Models of care for treatment of adult drug misusers: Update 2006
Inpatient substance misuse treatment and residential rehabilitation (Tier 4) interventions have not expanded at the same rate as Tier 2 and Tier 3 drug treatment provision in the last few years. The coverage of Tier 4 interventions in England is still inconsistent and substance misuse inpatient treatment and residential rehabilitation are sometimes only (incorrectly) used as a last resort for drug misusers, when Tier 4 interventions should be available to clients at different stages in their treatment journeys. Commissioning to expand Tier 4 is crucial to improve clients’ journeys and to maximise treatment exits and access to abstinence-based aftercare. The development of inpatient treatment and residential rehabilitation services is of increasing importance for a number of reasons:
There is high level of expressed need for residential provision from service users and carers
Specialist inpatient interventions – assessment, stabilisation and assisted withdrawal/detoxification – are necessary to provide the optimal local drug treatment system for clients with complex drug, alcohol and other health needs; those in crisis; those requiring medication stabilisation (e.g. on injectable or high-dose opioids, or for effective detoxification)
Inpatient detoxification followed by residential rehabilitation is the most effective way for drug misusers to become drug- free, if they are motivated and this is the agreed objective (NTA, 2005)31
There is evidence to show that detoxification in specialist substance misuse facilities is more effective than in general hospital or psychiatric wards, which are associated with low success rates32
It is recognised that service users must have social support upon leaving rehabilitation units and secure adequate housing
Shared care services Commissioners should ensure that every local area has shared care arrangements in place. There are many different models of shared care but the underpinning principles are:
Patients in all local areas should have access, where clinically appropriate (usually the more stable patients), to long-term care – even after exit from drug treatment – and community- based multidisciplinary support inherent in the primary care setting
There should be unobstructed transfer of patients between the services sharing their care as their clinical needs change.
There are a wide range of models of shared care, which may include the following variations:
GPs or non-medical prescribers commissioned as providers of drug treatment, and depending on arrangements and level of competence, offering different levels of care from long-term maintenance prescribing in shared care arrangements to more specialised packages of care for complex needs
Drug treatment delivered from a base in a primary care setting by a multidisciplinary team, to patients registered with those GPs or patients registered with other GPs in the locality
Support for specialist provision from primary care, or more usually secondary care-led services, which provide shared care support and direct care for more severe and complex cases
Arrangements set up to deliver services to specific vulnerable patient groups, such as homeless people, refugees and sex workers. These services will be based in primary care and provide a range of services including drug treatment and have often been commissioned as personal medical services. They are supported by specialist secondary care drug services, which provide direct care, particularly for more severe or complex cases.
Whatever models of shared care are commissioned locally, they should be commissioned according to local needs, and in line with medical competences30 and appropriate clinical governance arrangements. These shared care arrangements should be reviewed, refined and developed regularly.
Primary care-led services Some areas may have a primary care-led service depending on the local configuration of specialist services. In these services, GPs act as clinical leads for community drug services, where there is no formal secondary care or specialist addiction psychiatry leadership available within the service or through shared care arrangements.
Commissioners may support such arrangements because of the advanced specialist competence of the particular GPs involved (e.g. as described in Roles and Responsibilities of Doctors in the
Provision of Treatment for Drug and Alcohol Misusers).30 Sometimes the GP may act as a clinical lead in substance misuse for their area in conjunction with specialist psychiatric support. This may be in a service overseen by or in partnership with an addiction psychiatry team.
Primary care-led services may sometimes be commissioned in this role because it has not been possible to obtain suitable shared care support in the area. However, this is not ideal and suitable shared care services should be encouraged and developed in every area.
It is important to ensure that the needs of the most severe and complex patients are adequately addressed in any system. There are clearly advantages for patients in having access to a range of provision, from GPs with a range of competences and from secondary care specialists across an integrated system of care.
Inpatient treatment and residential rehabilitation: The need for expansion