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National Treatment Agency for Substance Misuse - page 23 / 52





23 / 52

Models of care for treatment of adult drug misusers: Update 2006

Tier 4 interventions


Tier 4 interventions include provision of residential specialised drug treatment, which is care planned and care co- ordinated to ensure continuity of care and aftercare.

Tier 4 interventions that should be commissioned to meet local area needs include:

Inpatient specialist drug and alcohol assessment, stabilisation, and detoxification/assisted withdrawal services A range of drug and alcohol residential rehabilitation units to suit the needs of different service users A range of drug halfway houses or supportive accommodation for drug misusers Residential drug and alcohol crisis intervention units (in larger urban areas)

Inpatient detoxification/assisted withdrawal provision, directly attached to residential rehabilitation units for suitable individuals

Provision for special groups for which a need is identified (e.g. for drug-using pregnant women, drug users with liver problems, drugs users with severe and enduring mental illness). These interventions may require joint initiatives between specialised drug services and other specialist inpatient units

A range of the above interventions for drug-misusing offenders.



Ideal settings to provide inpatient drug detoxification and stabilisation are specialised dedicated inpatient or residential substance misuse units or wards.

Inpatient provision in the context of general psychiatric wards may only be suitable for some patients with co- morbid severe and enduring mental illness, but many such patients will benefit from a dedicated addiction specialist inpatient unit.

Those with complex drug and other needs requiring inpatient interventions may require hospitalisation for their other needs – for example pregnancy, liver problems and HIV-related problems – and this may be best provided for in the context of those hospital services (with specialised liaison support).

Continuity of care is essential for preserving gains achieved in residential treatments. Therefore, there is a compelling argument for providing, for suitable patients, inpatient detoxification beds attached to residential rehabilitation units (provided there are adequate medical supports). Other patients need inpatient detoxification first in an addiction specialist inpatient unit (e.g. because of severity and complexity), but this still requires significant strengthening of the links with residential rehabilitation provision, to ensure the seamless transition of clients between the two.

Service users requiring residential rehabilitation or halfway houses may wish to be located away from their area of residence and drug misusing networks.

Within prisons, specialist detoxification units, therapeutic communities (drug specific) and some (residential) 12- Step programmes are Tier 4 interventions.


Inpatient or residential interventions providing detoxification and pharmacological stabilisation would normally require medical staff with specialised substance misuse competency (rather than be provided by generalist GPs). The level of specialised medical staff competence required will depend on the types of services provided and the severity of the problems of the clients. Addiction specialist competences will be needed for inpatient units for severe and complex problems, but suitably competent GPs can provide support to some units for patients with less complex needs.

Staff in residential rehabilitation units that are registered care homes will need to meet relevant social care National Occupational Standards and relevant standards currently inspected and monitored by the Commission for Social Care Inspection. Hospital-based services will also be required to meet practitioner standards for independent or NHS hospitals currently inspected and monitored by the Healthcare Commission.

Non-registered residential rehabilitation services should meet other appropriate standards, where applicable, e.g. Supporting People arrangements, EATA accreditation.

All staff working in all residential settings are advised to demonstrate competence against DANOS39 manager and practitioner levels.

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Tier 4 interventions: Drug specialist inpatient treatment and residential rehabilitation


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