The four tiers reiterated
The following reiteration of the tiers describes:
The drug interventions it is best practice to commission and provide in each local area
The range of settings these are normally provided in
The competence or level of drug treatment skills and training that is normally required.
Commissioners need to ensure that all tiers of interventions are commissioned to form a local drug treatment system to meet local population needs. Local systems should allow for some flexibility in how interventions are provided, with the crucial factors being the patterns of local need and whether a service provider is competent to provide a particular drug treatment intervention.
Treatment effectiveness: Improving clients’ journeys
Evidence for treatment effectiveness
Models of Care: Update 2006 has a greater focus on improving clients’ treatment journeys through systems. Drug treatment is not an event, but a process usually involving engagement with different drug treatment services, perhaps over many years. Each client’s drug treatment journey is different and depends on a range of factors including health status, relationships, nature of the drug problem and the quality of the drug treatment they receive. However, drug treatment use is often episodic, with service users dipping in and out of treatment over time. Evidence from the US36 suggests that an average time in treatment for someone with a heroin or crack dependence problem is five to seven years, with some heroin users requiring indefinite maintenance on substitute opioids. Evidence also tells us that service users gain cumulative benefit from a series of treatment episodes. However, the biggest improvements in client outcomes are likely to be made in the first six years of treatment (DATOS).37
Evidence indicates that entry into treatment has an immediate positive impact on drug use and crime, particularly for someone prescribed substitute medication. However, this is not sustained if the client is not retained in treatment. Optimised treatment usually involves retaining clients in drug treatment for a minimum of three months. This is the point at which treatment begins to accrue generalised long-term benefit. Engaging the service user sufficiently in a therapeutic relationship enables positive lifestyle changes to occur. This approach requires a partnership between the treatment provider and the client or service user, with both working towards common explicit goals. This also requires a concerted effort on behalf of the treatment provider to enable all of the clients’ needs to be met, not just their drug treatment needs. This may include addressing alcohol misuse, health needs due to blood-borne virus infections such as hepatitis C, treatment for underlying anxiety or depression, building social support
Models of care for treatment of adult drug misusers: Update 2006
networks, and providing access to appropriate housing, education or employment. All of these may be crucial to prevent relapse back to illicit drug misuse.
While much of the focus of outcome research has been on identifying key individual characteristics that predict better treatment outcomes, such as higher levels of personal and social capital and lower levels of problem severity, increasing attention is being paid to service characteristics that can improve outcomes. The National Drug Evidence Centre research (2004)23 for the NTA showed that the best predictor of retention in community treatments in the north-west of England was related to service factors rather than client characteristics. Similarly, Meier (2005)38 has also reported that much of the variability in retention in residential rehabilitation services derives from the service itself rather than the service user. This is consistent with empirical research conducted in the US, which shows that organisational development work can lead to significantly enhanced treatment outcomes across patient populations.37