DAR) to a community rehabilitation or punishment order requiring the offender to abstain from using Class A drugs and to be tested for cocaine and heroin. A DAR is mandatory if the offender is over 18, has been convicted of a trigger offence and the court is of the opinion that the offender is dependent or has the propensity to misuse Class A drugs. CJCS also allows for a drug testing requirement to be imposed on those being released from prison on licence if they are over 18, serving a sentence for a trigger offence and drug misuse is identified as a contributing factor to the prisoner s offending. The final evaluation is due to be published in spring A summary of the first interim evaluation report, Findings 176, can be obtained from [email protected] Drug Treatment and Testing Orders Established as part of the Crime and Disorder Act 1998, Drug Treatment and Testing Orders (DTTOs) replaced the power to add a requirement for drug treatment to a 185

192 probation order. The purpose of the DTTO is to break the link between drug use and crime. It can be imposed on any offender over 16 who has a dependency on or propensity to misuse drugs and for whom treatment may be helpful. It obliges the offender to: undergo treatment as specified for a set period of between six months and three years be tested regularly for drug use attend regular court review hearings at which progress under the Order will be reviewed. Drug testing is mandatory and courts regularly review the offender s progress. If testing requirements are not met and/or attendance at mandatory treatment is not adhered to, the court can revoke a DTTO and re-sentence the offender. DTTOs cannot be imposed without the consent of the offender. DTTOs aim to bring persistent and dependent drug-misusing offenders into a closely supervised programme of treatment in order to effectively break the links between their drug misuse and their offending. DTTOs were implemented nationally in October 1999 following pilot schemes in Croydon, Gloucester and Liverpool. The pilot sites demonstrated the following areas of impact (through self-report interviews with offenders): reductions in drug use and offending at the start of the order fall in average weekly spend on drugs reduction in levels of polydrug use six-monthly interviews with offenders demonstrated that these reductions were sustained over time (Turnbull et al. 2000). Assessment An offender s suitability for a DTTO must be assessed according to four main criteria: type and seriousness of offence seriousness of drug problem and susceptibility to treatment motivation to change volume of drug-related offending. The assessment is usually provided within a pre-sentence report but is undertaken jointly by probation and treatment staff. It should include the following: a statement that the offender has been assessed by probation and treatment staff as being dependent upon or having a propensity to misuse drugs and as being susceptible to the kind of treatment being proposed a treatment plan, including the name and address of the treatment provider, and whether the treatment will be residential or non-residential confirmation that arrangements for this treatment are in place the suggested length of the order a signed statement from the offender that the requirements of the order and the consequences of a failure to comply have been fully explained by the responsible officer and confirming that the offender is willing to comply with the order a proposal for the minimum frequency of drug testing and of court review hearings to be specified in the order where there is a need for a residence requirement (other than for residential treatment) a proposal that a probation order be made alongside the DTTO and an explanation of the reasons why this residence requirement is deemed necessary. 186

193 DTTO national standards The first appointment with the probation service to take place within one working day of the order being made and contact with the treatment provider shall be arranged to take place within two working days of the order. Contact, including treatment, across all the requirements of the order to be on five days a week, for a total of 20 hours a week, for the first 13 weeks of the order. There is discretion for this to be reduced to a minimum of three days a week and 12 hours a week thereafter, if the offender is responding well. The minimum for the first 13 weeks of the order shall be 15 hours a week and nine hours a week thereafter. Contact with the offender to include provision for treatment, offence focused work and lifestyle programmes. It is anticipated that the offender will not usually be employed at the commencement of the order. If the offender obtains employment, the probation service and treatment provider shall consider whether the treatment and contact requirements should be reduced to facilitate this and an early review hearing arranged for this to be considered by the court. Nevertheless, the minimum treatment and contact requirements shall be met in all cases. Treatment provided under the order must comply with co-existing national standards, i.e. QuADS: organisational standards for alcohol and drug treatment services (Alcohol Concern and Standing Conference on Drug Abuse 1999) and Drug misuse and dependence: guidelines on clinical management (Department of Health et al. 1999). Testing The purpose of regular testing is to provide supervising officers, treatment providers and the courts with an objective measure of the offender s progress towards becoming drug free. The supervising officer must put these results into the context of the offender s overall progress on the order when reporting to the sentencing court for each review hearing. Offenders should be tested at least twice a week for the first 13 weeks of the order with discretion for this to be reduced to a minimum of once a week thereafter depending upon progress. Joint commissioning From 2002/03 the contribution to the pooled treatment budget has been top-sliced from the overall National Probation Service budget. The DTTO element of the pooled budget is no longer ring-fenced and treatment provision is commissioned through DAT joint commissioning groups Youth offending teams The purpose of youth offending teams (YOTs) is to co-ordinate the provision of youth justice services with the overall aim of preventing offending by children and young people (Home Office et al. 1998). They work with young offenders throughout all stages of the youth justice process. They are multidisciplinary and include representatives from education, social services, the police, probation services and the health service (Newburn and Elliot 1999). In addition to working with identified young offenders, YOTs are designed to work with young people identified as being at risk of becoming involved in crime, including those who are regular truants. YOTs are tasked with reducing reoffending by young people aged years, and reducing the number of young people starting to offend through proactive primary prevention strategies. 187

