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Substance misuse: providing remote and in-person interventions – GOV.UK

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Published 7 March 2022

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Alcohol and drug treatment services were subject to restrictions and limitations early in the coronavirus (COVID-19) pandemic and had to change their practices to keep staff and service users safe. This included reducing in-person interactions and introducing new and expanded remote interventions.
Most of these restrictions have now been lifted and services have reviewed and revised their practice, mostly returning to pre-pandemic guideline-compliant practice. However, some of the changes to practice were (and could still be) beneficial to service users. These can be continued as long as they are individually assessed for risks and benefits and are in line with clinical guidance.
Deaths of people in drug and alcohol treatment increased during the pandemic and have not returned to their pre-pandemic levels. These deaths are mostly not attributable to COVID-19 itself, though they may be connected to restrictions on people’s freedoms and related stresses, and to changes in healthcare practice made necessary by the pandemic, including in drug and alcohol treatment. For example, deaths of people who use alcohol were 44% higher in 2020 to 2021 than they were in 2019 to 2020 – some people have been drinking more in the pandemic and some have not been able or willing to get the hospital care they needed early enough to prevent death. Deaths of people who use opioids may be partly connected with reduced supervised consumption of opioid substitution treatment (OST), primarily methadone. Methadone deaths of people not in treatment have also increased, likely as a result of more diverted methadone being available.
This guidance gives advice about how alcohol and drug treatment services can achieve a good balance between remote and in-person interventions for different service user groups.
Most people will need some in-person interaction at the beginning of their treatment programme to receive an accurate, comprehensive assessment of their needs and to start the process of building rapport between them and their keyworker.
Without this initial in-person meeting, there is a risk of missing signs of mental and physical health problems. However, remote contact and simplified referral procedures can improve people’s engagement in services. It may be best to combine the 2 approaches, for example quickly collecting initial information collection with an online form or phone call and then meeting in-person to assess the person and start to build a relationship.
For people already in treatment, deciding on in-person or remote contact will depend on individual need. This need should be continuously monitored as a person’s situation can change throughout their treatment.
Remote communication might be suitable for regular check-ins, but you should conduct care plan reviews and other major reviews in-person. You will also need to have some intermittent in-person contact to assess the service user’s mental and physical wellbeing, as well as to maintain a relationship with them.
If people cannot or will not attend the service, you should consider home visits or meeting off-site for the in-person contact.
You will need to have in-person meetings before starting someone on OST and when significantly changing their dose of OST medication.
You should assess the need for supervised consumption of medication at the start of treatment and regularly after that. The UK clinical guidelines on drug misuse and dependence recommends that in most cases, service users will need supervision for “a period of time to allow monitoring of progress and an ongoing risk assessment”. Most people can have supervision relaxed when they can show that they are sticking to their treatment plan and are not using other drugs, and if the home environment is suitable for safe storage of medicines.
You should use drug testing when necessary to check that service users are sticking to the treatment plan. You should reintroduce supervision if it will help the person to stop taking other drugs that are not allowed by their treatment plan.
Community medically assisted withdrawal for alcohol dependence should now be delivered through in-person meetings in line with the National Institute for Health and Care Excellence (NICE) guidelines on alcohol-use disorders.
Ongoing monitoring of physical and mental health status, problems and treatment progress will usually require in-person contact. This is especially true of administering physical health checks and tests that cannot be done remotely.
It will be down to your clinical assessment and judgement when and how often people need to be seen in-person. The more severe someone’s health condition is, the more frequently they may need to be seen. If you become aware of any symptoms during a remote check-in (for example, wheezing on a phone call or jaundice on a video call) you should insist that the person come in for a more thorough check-up.
During the pandemic, some drug services started online ordering and postal delivery of injecting (and other) equipment to people who inject drugs (PWID). This has benefited many people as a supplement to existing physical needle and syringe programmes (NSP) in services, community pharmacies and other venues. It seems likely that PWID will benefit from continuing this option.
However, postal NSP should not replace physical NSP entirely and you should encourage PWID to visit NSP in-person at least some of the time. In-person meeting with NSP staff has benefits for service users, including:
Some drug services also developed online ordering and postal delivery of hepatitis C testing during the pandemic. This has benefited many people as an addition to existing, in-person testing. Continuing to provide this service will likely be beneficial, making accessing hepatitis C tests easier for those who need it.
