Young people experiencing harms from alcohol and drugs: literature and evidence review

Appendix I – Detailed Description of Tiered Model of Alcohol and Drug Treatment Services

Alcohol and drug treatment services for those of all ages in Scotland are delivered through a tiered model of increasing intensity of intervention^[121]. A brief description of these are outlined below.

• Tier 1 interventions involve;
  • the provision of general information and advice;
  • screening and assessment, and;
  • referral to specialist alcohol or drug services if necessary.
  • Partnership of ‘shared care’ working with specialised alcohol or drug treatment interventions for those with problem use may also be undertaken within the context of their generic services.

  Tier 1 services are provided by practitioners (including GPs, teachers and social workers) in the context of universal healthcare settings (including liver units, Accident and Emergency, pharmacies) or social care, education, or criminal justice settings (including probation, courts, prison reception) where the main focus is not drug treatment.

• Tier 2 interventions include the provision of drug-related information and advice, triage assessment, referral to structured drug treatment, brief psychosocial interventions, harm reduction interventions (including needle exchange) and aftercare. More specifically, these services can include;
  • triage assessment and referral for structured alcohol and/or drug treatment;
  • interventions which attract and motivate those with problem use into local treatment systems, including engagement with priority groups;
  • interventions to reduce harm and risk due to blood-borne viruses and other infections for active drug users;
  • interventions to minimise the risk of overdose and diversion of prescribed drugs;
  • brief psychosocial interventions for alcohol and drug misuse;
  • brief interventions for specific target groups including high-risk and other priority groups;
  • support for clients seeking abstinence;
  • aftercare support for those who have left structured treatment, and;
  • outreach services to engage clients into treatment and re-engage people who have dropped out of treatment.

  These tier 2 interventions will often be delivered in the same setting and by the same staff as tier 3 interventions. Other typical settings to increase access are through outreach, including home visits, general detached or street work, peripatetic work in general service, and primary care settings. Criminal justice and pharmacy settings are also important here in engaging individuals at risk and, for the latter, due to their unique role in pharmacy based needle exchange schemes and their role in the supervised consumption of prescribed drugs.

• Tier 3 interventions centre on the provision of community-based specialised drug assessment and coordinated care-planned treatment and liaison with alcohol and/or drug specialists. More specifically, services here include;
  • comprehensive alcohol and/or drug misuse assessment;
  • care planning, co-ordination and review for all in structured treatment, often with regular key-working sessions as standard practice;
  • community care assessment and case management for those with problematic alcohol and drug use;
  • harm reduction activities as integral to care-planned treatment;
  • a range of prescribing interventions for problem drug use, in the context of a package of care and in line with ‘the Clinical Guidelines’. These are updated according to the National Institute for Clinical Excellence (NICE) guidelines, and in line with other evidence-based clinical standards with specific interventions, including prescribing for stabilisation and oral opioid maintenance prescribing; community based detoxification; injectable maintenance prescribing, and a range of prescribing interventions to prevent relapse and ameliorate alcohol- and drug-related conditions;
  • a range of structured evidence-based psychosocial interventions to assist individuals to make changes in alcohol and drug using behaviour;
  • structured day programme and care-planned day care (e.g. interventions targeting specific groups);
  • liaison services for acute medical and psychiatric health services (e.g. pregnancy, mental health and hepatitis services);
  • liaison services for social care services (e.g. child protection and community care teams, housing, homelessness), and;
  • a range of the above interventions for drug-misusing offenders.

  Tier 3 interventions are typically delivered in specialised alcohol and/or drug treatment services with their own premises in the community or in hospital settings. Other delivery may be undertaken by outreach (including work in generic services or other agencies or domiciliary or home visits). These may be provided along tier 2 interventions. Some of the tier 3 work in primary care settings (shared care schemes and GP-led prescribing services), as well as in pharmacies, but drug-specialist-led services are required within the local systems for the provision of care for severe or complex needs and to support primary care. Alcohol and drug-treatment interventions for offenders may also be delivered in prison settings, and community criminal-justice programmes can be delivered in contracted community drug-treatment services (statutory or third-sector).

• Tier 4 includes the provision of residential specialised alcohol and/or drug treatment and rehabilitation services. These services are typically care planned and care-coordinated to ensure continuity of care. Tier 4 interventions include;
  • inpatient specialist drug and alcohol assessment, stabilisation, and detoxification/assisted withdrawal services (sometimes provided within residential rehabilitation services);
  • a range of alcohol and drug residential rehabilitation services (typically provided by the third sector in Scotland);
  • a range of supported accommodation services;
  • residential alcohol and drug crisis intervention units, typically in larger urban areas;
  • provision for special groups for which a need is identified (eg. for pregnant females, those with liver problems, those with severe and enduring mental illness) which may require joint initiatives between specialised drug services and other inpatient units, and;
  • a range of the above for offenders with alcohol and drug use.

  Inpatient tier 4 services are typically provided within specialist dedicated inpatient or residential units or wards. Provision may also be undertaken in general psychiatric wards for 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 pregnancy, liver problems and HIV-related problems, for example). 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 (if there are adequate medical supports). Other patients may 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 between the two.