194 Drug Treatment and Testing Orders (DTTO) can be made in respect of young offenders at either the Youth Court or the Crown Court. The DTTO is a very demanding and intensive sentence, which involves contact, including treatment, of at least 15 hours 1 week for the first 13 weeks of the order and is subject to rigorous enforcement. It is, therefore, likely to be appropriate for only a very limited number of young offenders. There are a number of other sentences available under the youth justice system, within which drug education prevention and/or treatment may be included, which may be more appropriate than a DTTO. These include: Referral Orders Action Plan Orders Supervision Orders, Community Rehabilitation/Punishment Orders Detention and Training orders, if the offending behaviour is sufficiently serious to warrant detention. Drug-related interventions, which are not sentence requirements, may also be provided as a result of: Final warning assessments and interventions Arrest referral projects Bail support schemes Remand fostering. The stringent demands placed upon offenders within DTTOs will usually make this form of sentence inappropriate for those with dual diagnosis (substance misuse and mental health problems). From April 2002 all 154 YOTs in England and Wales have access to a named drug worker (NDW). The NDW initiative is working to ensure Tiers 2, 3 and 4, as outlined in the Health Advisory Service report (2001b), are available to all YOT clients. The aims of the initiative are to: ensure that YOTs have access to a named drugs worker and can access a budget to purchase services which will contribute to a treatment programme for young offenders assess all young offenders for substance misuse and organise intervention programmes to meet identified needs. In some cases these workers are placed with the YOT and in some instances they are based with the provider agency Prison-based treatment CARAT services Counselling Assessment Referral Advice and Throughcare (CARAT) services were made available in all prison establishments from October CARAT services are designed to provide treatment and support for drug misusers while they are in prison, through liaison with prison healthcare and by acting as an interface between prison and community service provision. CARAT services are commissioned by the Prison Service and are provided by substance misuse specialist treatment services. The CARAT teams are not prison service staff but provide direct assessment and treatment services within the prison environment. 188

195 CARAT services offer: initial assessment on first reception health liaison with community agencies at the time of reception specialist input into pre-sentence reports, bail applications and assessments for home detention curfews post-detoxification assessment and support specialist input into sentence planning counselling aimed at addressing drug problems (on an individual and group basis) support and advice on a range of drug, welfare, social and legal issues, including harm minimisation assessment for in-prison rehabilitation programmes assessment for post-prison rehabilitation programmes/drug services pre-release training health liaison with community agencies on a prisoner s release liaison with and referral to community agencies to enable effective resettlement (Drugs Prevention and Advisory Service and Standing Conference on Drug Abuse 1999). The nature of CARAT services requires the development and agreement of policies and protocols that support effective working arrangements between CARAT services and other parts of the prison establishment, and between CARATs and community-based services. The prison service drug strategy unit are undertaking a review of CARAT services which is due to report in Clinical services Prison Service Order 3550 sets out the standards for the delivery of clinical services in prisons. It requires healthcare staff to provide services which: identify, assess and treat substance misusers in line with Department of Health guidelines contribute to throughcare plans provide information on high-risk behaviour, harm minimisation and secondary prevention to prisoners. Under the standards, each prison is required to have a detoxification service for opiate users and to provide treatment for symptoms associated with stimulant and benzodiazepine withdrawal Treatment programmes Across the country, a number of prisons run a range of structured treatment programmes that are often delivered by a combination of external drug agency and prison service staff. These include 12-step and cognitive behavioural-based group work programmes as well as those based on a therapeutic community model Recent developments in criminal justice interventions The updated drug strategy 2002 sets out plans to break the link between drugs and crime by extending or enhancing a range of interventions from arrest to court, to sentence, which are aimed at getting drug misusing offenders into drug treatment. This will involve a major expansion of services within the criminal justice system and take forward work already started on arrest referral and DTTOs, building on the pilot drug testing projects by extending this approach more widely and developing better systems for throughcare and aftercare. Initially focusing on the high crime areas, this model will fast-track the development of integrated care pathways for offenders. 189

