This page provides key information to explain what substance misuse services are and will help build your understanding of the role this service has in suicide prevention.
- What are substance misuse services?
- Use of substance misuse services
- Why are substance misuse services important in the context of suicide prevention?
- ZSA Suicide Prevention Resource Map - key takeaways
- National guidelines for practice
- Impact of COVID-19
- ZSA Suicide Prevention Resource Map - related indicators
A substance misuse service is defined as a service that provides treatment and support for people with that misuse substances or have a dependency problem (GOV UK, 2017). Substance misuse services are split into three sectors, opiate drug services, non-opiate drug service and/or alcohol services. These services are made up of multidisciplinary teams which can include doctors, nurses, psychologists, occupational therapists, pharmacists and social workers (Public Health England, PHE, 2017).
The aim of these services are to reduce drug and/or alcohol misuse in the community. This has a larger knock-on effect, including preventing substance misuse ill-health (physical and mental health), the spread of blood-borne viruses and preventing premature mortality (Nuffield Trust, 2021). Substance misuse is often co-morbid with mental health conditions or serious mental illness, as substances are often used as an accessible coping mechanism to manage stress (Public Health England, 2017). Therefore it is common that people who present to mental health services also often need support with misuse of substances.
For more information, visit our Facts for Action series on substance misuse for more information.
For people that use a substance misuse service, treatment requires an approach that considers the role of psychological, biological, social and physical factors. Recovery services use a consistent, locally agreed approach to treatment that is respectful, non-judgemental and proportionate to the person's presenting vulnerabilities (NICE, 2017). The service that people will use is dependent on the level of care that they need. Care Quality Commissioner (CQC, 2018) differentiate between the different types of substance misuse services provided:
Community based services
These services provide care, treatment and support in the community for people with substance misuse problems. They may also help people who have a dual diagnosis or co-morbid disorders, where the person is experiencing a mental health problem and also has a substance misuse problem. Treatment is likely to involve the use of medicines, usually opioid substitution therapy, alongside psychosocial interventions.
Maintenance therapy is where a patient switches from a substance to a substitute, for example, methadone or buprenorphine is used to substitute heroin (NHS, 2020). This is used so an individual can stay on a stable dose of the substitute and gradually detox off them in a safe way.
Brief psychosocial interventions can be used in a variety of settings for people not in contact with drug services (for example, in mental health, general health and social care settings, and emergency departments) and for people in limited contact with drug services (such as at needle and syringe exchanges, and community pharmacies). These interventions consider the psychological and social factors that contribute to developing and maintaining a substance use disorder.
Contingency management is a set of techniques that focus on changing specified behaviours. In substance misuse, it involves offering incentives for positive behaviours such as abstinence or a reduction in illicit drug use, and participation in health-promoting interventions. Contingency management programmes involve (NICE, 2007):
- Measurable targets
- Positive reinforcement (incentives, rewards) e.g. praise, vouchers, prizes, privileges, cash
- A clear relationship between behaviour and reinforcement
There are also informal facilities such as the Needle and Syringe Exchange Service that can be accessed in the community. These services include a free, confidential service for people who inject drugs. They are designed to reduce the spread of blood borne viruses by providing free, sterile injecting equipment and by disposing of used equipment safely (Public Health Agency, 2020).
Admission to hospital is often the first time substance misuse is identified and diagnosed as an underlying or primary condition, so hospital admission provides an ideal opportunity for early intervention.
Alcohol Care Teams (ACTs) are based in A&E settings and acute inpatient settings. Following discharge from hospital, ACTs liaise with community alcohol services to ensure alcohol treatment is continued. If someone needs more intensive support, they may be admitted into a residential detoxification programme or an inpatient unit (NHS, 2016). By identifying and ensuring treatment for patients with alcohol dependence, they reduce the likelihood of future ill-health and alcohol-related readmissions.
Where patients present to A&E whilst they are withdrawing from alcohol, the ACT will stabilise their condition and manage a medically assisted withdrawal (MAW) regimen alongside providing support such as psychosocial intervention. This addresses their immediate needs in relation to alcohol dependence.
Inpatient services services provide assessment and assisted withdrawal for people with substance misuse problems. Services are available 24 hours a day and are provided by a multidisciplinary clinical team with specialist training in managing addiction and withdrawal symptoms. People whose use of alcohol or drugs need to be supervised in a controlled medical environment such as a specialist inpatient ward, or as part of their care on another ward (NHS, 2021).