However, postal hepatitis C tests should not entirely replace in-person testing. You should encourage in-person testing because this has benefits including:
Drug and alcohol services had to be flexible during the pandemic to ensure they still delivered beneficial interventions for young people. For example, practitioners replaced in-person meetings with regular online contact.
There has been a drop in the number of young people getting the help they need due to the pandemic. The Young people’s substance misuse treatment statistics 2020 to 2021 show that there was a 23% reduction in the number of young people starting treatment compared to the previous year. In particular, school closures and reduced face-to-face contact across all children and young people’s services meant there were fewer opportunities for young people to be referred to substance misuse services.
Research by the Early Intervention Foundation found that many young people reported increased anxiety and feelings of isolation, often made worse by more exposure to family conflicts and cyber bullying during lockdowns. Also, many young people said they were not able to freely discuss issues on the phone with workers while they were in their family home.
Remote contact time can be beneficial, but it should not entirely replace in-person meetings. You should consider a combination of in-person and digital interventions, depending on individual need. For vulnerable young people, you should prioritise in-person appointments or home visits over remote sessions.
Many older children, parents and carers engaging with treatment and social care have responded well to video chats. However, research has found there were challenges to offering effective support to children and families during the pandemic. These included:
These issues show how important it is for treatment services to have safeguarding policies that are regularly reviewed. They should ensure that staff are trained and supported in their safeguarding roles.
Referrals from social care must be treated as a priority. Staff should regularly review child living arrangements with their service users either in-person or remotely, recognising that family situations can change. If you feel that a service user is using remote treatment appointments to prevent them from assessing parenting capacity or child wellbeing, you should make a home visit or refer to children’s social care.
Perinatal and postnatal women are particularly vulnerable, so you should consider providing them with in-person appointments or home visits instead of remote sessions.
Research on substance use and intimate partner violence shows that substance misuse and domestic abuse often occur at the same time. Since the start of the pandemic, there has been an increase in demand for domestic abuse victim services. A report on domestic abuse during the pandemic by the Office for National Statistics found that this increase in demand does not necessarily mean an increase in the number of victims, but a possible increase in the severity of abuse and a lack of coping mechanisms. For example, not being able to leave the home to escape abuse or attend counselling.
Alcohol and drug service staff should understand the new statutory definition and guidance, and consider what that means for the service users they see in-person and remotely. Services should follow the NICE guidance on domestic violence and abuse and routinely enquire about domestic abuse. Staff should be trained to avoid raising and addressing domestic abuse in telephone and video appointments, where a perpetrator might be listening and where it may be easier for a victim to hide the truth.
Injecting equipment and medicines being posted to a service user could be intercepted by a perpetrator and used to exert control. If you know or suspect that domestic abuse is occurring, you should enable the person to collect injecting equipment and medicines in person.
If you suspect domestic abuse and the service user needs alcohol or drug detoxification, the treatment should be delivered in a separate setting, like a hospital. This is because home detox requires a family member to support the service user and this can cause stress in a relationship and increase abuse where it already exists. Also, the need for support during detox can create an opportunity for coercive control.
Underreporting of domestic abuse is common, and services need to ensure that remote working does not prevent someone from disclosing domestic abuse. For example, information on domestic abuse support that was previously displayed in treatment services (like posters, leaflets and business cards) will need to be shared safely and sensitively to all service users receiving remote support.
Mutual aid services (such as Alcoholics Anonymous, Narcotics Anonymous (NA) and SMART Recovery) and peer-led lived experience recovery organisations (LEROs) have made huge efforts to continue supporting members, by replacing in-person meetings with online and telephone alternatives. For example, there are now more than 900 NA meetings held online across the UK. As well as more online meetings, the 12-Step fellowships have also reported big increases in new members.
Despite this, many members of these fellowships have emphasised the importance of returning to in-person meetings, as soon as it is safe to do so. Mutual aid groups are advising each group to assess risk and determine whether they can safely return to in-person meetings.
Some groups are considering a hybrid approach to meetings, where in-person meetings use technology to have online members join in. It can be difficult to provide a good experience for people online and in-person simultaneously. Groups should consider hybrid approaches carefully with group members before offering them and should review their effectiveness regularly.
Groups need to consider new ways of reaching out to and supporting potential newcomers. For example, using social media to inform members on how to connect to virtual meetings, and placing leaflets and posters in treatment services with all local options for support (online, in-person and hybrid).
Groups that have changed their ways of operating must regularly review their processes and effectiveness with staff, volunteers and attendees.
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