196 4.6 Users, carers and self-help groups Background The NHS and Social Care Act 2001 demands that every NHS body, including drug treatment services, now has a statutory duty to consult and involve patients and the public in its activities. The duty to involve and consult commenced on 1 January The Department of Health is providing guidance on how this can be done via a new system of patient and public involvement. Drug service users and their carers can also take advantage of these new opportunities. In every NHS trust there will be a Patient Advice and Liaison Service (PALS) to provide on-the-spot help and information to patients about the trust s services, including complaints procedures, and advice about local voluntary and self-help groups. PALS will be part of each trust. Patients forums will be set up as independent statutory groups to monitor and review services and to influence the day-to-day management of the trust s health services and monitor the work of each PALS. In every community, local networks will be set up to provide advice and information to local people and to enable them to get involved in their healthcare services. They will do this through local outreach teams which will also support the work of PALS and patient forums by bringing them together to share information and lessons that they have learned. Local people will be able to join a panel to ensure that the outreach teams are concentrating on issues of real local concern. Local Overview and Scrutiny Committees will be set up to inspect regional NHS services. Local networks will also employ the services of the Independent Complaints Advocacy Services (ICAS) to support people wishing to complain about their healthcare. Local networks will be monitored and supported by the national Commission for Patient and Public Involvement in Health (see below). At national level, the Commission for Patient and Public Involvement in Health will be an independent organisation that collects, compares and promotes information picked up by its local networks, and by PALS and patient forums. It will carry out research, set national quality standards for patient and public involvement, develop and provide training to ensure that local volunteers and representatives are able to meet these standards, and monitor PALS, patients forums and ICAS. The Department of Health is also changing how people can complain about the NHS. A listening exercise was conducted in September The feedback obtained was used to construct a final package of measures and a timetable for implementation. This is available on the Department of Health website: The NTA s user and carer involvement The NTA wishes to advocate partnerships with drug treatment service users and carers, because we recognise that users have the right to become involved in activities that affect their health and well-being. We also respect the unique expertise and experiences of drug users and carers and know the health, esteem and other personal benefits which involvement can bring. The NTA will work with drug users, drug treatment services, joint commissioners of drug treatment services and local drug action teams (DATs) to develop a national strategy for involving users and carers. The NTA s user and carer involvement strategy aims to: 190

197 make agencies that provide drug treatment services more accountable to service users and carers create more opportunities for people who use, or want to use, drug treatment services to get involved. We are particularly concerned about people whose needs are under-represented by existing services, such as women and black and Asian users enable service users to complain about services. We will make the system easier to follow and make sure that it is well advertised. We will also make sure that the general NHS complaints procedures are open to drug treatment service users seek to ensure that specialist drug treatment services are independently monitored be flexible and be based on what works. Existing standards on involving service users and carers in the commissioning and provision of drug treatment are set out below. Service users should be involved in the planning of local drug treatments services (Substance Misuse Advisory Service 1999). Drug treatment service users (as with any health and social care service user group) should be regularly consulted on their satisfaction with the treatment provided and should be actively involved in their own care (Alcohol Concern and Standing Conference on Drug Abuse 1999; Standing Conference on Drug Abuse 1997b; Department of Health 1991). As a matter of good practice, service users should be made aware of complaints procedures and local advocacy and support services (Standing Conference on Drug Abuse 1997b). A service users charter of rights and responsibilities is built into QuADS standards for drug and alcohol treatment providers. Drug treatment commissioners and providers should ensure that these standards are met (see Box 2 below). The NTA, in partnership with users, carers, service providers and commissioners, and other parties, will build on this existing good work and provide guidance and implementation to enable the construction of a more patient-centred drug treatment system in line with the NHS Plan Self-help networks There are a variety of self-help networks in England. These groups have a variety of purposes, aims and philosophical backgrounds and vary from abstinence-based support networks to advocacy to harm reduction peer interventions. There is an emerging evidence base from the USA that the regular use of self-help groups (in particular NA) can be beneficial to client outcome from drug treatment. Fiorentine and Hillhouse (Fiorentine 1997; Fiorentine and Hillhouse 2000) have found that attendance at mutual aid groups can improve and sustain outcomes from compatible forms of drug treatment Types of help Advocacy Some groups, such as the Methadone Alliance, advocate for better methadone treatment and provide service-user support networks. A national network of drug users support groups now exists. It can be contacted through the National Drug Users Development Agency. User-focused magazines such as Monkey and Black Poppy offer another source of information and support for drug users and their families. 191

198 Safer use Some agencies (such as Mainliners) play an active role in harm reduction work, including: peer education in safer drug use and safer sexual behaviour; first aid training in the event of overdose; provision of drug-related advice and information; and service user advocacy Self-help groups The largest of these self-help groups for drug users is the fellowship of Narcotics Anonymous (NA). NA is a worldwide self-help network for people trying to remain abstinent from illegal drugs. It is one of the 12-step fellowships borne out of Alcoholics Anonymous (AA). It has an abstinence-based philosophy and the 12 steps are used to instil a new attitude and develop a drug-free lifestyle. Members are encouraged to attend support groups regularly for ongoing support and prevent relapse. In 1997, NA estimated that their London membership alone was 3,000, with about 20 meetings each day in the capital (Standing Conference on Drug Abuse 1997b). Mentors work with other members to support them and help them understand the 12 steps. Many drug services have active links with NA and encourage service users to link with local groups. Some drug services host NA meetings. Another 12-step, fellowship-based, self-help group is Cocaine Anonymous, although the number of these meetings is much smaller than NA. Some parts of England may not have NA meetings available and many drug users have found attendance at AA meetings, which are much more widely available, a very supportive source of help Carer and family support The needs of carers and families must also be considered in line with the Carer (Recognition & Services) Act, Carers have to cope with a number of problems in supporting drug users in their families (Velleman et al. 1993). Primary care staff can provide effective help to carers (Copello et al. 2000). ADFAM is a national charity set up to support the families and friends of drug users. It provides a range of services including a telephone helpline, publications and training. Families Anonymous is a self-help network of group meetings offering support to families. 192