These services provide an inpatient structured drug and alcohol treatment where people have to be resident at the service in order to receive treatment. This includes abstinence-based recovery services, as well as medicine-assisted recovery programmes, such as detoxification or stabilisation services.
HM Government drug strategy is centred around three aims: to restrict supply, reduce demand and build recovery (GOV UK, 2019). The purpose of health care in prison, including care for drug and alcohol problems, is to provide an excellent, safe and effective service to all prisoners, whether the aim is stabilisation, crisis intervention or recovery from dependence whilst considering other related mental and physical mental health needs (NHS, 2018).
NHS Digital publishes an annual report on admissions to hospital in England. The latest publication from NHS Digital (2021) shows that in the year 2019/20:
- 76,000 people were treated for alcohol misuse compared and 29,000 were treated for non-opiate and alcohol problems.
NHS Digital also publishes an annual bulletin on the use of substance misuse services on the Mental Health Services Data Set submissions by providers. The latest publication from NHS Digital (2021) shows that in the year 2020/21 16,114 attended substance misuse teams, in comparison to 2019/20.
Public Health England publishes an annual report which reports on the use of adult substance misuse treatment services based on the Mental Health Services Data Set submissions by providers. The latest publication from Public Health England shows that in the year 2020/21:
- There were 270,705 adults in contact with drug and alcohol services between 2019/2020, an increase from 270,705 in 2019/20.
- There was 130,490 people entering treatment.
- Over half of all adults (51%) received treatment for problems with opiates, 21% with other drugs and 28% with alcohol only.
- 68% of people in treatment were male, compared to 32% female.
- For drug treatment, males make up just over two-thirds (opiate 72%, non-opiate only 68%, non-opiate and alcohol 70%).
- For alcohol treatment, males make up 58% and females 42%.
- More than half of the people in treatment were over 40 years old (56%), while less than 10% of people in treatment for opiates or alcohol only were under 30 (7% for opiates and 9% for alcohol only).
- For adults starting treatment, 63% required mental health treatment. Over half of new starters in all substance groups needed mental health treatment, including 57% in the opiate group to nearly two-thirds (71%) of the non-opiates and alcohol group.
Treatment exits and deaths in treatment:
- There were 110,095 people who exited the drug and alcohol treatment system in 2020/21. Half (50%) of those left having successfully completed their treatment.
- The total number of people who died while in contact with treatment services in 2010 to 2021 was 3,726 (1.4% of all adults in treatment), representing a 27% increase from 2019/20.
- There was a increase in the proportion of people dying whilst in treatment:
- opiate users by 20%
- non-opiate only users by 36%
- non-opiate and alcohol users by 37%
- alcohol only users by 44%
- Of the people starting treatment in 2020/21, 61% self-referred.
- 15% of referrals were from healthcare, and referrals from GPs accounted for 6%, hospitals made up 4% of all referrals and 3% of referrals came from social services. Referrals from healthcare varied between the individual substance groups. Only 8% of opiate referrals came from healthcare compared to 21% of alcohol only referrals.
- Referrals from the criminal justice system made up 12%, accounting for 23% of opiate referrals compared to just 6% for those with only alcohol problems. Prison referrals accounted for 5% of all referrals.
Almost all (99%) people in treatment received a form of structured treatment:
- 98% received a community-based treatment
- 7% received treatment in a primary care setting
- 3% received treatment in an inpatient setting
- 1% received treatment in a residential setting
Trends over time
The National Drug Treatment Monitoring System (2021) has created a view it tool to show the trends of people in treatment over time. Figure 1 shows that the number of people in treatment for opiates and alcohol only has slowly decreased from 2016/17 to 2019/20 and remained the same in 2020/21. Whereas numbers of people in treatment for non-opiate only, and opiate and alcohol has gradually increased.
Figure 1: The trends in numbers of people in treatment, split by substance group (2009-21).
Public Health England publishes an annual report which reports on the use of adult substance misuse treatment services in secure settings. The latest publication from Public Health England (2022) reports that in 2020/21
- There were 43,255 adults in alcohol and drug treatment in prisons and secure settings between April 2020 and March 2021.
- Of the people starting treatment, 49% said they had a problem with opiate use.
