Models of care for treatment of adult drug misusers: Update 2006
3.9.2 Component parts of the treatment journey
In addition to implementing the framework advocated in Models of Care 2002, the NTA is committed to pushing for an improvement in drug treatment effectiveness. The Treatment Effectiveness strategy, with a focus on improving clients’ journeys through drug treatment, is integrated in Models of Care: Update 2006. The treatment journey is conceptualised into four overlapping components, each with key objectives. These components are illustrated in Figure 1 and comprise:
Treatment delivery (including maintenance)
Community integration (which underpins both delivery and treatment maintenance or completion)
Treatment completion (for all those who chose to be drug-free and who can benefit).
Although it will be useful to see these phases of the treatment journey as conceptually separate, there is room for considerable overlap. It is important to note that the phases do not mean that treatment is a linear journey, with service users progressing through the three main phases of engagement, delivery and completion. Instead, these are the main elements of a treatment journey which may occur in a variety of combinations during a client’s time in treatment. Considering these phases can be particularly helpful in informing the focus of care plans at different stages and in maintaining a focus on the treatment journey.
Treatment engagement The treatment system needs to be able to engage people rapidly and retain them once they have entered treatment. Two issues important to improving treatment engagement are timely access to treatment and a focus on supporting retention for at least three months in structured treatment for adults with dependent drug misuse. Each drug treatment system will be assessed on its ability to engage service users on these two issues, through performance management on national waiting times and retention targets by the NTA, as outlined in the Government’s treatment effectiveness strategy.
During the engagement phase of treatment, service users will need to be assessed to ensure treatment can be tailored to their needs and at this stage they may benefit from motivational work focused on maximising engagement. Particular consideration may need to be given to preventing disengagement of certain drug users (e.g. those from some Black and minority ethnic groups, younger drug users and clients with mental health and substance misuse problems). The engagement of service users may be enhanced by a specific process of induction into treatment, so it is made clear and comprehensible for individuals what are the roles and responsibilities of the service provider and what are the expectations on service users themselves.
Following assessment, care plans will be agreed with the clients and structured treatment will begin. There also needs to be more explicit commissioning of interventions that engage service users and build “therapeutic alliances”, which are crucial to treatment retention and positive changes in treatment.
A range of interventions to support engagement could be explicitly commissioned, including brief interventions, services for the children of drug users, advocacy and support arrangements and interventions to contact, engage and follow up people (e.g. outreach for rough sleepers, motivational interventions).
Drug treatment delivery Drug treatment providers need to deliver effective and evidence- based drug treatment interventions, following completion of a care plan that has been agreed with the client. Drug treatment practitioners should work to build an effective therapeutic alliance with service users, encouraging full participation by them in delivering their own care plans. Good-quality drug treatment should be associated with improvement across a range of domains, including an individual’s substance use, health, social functioning and in reduced public health and offending risks posed to others.
In delivery of drug treatment, a greater emphasis is required on improving service users’ physical and mental health, importantly for those with hepatitis C infection and for those misusing alcohol. Increases in the use of cocaine and crack cocaine by service users may have a negative impact on client outcomes, unless this is addressed, particularly with injecting drug users.
The children, carers or significant others of service users should also be considered during care-planned treatment. The needs of the children of drug-misusing parents also require greater attention (ACMD, 2004).40
During this phase, clients should begin to receive other interventions to meet their wider needs. These interventions could include improving housing status, getting other healthcare needs met by other health specialists (e.g. liver disease and dentistry), help with children and family issues, and provision of assistance to enable service user back to work or education. These non- drug treatment interventions should be set out in the client’s care plan and links made with appropriate services to ensure the client receives them. This includes the initiation of elements of community integration.
To ensure that the delivery of drug treatment meets the client’s needs in a timely way, local treatment systems must ensure continuity of care between the criminal justice system and drug treatment. This is particularly relevant for clients entering and leaving prison.
Clients who are on long-term maintenance (ideally in shared care) should be considered to be continuing in the delivery phase of treatment.