199 Box 2 SCODA Service users charter of rights and responsibilities A drug service user has both rights and responsibilities. The service provider has an obligation to make each of these explicit to the service user. A service user has the right to: assessment of individual need (within a specified number of working days) access to specialist services (within a maximum waiting time), and the right of immediate access on release from prison full information about treatment options and informed involvement in making decisions concerning treatment an individual care plan and participation in the writing and reviewing of that care plan respect for privacy, dignity and confidentiality, and an explanation of any (exceptional) circumstances in which information will be divulged to others referral for a second opinion, in consultation with a GP, when referred to a consultant a written statement of service user s rights the development of service user agreements, specifying clearly the type of service to be delivered and the expected quality standards the development of advocacy an effective complaints system information about self-help groups and user advocacy groups. A service user s responsibilities to the service provider include: observing house rules and behavioural rules, as defined by the service (e.g. not using alcohol or drugs on the premises, treating staff with dignity and respect, and observing equal opportunities and no smoking policies) specific responsibilities within the framework of a care plan or treatment contract (e.g. keeping appointment times and observing medication regimes). References Task Force to Review Services for Drug Misusers Report of an independent review of drug treatment services in England London: Department of Health 1996 Purchasing effective treatment and care for drug misusers: guidance for health authorities and social services departments London: Department of Health 1997 Enhancing Drug Services London: SCODA 1997 Getting drug users involved: good practice in local treatment and planning London: SCODA

200 4.7 Complementary therapies Description Surveys and censuses of drug treatment services indicate that complementary or alternative therapies are increasingly being used in drug treatment settings. For example, in 1997, 40% of residential services were providing complementary therapies (Standing Conference on Drug Abuse 1997c). Community-based and residential drug services (primarily, though not exclusively, in the non-statutory sector) report providing a range of complementary therapies including: auricular acupuncture, homeopathic medicines and teas, visualisation, shiatsu and reflexology Evidence base The evidence base on the use of complementary therapies for drug misusers generally remains inconclusive or contradictory. The Effectiveness Review (Task Force to Review Services for Drug Misusers 1996) concluded that: Most of the reports [on the use of complementary therapies in drug treatment] are fairly positive but there are almost no data to support claims of treatment effectiveness. It is difficult to subtract out the general effect of care and attention to isolate the impact of the specific intervention. These therapies do apparently attract some drug misusers, e.g. cocaine misusers, into treatment services. Much of the research evidence on complementary therapies focuses on the use of auricular or other acupuncture with stimulant users, particularly, but not exclusively, with cocaine users. Evidence is inconsistent and can be contradictory. Some evidence has recently emerged that indicates beneficial effects of auricular acupuncture for drug misusers. Trials that randomised patients to receive acupuncture at sites on the ear recommended for addiction or at nearby sham sites have not demonstrated an advantage for the recommended sites (Sapir-Weise 1999; Otto et al. 1998). However, both groups of acupuncture patients were retained in treatment longer than patients not given acupuncture. However, recent research by Bullock et al. (1999) found no advantages attributable to auricular acupuncture when she tested whether both recommended and sham sites exert a positive effect. Results found no impact in terms of treatment retention or cocaine use/craving during treatment. A companion study of outpatients also reported no difference in outcomes between three different intensities of acupuncture at recommended sites. Similarly, a randomised controlled trial of acupuncture as a treatment for cocaine addiction in the US compared outcomes for auricular acupuncture using recommended sites in comparison to controlled needle insertion (sham sites) and relaxation treatment. All three showed similar impacts upon levels of cocaine use and retention in treatment, demonstrating no specific benefits to be gained from the auricular acupuncture (Margolin et al. 2001). However, a similar randomised controlled trial with cocaine and opiate dependent patients in methadone treatment showed dissimilar results. Here, patients were also allocated to receive either auricular acupuncture using recommended sites, acupuncture using sham sites or relaxation sessions. In this study, those receiving 194

