Assessing Need and Organizing Services for Drug Misuse Problems
John Marsden
Colin Bradbury
John Strang*
*The views expressed in this chapter are those of the authors and do not necessarily reflect the views of the National Treatment Agency. The commissioning, performance management and planning of drug treatment varies significantly across the United Kingdom. Unless stipulated to the contrary, the following text applies specifically to England.
Introduction
In the present decade, there has been substantial investment in drug misuse treatment thereby expanding the workforce, the capacity of the treatment system and leading to reduced waiting times and better integration of local services. In 2006–07, an in-treatment population of approximately 200 000 individuals were recorded by the National Drug Treatment Monitoring System (NDTMS). Capture-recapture estimates suggest that there are approximately 327 000 users of opioids and/or crack cocaine.
About two-thirds of adults entering drug misuse treatment services are dependent on illicit heroin—a clinical presentation complicated by between 20 per cent to 50 per cent of admissions by concurrent dependence on cocaine and other substances such as the misuse of pharmaceutical medications (such as benzodiazepines). Cannabis is reported as the main problem drug for younger patients under 18 years of age. Overall, treatment services for clients of all ages are able to assess and provide interventions across all illicit drugs including amphetamine-type stimulants, sedative/hypnotics, cannabis, hallucinogens and volatile substances (solvents and inhalants). Hazardous and harmful alcohol use characterizes a significant, but priority group of drug misuse treatment seekers.
In 2006, a revised national drug misuse treatment effectiveness strategy stressed the need for better local partnerships to commission and organize local services and promote reintegration of treated patients into the community. A core component of the strategy was the creation of Criminal Justice Integrated Teams (CJITS) who were given the role of treatment case coordination for individuals involved in the justice system with identified drug misuse. Nevertheless, improvements to the reach, operation, and effectiveness of treatments remains a priority—particularly tackling high-risk behaviours linked to the acquisition and transmission of blood-borne infections and ensuring that all service users receive good quality assessment and care coordination.
Local coordination of treatment
Drug Action Teams (DATs) were originally set up in 1995 under a Government white paper on drug misuse. The purpose of the DAT was to co-ordinate the activity and spend of local statutary commissioning agencies who have an interest in reducing the harm caused by illicit drug use to individuals, their families, and the community. DATs and their membership typically consists of senior commissioning representatives from local Police, Health, Local Authority and Probation services. Increasingly, the Prison Service are represented following the announcement of a new Integrated Drug Treatment System for prisoners which seeks to ensure that the same appropriate and evidenced drug treatment interventions are available to individuals regardless of whether they are in prison or in the community. Under the Police Reform Act (2002), the process of combining the activity of DATs with their equivalent bodies for crime (Crime and Disorder Reduction Partnerships (CDRPs) was started. Local areas organize their activity in differing ways, but the concept of co-ordination of action between the DAT and CDRP is now universal.
DATs are charged with consulting with and involving local communities, stakeholders, treatment providers, and crucially—users and carers—in the development of their local commissioning strategies. DATs are allocated a hypothecated fund for improving capacity and quality of drug treatment services for their residents. This Pooled Treatment Budget is typically banked by a partner agency (usually the PCT) but is intended to be commissioned jointly (along with mainstream monies that partner agencies allocate for drug treatment) via the DAT Partnership structure. DAT Partnerships typically have a sub-group know as the Joint Commissioning Group (JCG) which seeks to operationalize the DAT’s agreed strategy for the locality.
The National Treatment Agency for Substance Misuse (NTA) is a Special Health Authority set up in 2001 to oversee and performance manage the commissioning of effective drug treatment.
DAT Partnerships submit a treatment plan on an annual basis which is signed off by the NTA and other regional partners and performance monitored on a quarterly basis. Since 2005–06, the NTA has issued guidance on conducting a Needs Assessment for the local population and increasingly assessment of need is being seen as the centrepiece of DAT Partnership commissioning activity. DAT Partnerships are encouraged to set up expert groups which (in combination with available local data sources of prevalence and treatment) should be used to carefully consider available information and intelligence in order to inform the local Joint Commissioning Group of assessed levels of unmet need, therefore enabling them to set and update commissioning priorities on a cyclical basis.
