1. Specialist service provision

2. Who is involved in specialist services? Statutory services –Run by NHS and Social Care, these deliver medical and psychosocial interventions. 3 rd sector commissioned services –These are commissioned by local commissioners to deliver treatment and particularly street level (outreach) social and educational help. Community enterprises –Like 3 rd sector, these may be local projects funded by charities or commissioned for specific services. Community led groups –These may be unfunded, self-funded or rely on donations and are led by service users themselves.

3. Levels of intervention Specialist services for substance misuse can be divided into different levels or stages of intervention. This is because people’s ‘journey’ toward recovering from their problematic substance use can be seen in stages: –Early contemplation about the harms. –Trying to access the right sort of intervention for them (engagement). –Participating in intervention or treatment. –Maintaining a healthier relationship with substances.

4. Levels of intervention Harm reduction – education, needle-exchange, health promotion, brief intervention. Engagement – motivational work, incentives for engagement, outreach, brief assessments. Treatment – substitute & reducing prescribing, talking therapies, rehabilitation. Maintenance of reduced use or abstinence.

5. NHS medical services are likely to provide: Substitute prescribing (methadone or buprenorphine – Subutex). Detoxification from alcohol (controlled withdrawal using benzodiazepines such as valium). Extinction therapy (to reduce craving – prescribed naltrexone, acamprosate). Symptom treatment (prescribed anti-depressants, anxiolytics, or talking therapies for depression, anxiety etc). Heroin prescribing (substituting street heroin with clean, controlled doses of heroin). Psychological therapies – (cognitive behavioural therapy, counselling, psychotherapy, family work). General health screening and treatment – (especially for blood borne viruses, mental health, sexual health).

6. Commissioned and bought-in services Residential rehabilitation – (longer term psychosocial therapies focussing on identity, resilience, self esteem. Often private sector). Street level outreach (& prison in-reach) and engagement – (3 rd sector ‘user-friendly’ services, often staffed by or involving ex-users). Commissioned residential or inpatient services – (3 rd or private sector specialists). Day attendance activities and day clinics

7. Statutory service medical support: in more detail Substitution/maintenance prescribing (methadone, buprenorphine, heroin) This can break the person’s reliance on accessing street heroin and reduce associated harms such as stealing and risk of blood borne infections. It is criticised for replacing one type of addiction with another but has benefits over street drug use. Substitution reducing prescribing (methadone, buprenorphine, prescribed heroin) This aims to wean the person off the opiate gradually. It has the same benefits as above. It takes months or years for many people.

8. Statutory service medical support: in more detail Detoxification from alcohol. –This aims to help someone withdraw safely without the dangers involved in sudden alcohol withdrawal. It does not stop someone from drinking again. Extinction therapy. –This uses naltrexone and acamprosate to block opiate receptors resulting in little effect from any further heroin or alcohol use. Aversion therapy. –This may use disulfiram (antabuse) which creates unpleasant side effects if someone drinks alcohol while using this medication. Less used by specialist services but may still by used in primary care for maintaining abstinence in long term patients.

9. Statutory service medical support: in more detail Symptom management –Many people with substance use problems will also be experiencing negative symptoms associated with their use and require compensating medication (i.e. depression, anxiety, constipation, sleeplessness, psychosis). Psychological therapies –Trained substance use specialists from different professional backgrounds (i.e. psychology, social work, nursing, occupational health). Health screen –Testing and referral to specialist services for blood borne viruses, mental health, sexual health, general health.

10. 3 rd sector commissioned services There are national 3 rd sector enterprises who deliver local projects around the country, commissioned by local health commissioners. These can range from fully professionally staffed health based agencies delivering inpatient and rehabilitation services to social support or self help groups run by ex-users. They provide a range of general or specific services for substance misuse communities and service users. They are best explored specifically to see what they provide in your area.

11. Examples of commissioned services* Click on the following links to go to websites for common 3 rd sector and private sector national providers of substance use services: Lifeline: http://www.lifeline.org.uk/http://www.lifeline.org.uk/ Turning Point: http://www.turning-point.co.uk/substance- misuse.aspxhttp://www.turning-point.co.uk/substance- misuse.aspx CRI: http://www.cri.org.uk/about-ushttp://www.cri.org.uk/about-us Action on Addiction: http://www.actiononaddiction.org.uk/home.aspx http://www.actiononaddiction.org.uk/home.aspx * there are many more, often local providers.

12. Community enterprises and self help organisations You will find more on community based enterprises and self help groups in the resource Asset-based approaches and the resource Pathways to recovery.Asset-based approaches Pathways to recovery These services are usually community run, sometimes as national or even international organisations, sometimes as highly localised self help groups.

13. Community enterprises and self help organisations (cont.) The most well known are probably Alcoholics Anonymous and Narcotics Anonymous. These provide a structured abstinence- based group and individual pathway to recovery, and highly regarded by many people who are helped by them. There are also groups to support families and carers of people with problem substance use such as Al-Anon. However, their approach doesn’t suit everyone and other organisations such as the SMART recovery groups are good alternatives.

14. Mutual aid groups These groups can be highly structured or very informal links between individuals who help each other. There are many different variations of groups. Some may specialise in creative activities such as music, art, dance. Some may be spin- offs from AA or NA or 3 rd sector services. It is best to find out what is in your area by seeing how the statutory and 3 rd sector services link up with mutual aid groups.