201 auricular acupuncture demonstrated better rates of retention in treatment and provided cocaine-negative urine samples (Avants et al. 2000). An US government expert panel recently found the evidence for acupuncture in addiction as less convincing than in other sectors but promising enough to support its use within a comprehensive management programme (National Institutes of Health 1997). Some service user satisfaction surveys show that service users positively rate complementary therapies. This is an important factor that may enhance client retention (Burns 1999). An outcome study examining the impact of acupuncture for chronic repeat offenders (50% methamphetamine users and the rest primarily alcohol misusers), found an impact on retention in treatment as well as positive impacts on new arrests and drugpositive urinalyses (Russell et al. 2000). This finding has been replicated in a study of inpatients, which found improved retention and treatment compliance rates in patients offered acupuncture compared to a control group who received no acupuncture (Gurevich et al. 1996) Management As with any discrete form of intervention, it is important to ensure that practitioners delivering complementary therapies are competent and accredited by relevant professional bodies and operate within good practice guidelines. See also Stimulant users, in Chapter

202 4.8 Performance and outcome monitoring Description There is an increasing central imperative to monitor the activity, cost and outcomes of substance misuse treatment and care services. Structured community and specialist substance misuse service providers are now expected to report at least some information about how effective they are at helping people who present for treatment. This reflects a desire to gauge the return on national investment in treatment services and to ensure that resources are directed to treatments that are effective Definitions Monitoring Monitoring can be defined as the ongoing checking of progress against a plan, through routine systematic collection and review of information. It has been defined by the World Health Organization (WHO) as the following up of activities to ensure that they are proceeding according to plan. It is concerned with noticing differences over time and provides information with which to check progress Process or activity monitoring Process or activity monitoring is concerned with questions about how a service is operating. Process measures (sometimes referred to as output measures) are indicators of the level, amount or volume of activities undertaken by the treatment programme. They monitor activity in terms of volume and time, and can be used to gauge the workload and cost of a programme. The measuring process does not indicate whether the IMPACT objectives of a treatment programme have been met. The conversion of inputs (e.g. staffing, funding) to processes provides an indicator of the efficiency of the programme, but not the extent to which it is effective Measuring input Inputs refer to the resources that are required to provide an intervention and include funding, staff numbers and competencies, and infrastructure such as buildings. With the increase of government resources aimed at substance misuse treatment, it is now expected that providers, commissioners and DATs will be able to report accurately on the cost of substance misuse treatment, including cost per unit where possible. Reporting mechanisms have been identified in the DAT reports and treatment plans Outcome monitoring Treatment outcomes may be defined as the attributable results or effects of processes, or a measurable change that can be directly or indirectly attributable to a treatment intervention. Outcome measures are the critical indicator of whether and to what extent the programme is meeting its desired goals and what impact this has. Some programmes will specify these on a time dimension, showing intermediate, short-term outcomes as well long-term outcomes, and when these are likely to be achieved. Outcome determination is tied to: specifying the objectives of treatment services assessing the functional status of a client and the attainment of their desired treatment goals attributing these changes to the treatment received. 196

203 The outcomes that drug treatment services are working to achieve with service users were defined by the Task Force Review of Services for Drug Misusers (1996). These are: Drug use abstinence from drugs near abstinence reduction in quantity consumed abstinence from street drugs reduced use of street drugs change from injecting to oral consumption reduction in frequency of injecting. Physical and psychological health improvement in physical health no deterioration in physical health improvement in psychological health no deterioration in psychological health reduction in sharing reduction in sexual risk. Social functioning and life context reduction in criminal activity improvement in employment status fewer working/school days missed improved family relationships improved personal relationships domiciliary/stability/improvement. These outcomes can be referred to as true outcomes and are the treatment goals to be agreed with the service user at the onset of care. Monitoring outcomes is achieved by measuring the effectiveness of treatment in meeting the goals set out in the service user s care plan. The attainment of treatment goals may require a considerable length of time. In this case, services may need to have immediate outcome measures to review progress of a care plan. Intermediate outcomes can include results of urinalysis, haematology or swab tests. Outcome measurement tools are also used. They provide evidence that an individual is progressing towards achieving successful outcomes, or that a particular outcome has been achieved. There are a number of standardised instruments for the monitoring of intermediate outcomes (e.g. the Maudsley Addiction Profile and others) which have been used by a DATs and joint commissioning groups. Some DATs and provider agencies have established their own measurement system. We do not recommend any outcome instrument over any other, but suggest that the choice of a suitable and validated outcome questionnaire should be guided by the following considerations: relevance to the target population and treatment programme evidence base of the treatment provided, with less well evidenced treatment requiring more comprehensive intermediate outcome monitoring and evaluation relevance to the drugs strategy and ability to report directly against national targets and priorities suitability for face-to-face or telephone interview with a client or self-completion by the client the instrument must have established psychometric properties (validity and reliability) 197