DAT Partnerships submit a treatment plan on an annual basis which is signed off by the NTA and other regional partners and performance monitored on a quarterly basis. Since 2005–06, the NTA has issued guidance on conducting a Needs Assessment for the local population and increasingly assessment of need is being seen as the centrepiece of DAT Partnership commissioning activity. DAT Partnerships are encouraged to set up expert groups which (in combination with available local data sources of prevalence and treatment) should be used to carefully consider available information and intelligence in order to inform the local Joint Commissioning Group of assessed levels of unmet need, therefore enabling them to set and update commissioning priorities on a cyclical basis.
Types of treatment
In the UK, treatment for substance use disorders vary on several core dimensions, as follows: (a) setting (outpatient/community or inpatient/residential), modality (pharmacological or behavioural); (b) content (e.g. cognitive behavioural therapy, motivational approaches, contingency management; couples therapy); (c) goals (harm reduction, partial or complete abstinence); (d) intensity (brief interventions or intensive therapeutic contact); (e) extent of external contingency (e.g. self-referral or criminal justice mandate); and (f) type of provider (NHS, non-governmental organiztion and private/commercial). In 2002, the NTA promulgated a national service framework for drug misuse services and updated this four years later. The framework uses a practical framework to aid rational and evidence-based commissioning of drug treatment in England with services for drug misusers grouped into four broad bands, or tiers.
Tier 1 interventions
This first tier involves the provision of information, advice, screening and referral to drug users by generic medical and social care services (e.g. Accident and Emergency Departments, community retail pharmacies). It includes liaison and partnership working with specialist drug treatment services to provide specific interventions (e.g. treatment of patients with health problems caused by Hepatitis C infection).
Tier 1 services for adults are not structured drug or alcohol treatment, but can be part of the local substance misuse treatment system. These services work with a wide range of clients including drug and alcohol misusers, but their sole purpose is not drug or alcohol treatment. Tier 1 services comprise a range of interventions which are not drug-specific, but offer a variety of generic health and social care interventions. In this context, the role of Tier 1 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 specialized 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 2 interventions
The second tier describes interventions involving specific drug-related information and advice to help drug users reduce or avoid hazardous and harmful patterns of use or attain and maintain abstain harm. Services are delivered from dedicated community locations as well as outreach and may also include brief, structured psychosocial interventions, various harm minimization interventions (including syringe and needle exchange) and aftercare support. Tier 2 services may also provide triage assessment and linked referral to structured drug treatment and in this respect may operated independently or in the same setting as a Tier 3 intervention team. Tier 2 interventions for adults provide accessible drug and alcohol specialist services for a wide range of drug and alcohol misusers referred from a variety of sources, including self-referrals. 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. Tier 2 interventions include advice and information, drop-in services, needle exchange and motivational interviewing.
Tier 3 interventions
In terms of the volumes of people receiving treatment, this tier is at the centre of the system. It includes specialized care-planned pharmacotherapy (opioid agonist and antagonist and adjunctive medication prescribing to treat dependence) and a broad array of psychosocial interventions delivered by combined or separate teams in the community and primary care. There is an emphasis on high-quality assessment, care planning, liaison and review and regular contact with a clinical keyworker and other team members. The frequency of scheduled contact varies widely across Tier 3 services but is particularly indented to be intensive among users attending ‘structured day programmes’. Tier 3 interventions for adults 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 interventions. There is interest in developing behaviour therapies to treatment drug dependence on contingency management. Psychoactive substances can exert unconditioned reinforcing effects and repeated administration produce several conditioned responses. For example, voucher-based reinforcement therapy uses vouchers of increasing value for goods and services with various bonus incentives to subjects who can provide drug-free urine tests. The National Institute for Health and Clinical Excellence (NICE) has produced guidelines for the effective delivery of various psychosocial treatment interventions tailored to the needs of drug misusers, including brief motivational interventions, contingency management and behavioural couples therapy.
