Main providers
In the UK, community-based specialist drug treatment centres are the most common providers of substance misuse services. Specialist services account for 92% of community-based treatment units reporting to the NDTMS in England (n=786). GPs prescribing OST medications in a shared care arrangement report to NDTMS through the specialist service providing the shared care component. Some GPs prescribing in isolation do not report to NDTMS; therefore there is some under-reporting from these services.
33 The term ‘club drugs’ is used here to refer to a group of psychoactive substances typically used in dance venues, house parties, music festivals and sometimes in a sexual context.
Specialist drug treatment centres are predominantly public services, commissioned and funded by local government. The contracts to deliver drug treatment services commissioned by LAs are often held by registered charities. Some organisations specialise solely in substance misuse, while others deliver contracts for mental health services and services for people with learning disabilities. Specialist drug treatment services are also provided by the NHS by Mental Health Trusts.
Client utilisation
Almost all clients treated in the UK receive treatment in a community setting, including some who receive treatment in the community before or after attending a residential unit. The majority of all clients in the UK (both outpatient and inpatient) cite heroin as a problematic drug (see section 4.4.3). Comparisons with Problem Drug Use estimates suggest that in England around half of the problem opioid and/or crack using population access community treatment services.34 However, the most recent problem drug use estimates cover 2011/12, therefore this figure should be considered an approximation.
4.3.2 Inpatient drug treatment system
Main providers
Inpatient and residential facilities account for 11% (n=128) of all substance misuse treatment units reporting data to the NDTMS in England.
Inpatient units are for those alcohol or drug users whose needs require supervision in a controlled medical environment. These units provide assessment, stabilisation and/or assisted withdrawal, with 24-hour cover from a multidisciplinary clinical team who have had specialist training in managing addictive behaviours. In addition, the clinical lead is a consultant in addiction psychiatry or another substance misuse medical specialist. The multi-disciplinary team may include psychologists, nurses, occupational therapists, pharmacists and social workers. Inpatient units are often based within hospitals, but can be attached to residential rehabilitation services or standalone. Inpatient detoxification interventions may also be delivered on a general ward within a hospital.
Residential rehabilitation services are primarily run by voluntary and private sector organisations. They offer structured programmes that may include psychosocial interventions, individual and group therapy, education and training, and social and domestic skills. There is a wide range of different types of residential rehabilitation available, and services differ widely in terms of their philosophy, intensity, inclusion criteria, programme content and duration.
Another non-hospital based residential setting in the UK is a recovery house. This is a residential living environment, in which integrated peer support and/or integrated recovery support interventions are provided for residents who were previously, or are currently, engaged in treatment to overcome their drug and alcohol dependence. The residences are also referred to as dry-houses, third-stage accommodation or quasi-residential.
Client utilisation
The proportion of the overall treatment population who receive treatment in inpatient/residential settings is low compared to those who receive it on an outpatient basis. In England in 2015/16, 5.2% of the total treatment population were reported as having been treated in an inpatient unit;
34 Based on the most recent estimates for prevalence of opioid use and/or crack cocaine use: 293,879 from 2011/12 (Hay et al., 2014).
2.6% were treated in a residential service;35 and 0.2% were treated in a recovery house (with some clients having been treated in more than one setting).
The average cost of inpatient treatment is £160.42 daily compared with £100.86 for residential rehabilitation.36 Given the average time spent in residential rehabilitation is 11 weeks, this equates to an average of over £7,750 for every treatment episode commissioned by LAs. As such, clients accessing rehabilitation will usually be required to meet certain admission criteria, including: being abstinent from drugs and alcohol following detoxification; a commitment to becoming substance free; a desire to leave treatment; and having been assessed as capable of achieving abstinence and being prepared to do so. Clients are usually also required to complete a period of community treatment prior to rehabilitation and may return to community services for further support after exiting inpatient facilities.
The NICE guideline CG51 (National Institute for Health and Care Excellence, 2007b) recommends that residential rehabilitation be used for the “most complex” clients. As such, those accessing residential rehabilitation will usually have:
• not benefited from previous community-based psychosocial treatment
• longer and more entrenched drug and alcohol misusing careers
• a range of problem substances
• more significant housing problems
• co-morbid physical and/or mental health problems.
In addition, residential rehabilitation services treat a higher proportion of clients who are using both heroin and crack, injecting drugs, polydrug users, and offenders.
In 2015/16, in England 5,217 clients accessed support through residential rehabilitation, as reported by the NDTMS (Public Health England, 2015a).
4.3.3 Prisons
There are 138 prisons across the UK (120 in England and Wales, 15 in Scotland and three in Northern Ireland), and the majority offer some form of treatment for substance misuse. Prison drug treatment reporting is not yet fully integrated with community datasets, and until 2014 only Northern Irish prison treatment data was included in TDI figures. However, from 2015 data from prisons in England will also be included. The provision of treatment in prisons is covered in section 5.