204 the measures must be sensitive to change over time ideally, the administration time should be brief the client and other non-professional audiences should be able to understand scores and reports immediately. It has been recommended that a structured review of outcome measures looks at the following: Review criteria Key question Purpose - What does the measure aim to do? - What does it aim to measure? Background - Why was this particular measure needed? - What was the rationale behind its design? Description - Description of the main domains covered, number of items and sub-scales, response format, reference period and method of administration and scoring User perspective - Whose perspective does the measure capture? - To what extent does this measure capture user or carer desired outcomes? - Is it faithful to the content and form of user and carer views? Psychometrics - Is the measure psychometrically sound? Feasibility - How feasible is the measure to use within routine practice? - Consideration of length and ease of administration, scoring, interpretation and feedback of information within the health and/or social care interaction. Utility - Can the information provided by the measure become an integral part of treatment and care decision making? - Does the measure involve the user in this process? - Does it provide extra information not already available to the care provider? Source: Reviewing outcome measures, Clearing House Health Outcomes The collection of reliable outcome measures is essential. However, it is recognised that in many substance misuse treatment agencies, as well as in many DATs, there are few resources available to monitor outcomes. It is therefore recommended that in the first instance, proxy outcome measures be collected, while local systems are being implemented enabling the monitoring of outcomes (see below) Developing local systems for monitoring process or activity and outcome DATs and joint commissioning groups have a critical role in working towards this objective. Some have been active in developing information-gathering initiatives for outcome monitoring, in addition to routine monitoring of treatment agencies in their areas through contract monitoring and participation in the National Drug Treatment Monitoring System (NDTMS), previously the Drugs Misuse Database. It is recommended that all others be encouraged to follow suit. It is, however, recognised that for some this may be an incremental process. DATs and joint commissioning groups should develop, in the first instance, reliable activity-reporting and move towards monitoring outcomes over time. 198

205 It is recommended that joint commissioning groups and DATs work towards the development of a system that collects a minimum dataset measuring service providers activity and outcomes. It is suggested that data includes: case mix of clients entering a service (e.g. age, sex, ethnicity, drugs misused, etc) the total number of people accessing screening and assessment the wait between referral and assessment and between different levels of assessment the total number of people who completed the different assessment waiting times between screening, referral, assessment and structured treatment the total number of people who began treatment the total number of people who left treatment the period over which treatment was provided the total number of people who were waiting to begin treatment at the end of the reporting period. proxy outcomes the total number of people who were discharged from treatment and the proportion of discharges as: - planned departures (i.e. completed their care plan at that agency) - unplanned departures (i.e. client dropped out or otherwise stopped treatment e.g. prison, death) - transferred to another agency - administrative/disciplinary discharge (non-compliance with treatment plan or rules of the service) NB Data on non-completers should cover ALL those admitted to a service, including those who leave in the early stages of treatment outcomes achieved in each of the three domains mentioned above (drug use, physical and psychological health, social functioning and life context). This information should be stratified by gender, age group, ethnic group and treatment category. It can also be expected that, increasingly, the collection of data pertaining to human resources and staffing will be required. The monitoring of racial equality in employment is now required by the Race Relations (Amendment) Act Principles The Models of Care team believes that monitoring must be based on the following principles: DATs and joint commissioning groups must establish a substance misuse treatment service information strategy. All relevant treatment services must participate in the National Drug Treatment Monitoring System (NDTMS). Monitoring must abide by the principles of the Race Relations (Amendment) Act 2000 and monitor racial equality in service delivery and staffing. The establishment of a system for routine activity monitoring of treatment services must be a priority for all DATs and joint commissioning groups. Outcome monitoring of structured treatment must be based on a small set of clear, unambiguous and national-strategy relevant indicators. As a minimum, proxy outcome measures must be collected as a priority. Detailed outcome monitoring should be an integrated and inseparable part of case management. 199

206 Reporting requirements placed on treatment providers must be agreed with providers and must be kept to a minimum. In most cases, properly resourced research groups should gather information on post-treatment outcomes National datasets Some information on substance misuse treatment services has been collected systematically for a number of years across England and includes data for the NDTMS, and for the DAT reports and treatment plans. The information collected by the NDTMS and the manner of its collection has been reviewed in the light of Models of care. A minimum dataset, based on the care pathways of structured treatment was agreed, and published by the National Treatment Agency (see for details). This dataset is person based and tracks the care received by an individual from an agency. It is intended that the primary function of this dataset is to determine whether desired outcomes are achieved effectively by services. The dataset is also intended to form the basis of a locally developed clinical record. The central collection of data by the NDTMS will in future be through the automatic transmission of the minimum dataset from the clinical record maintained by the agency on its own IT system. Details required to configure local IT systems to the NDTMS can be found at Performance indicators: Task Force to Review Services for Drug Misusers The Task Force to Review Services for Drug Misusers identified performance indicators to be used by the different elements of the drug treatment system (Task Force to Review Services for Drug Misusers 1996). This involves the collection and reporting of the following data. Outreach services: number of new clients contacted in a four-week period (i.e. not seen by any other service during last three months) number of clients remaining in contact with worker longer than three months number of clients referred per month to other services for help with drug misuse problems cost per new client contacted. GPs: percentage of specialist service clientele registered with a GP percentage of participating GPs with clear guidelines for shared care, including welldefined liaison arrangements percentage of GPs prepare to take shared care responsibility percentage of specialist drug service clients cared for in general practice costs per GP-managed client. Pharmacies: percentage of pharmacies participating in: - needle exchange - supervised consumption - offering advice 200