Tier 4 interventions
The fourth tier of the treatment system denotes specialist inpatient (and general ward) inpatient services providing stabilization and
medically supervised withdrawal (detoxification), residential rehabilitation programmes (providing psychosocial and practical, vocational supports designed to maintain abstinence and promote long-term recovery) and a range of halfway houses and supportive accommodation. Some inpatient and residential programmes are directly linked. These services vary in duration from brief (<10 days), short-term (<3 months) and long-term (>3 months). Tier 4 services are highly structured interventions underpinned by assessments and close monitoring of clinical progress. Rehabilitation programmes have been pioneered and then sustained chiefly in the voluntary sector. Some adhere to or have adopted a therapeutic philosophy (e.g. 12-Step based on the Minnesota Model of addiction recovery developed in the USA) or therapeutic community model, while others operate as ‘general houses’—which seek to foster responsible communal living and community reintegration. Tier 4 substance misuse interventions for adults are aimed at individuals with a high level of presenting need and usually require a higher level of commitment from drug and alcohol misusers than is required for services in lower tiers. Tier 4 services are rarely accessed directly by clients. Referral is usually from Tiers 2 or 3 services or via community care assessment.
medically supervised withdrawal (detoxification), residential rehabilitation programmes (providing psychosocial and practical, vocational supports designed to maintain abstinence and promote long-term recovery) and a range of halfway houses and supportive accommodation. Some inpatient and residential programmes are directly linked. These services vary in duration from brief (<10 days), short-term (<3 months) and long-term (>3 months). Tier 4 services are highly structured interventions underpinned by assessments and close monitoring of clinical progress. Rehabilitation programmes have been pioneered and then sustained chiefly in the voluntary sector. Some adhere to or have adopted a therapeutic philosophy (e.g. 12-Step based on the Minnesota Model of addiction recovery developed in the USA) or therapeutic community model, while others operate as ‘general houses’—which seek to foster responsible communal living and community reintegration. Tier 4 substance misuse interventions for adults are aimed at individuals with a high level of presenting need and usually require a higher level of commitment from drug and alcohol misusers than is required for services in lower tiers. Tier 4 services are rarely accessed directly by clients. Referral is usually from Tiers 2 or 3 services or via community care assessment.
NICE has produced guidelines for the delivery of psychosocial interventions in residential rehabilitation services and also for the organization and delivery of opioid detoxification services.
Commissioning treatment services
The national drugs strategy requires Crime and Drug Partnerships to commission services (or ensure access to) structured treatment (Tiers 3 and 4). The balance of l focal drug misuse treatment services and their detailed delivery mechanisms should be tailored to fit the needs of the local population; commissioners are encouraged to think systemically rather than focusing on putting in place individual services. Poorly defined care pathways between services and the lack of a joined-up care planned approach is clearly an unsatisfactory situation. Many individuals may require the provision of several different types of treatment service over time. It is quite common for an individual receiving treatment from one provider to receive additional welfare support and other social inclusion services which are provided by other agencies (e.g. housing support, legal advice). These supports are important elements in an effective package of care services that can evolve over the course of an individual’s treatment. Together, the four tiers are meant to imply a continuum of care. Generic service providers and state agencies can refer an individual both up and down the four tiers to access appropriate treatment or support services.
Needs assessment
In the following section, we use an epidemiologically-based conceptualization of population treatment needs to discuss the organization of treatment services and methods for assessing need. Needs assessment occupies an importance place in the evidence-based planning process for the design and delivery of substance misuse services. It is the systematic collection of information about a geographically defined population and then applying this to make changes that will be beneficial to health. In the drug misuse field, there is a specific focus on two groups in the community: (a) those that are not in contact with services and treatment agencies and have unmet need; (b) those in contact with inefficient, ineffective or inappropriate health care services who have unmet need or for whom outcomes could be improved. Good needs assessment practice involves the application of epidemiological (and sometimes spatial geographical) techniques to estimate the number of people in the two groups above, clear understanding of the costs and benefits of interventions, a close collaboration with clinical services and the range of community stakeholders, and a planning and evaluation process to effect change. There is active encouragement for drug misuse partnerships and commissioners to undertake comprehensive needs assessments in the area of drug misuse with a specific target to assess the needs of young people. However, there have been few systematic quantitative and qualitative studies conducted in the drug misuse field in the UK. In fact, most studies in the mental health service field have been mainly or exclusively qualitative, relying on focus group discussion material. Multiple indicator methods and capture-recapture techniques have enabled estimates to be derived of the number of problem drug users in local areas.
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