207 number of exchange packs given out per month number of needles/syringes sold per month number of individuals using the service (by gender) number of pharmacies willing to provide facilities for return of used injecting equipment return rates of used equipment cost per pack distributed. Arrest referral: number of clients who enter treatment following arrest percentage of drug misusers cautioned for drug offences, and the percentage who are arrested for drug offences following caution (for consideration by D(A)ATs). Hepatitis B: percentage of clients offered vaccination percentage of clients reporting completed vaccination. Syringe exchange schemes: percentage of clients reporting sharing injecting equipment in previous four weeks number of new attenders (not used a scheme in past three months) per month number of exchange packs given out per month per client number of individuals using the service (by gender) return rates of used equipment numbers moving on to engage in treatment percentage of staff trained in giving basic health checks cost per registered client month. Counselling: percentage of people working in drug services with accredited counselling qualifications or equivalent professional qualifications percentage of clients receiving counselling who report improvements in one or more of the three domains defined by the Task Force cost per completed counselling course. Detoxification: number of clients entering detoxification programmes percentage of clients (by main drug of use) who complete detoxification percentage who attend follow-up treatment percentage of completers who remain drug free after - three months - six months - one year costs of detoxification per client completing. Methadone reduction: number of clients entering reduction programmes percentage who become drug free by: - three months - six months - one year percentage of clients in treatment who report improvements in one or more of the other broader outcome domains number using other support (e.g. Narcotics Anonymous or other self-help group) after treatment completion 201

208 cost of methadone reduction per client completing. Methadone maintenance: number of clients: - in a maintenance programme - retained at one year average duration of retention percentage of clients who report improvements in one or more of the other broader outcome domains percentage of clients whose urine tests positive for other opiates cost per client per year. Residential rehabilitation: percentage assessed within a defined period percentage gaining admission within a defined period percentage remaining in treatment after four weeks (by main drug of choice) percentage successfully completing programme (by type of programme and length) percentage of clients who report improvements in one or more of the other broader outcome domains cost per completed programme. Inpatient detoxification: percentage successfully completing inpatient detoxification (per main drug of use) percentage of clients who report improvements in one or more of the other broader outcome domains cost of inpatient detoxification (per main drug of use) Other suggested performance measures The Task Force to Review Services for Drug misusers did not provide measures for all treatment modalities and types of agencies. The following indicators can also be used. Advice and information: number of people who contact services by telephone for advice (telephone helplines) number of people who contact services by telephone for information (telephone helplines) number of calls to services for advice and information number of people who access services following advice and information given by: - GPs - pharmacists - A&E - Probation - arrest referral schemes - CARATS - others. Structured day programmes: In March 1996 the Standing Conference on Drug Abuse held a national workshop to identify good practice in structured day programmes. Ten quality standards were developed as a result. These are as follows. A minimum client completion rate of one-third of all clients should be achieved. An attendance rate of at least 75% for each programme component should be maintained. 202

209 Minimum referral, internal assessment and acceptance response times are set and audited. Service users should be involved in individual care planning, service review and development. High-quality staff skills and expertise should be ensured. Staff handover systems should be established to provide programme continuity. Good communications, sound liaison and effective working arrangements should be established with other agencies and collaborators. Reporting requirements should be agreed with collaborating agencies at the outset and good recording and monitoring procedures should be established. Systems of individual client care planning (or equivalent) should be used, including discharge planning and aftercare services. A manageable timetable should be set (given staffing and any other resource constraints). (Standing Conference on Drug Abuse 1996). These standards have associated criteria. The majority of these standards areas have subsequently been included in the QuADS organisational standards (Alcohol Concern and Standing Conference on Drug Abuse 1999). If a structured day programme is criminal justice-focused, it may have to adhere to national probation standards. Drug using parents: The following data should be collected: number of pregnant substance misusers number of clients who are parents of, and/or caring for, children number of children assessed by substance misuse service number of children in need number of children at risk. Young people: There are currently no output or outcome monitoring instruments focusing on young people. Commissioners should be aware that outcome monitoring for adult drug treatment needs to be treated with caution and will not be child centred. Particular attention may be needed to ensure the quality and outcomes of the following services: needle exchange for under-18s services for those involved with the criminal justice system services for children looked after by the local authority services for those without fixed accommodation or who have disappeared from the care system services for those involved in sexual exploitation. Women: Services should provide better monitoring of a range of data specific to women drug misusers. The following are suggested outcome domains: health (including presence/level of depression and of other mental health problems e.g. eating disorder, self-mutilation, antenatal care, reproductive health and sexual health) social (including childcare/parenting, relationship/family functioning, entry into education/training, involvement with criminal justice system, access to appropriate housing) economic (including access to welfare benefits, entry into employment). 203

210 Minority ethnic substance misusers: There is evidence that data collection on ethnicity is particularly poor. It is recommended that commissioners require, through service specifications or service level agreements, that treatment agencies improve the collection of these data. The collection of this data is now a requirement from the Race Relations (Amendment) Act The monitoring of equality in employment is also required. Blood-borne diseases: The provision of interventions to assess for, prevent and manage blood-borne diseases should be viewed as an integral part of treatment. Access to health screening and testing for blood-borne diseases should be available for all clients in contact with all services across all tiers. Output monitoring should include details of the number of clients in contact with services who: receive an assessment of health needs relating to blood-borne diseases are referred for testing for hepatitis B undertake testing for hepatitis B are referred for testing for hepatitis C undertake hepatitis C testing are referred for pre-test HIV counselling undertake an HIV test receive post-test counselling and results are referred to other services for any of the above. Monitoring for hepatitis B vaccinations should include the number of patients who: are referred for testing require vaccination complete one injection complete two injections complete the course of three injections re-attend for follow-up to confirm immunity or receive a booster. Clear outcomes should be set by the service as agreed between the substance misuse service and the commissioner. Outcome monitoring should include behaviour changes such as changes in sharing behaviour, sexual behaviour and injecting behaviour. Alcohol: Alcohol outcomes should be routinely monitored in drug misuse treatment programmes. The measures are usually interview-based and can be quantitative (e.g. units per day or week), or categorical (e.g. abstinent, moderate drinking, heavy drinking) Concluding remarks: a comprehensive evaluation of substance misuse treatment The monitoring of activity, cost and outcome is only part of a wider process of evaluation, which is the determination of the effectiveness, efficiency and acceptability of a planned intervention in achieving stated objectives. It is a set of procedures to judge the quality of a particular service, by providing a systematic assessment of its aims, objectives, activities, outputs and outcomes. Evaluation is concerned with ongoing monitoring of the performance of treatment systems. It is intended to identify ways in which they can be improved and modified. 204

211 Comprehensive service evaluation includes the following: explicit monitoring requirements in service agreements (contract monitoring) definition of minimum datasets quality standards performance indicators (input, process, outcome, output) outcome measures eliciting user/carer views evaluations of service delivery (process evaluation) audit. Moreover, it is now widely acknowledged that for organisations to be effective, they must concentrate on issues/areas that will achieve client/service user satisfaction. It is therefore essential to measure client satisfaction with the treatment and services received. It is also important to consult service users in the development of information and monitoring systems. 205

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213 Appendices 207

214 Appendix 1 Consultation process for Models of care 1. Consensus events The Models of Care team held two consultative events in January and February 2001 to present their early findings and their work on building consensus towards an integrated model for the commissioning and delivery of drug treatment services. Representatives from the Royal College of General Practitioners, the Royal College of Psychiatrists, the Royal College of Nursing, universities, academic units, professional associations (ANSA, EATA), health authorities, primary care groups, primary care trusts, public health specialists, the NHS regional offices, the Department of Health, drug action teams, users and carers organisations, the Drugs Prevention Advisory Service (DPAS), the police, the Probation Service and the Prison Service were all invited to these meetings. In addition, each NHS regional office nominated a service manager (statutory and non-statutory) and a local commissioner to participate in either the London or York event. Participants were requested to give their reactions to the direction the project was heading and to give feedback on the early drafts presented by the team. Following the consensus events, the team considered the feedback and advice they had received from the more than 70 participants in the consensus events. This advice was incorporated into the next draft of the Models of care document. 2. Inter-departmental government review The final draft of the Models of care document was circulated within the Department of Health and by the Department of Health to a number of other government departments including the Home Office and the Department for Further Education and Employment to ensure that the guidance contained in Models of care was not in conflict with the policies of, or other guidance issued by, various government departments. 3. Public consultation The final draft of Models of care was released by ministers for public consultation in February 2002 with a period of three months allowed for this consultation. Summary copies of Models of care were posted to all drug treatment agency in England as well as to professional associations, membership organisations and academic institutions. The full report was made available to anyone who requested a copy and it was posted on the NTA website for anyone to review and download. Models of care was the subject of two workshops held at the NTA National Conference in Manchester on the 10 and 11 April More than 150 service users, commissioners, DAT co-ordinators and staff from drug treatment services participated in these workshops. A number of other workshops were provided around England on demand, including one for the London Drug and Alcohol Network. The public consultation came to an end on 31 May More than 50 detailed responses were received and these comments have been taken into consideration in the final report. 208

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