- 91% people in treatment in adult secure settings were men and 9% were women.
Of the people in treatment:
- 58% said they had a problem with opiate or crack use.
- 44% said they had a problem with alcohol (11% of which those had a problem with alcohol alone).
- 33% said they had a problem with cannabis.
- 24% said they had a problem with powder cocaine.
- Of the people with opiate problems:
- 40% said they had a problem with opiates but not crack.
- 39% said they had a problem with alcohol.
- 24% said they had a problem with benzodiazepines.
- New psychoactive substances (NPS) were a problem for 10% of people.
Pathways to treatment:
- 59% of the people starting treatment in an adult secure setting were taken directly into custody or detention from the community.
- 64% started treatment immediately on arrival into custody.
- 39% of people starting treatment were identified as having a mental health need.
- The highest proportion was seen in opiate users (42%), compared to 32% of non-opiate only users.
- 95% received psychosocial interventions.
- 4% received prescribing interventions only.
- 1% either did not start an intervention or an intervention was not recorded.
- Almost half (48%) of adults in treatment received a prescribing intervention. There were 80% of the opiate group receiving these, 32% of the alcohol-only group and just 5% of the non-opiate group.
In 2017, the Care Quality Commission (CQC) reported on substance misuse services through inspections of independent services that they identified as offering residential detoxification.
The CQC found:
- Poor assessment of risk. Some units did not undertake risk assessments to determine whether it was safe to treat a person in their facility and did not respond appropriately to changing risks.
- Failure to follow best practice guidance. Some units did not adhere to evidence-based guidance on how to assess, monitor and treat people withdrawing from drugs and/or alcohol.
- Poor management of medicines. Staff in some units did not handle, store and dispense medicines in a safe way.
- Staff with insufficient training. Staff in some services had not undertaken basic training to maintain safety nor the specialist training to support people withdrawing from drugs and/or alcohol.
- Lack of employment checks on staff. Managers in some units were not undertaking the employment checks required to protect those using their services.
The hospital admission profile of people presenting to specialist addiction services in England (Roberts et al, 2021).
- Inpatient data were available for 64,840 alcohol patients, and 107,296 opioid patients.
- The most common primary admission reason was alcohol withdrawal syndrome (5.3%) in alcohol patients or an unspecified illness (2.1%) in opioid patients.
Substance misuse services are key critical components of alcohol and drug treatment and recovery systems. This services work alongside emergency departments, community mental health teams, crisis teams, early intervention services and secure prison services to reduce alcohol and drug related ill-health, death, mental health and suicide, as well as reducing harm to others (Nuffield Trust, 2021 ).
The number of people that are misusing substances harmfully is increasing. People that misuse substances are at a higher risk of completing suicide than the general population and many people that have completed suicide have been under the influence of either drugs or alcohol, which may have caused them to be impulsive or reduced their inhibitions (Samaritans, 2021). 21% of patients that died by suicide were under the care of alcohol and drug misuse services between 2011-18 (The National Confidential Inquiry into Suicide, 2021).
Substance misuse increases the risk of suicide even more so for people with common mental health problems or serious mental illnesses (National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 2016). For example, there is a large proportion of people that die by suicide from substance misuse in mental health treatment, with self-poisoning (over-dose) being the second most common method of suicide contributing to 23% of patient suicide deaths in England .
Access to high quality substance misuse services is crucial in supporting people to recover from substance addiction and to manage their lives in as safe and stable way as possible.
For more information, visit our Facts for Action for substance misuse.
Our ZSA Suicide Prevention Resource map developed with the NHS Benchmarking Network includes a number of metrics which provide a picture of the overall situation for substance misuse services across England and shows wide variation in the number of people accessing these services and their experience in relation to key measures of relevance to suicide prevention. The data below relates to 2019-21 and is sourced from the NHS Benchmarking Project for Adult Mental Health Services unless stated otherwise*.
- Proportion of people referred for drug treatment waiting more than 3 weeks varies between 0% to 28.3%, with a median average of 0.3% in 2020/21.
- Proportion of people referred for alcohol treatment waiting more than 3 weeks varies between 0% to 39.5%, with a median average of 0.5% in 2020/21.
- Admissions due to alcohol for all ages per 100,000 population varies between 331 and 2,590, with a median average of 637 in 2019/20.
- Admission episodes for mental and behavioural disorders due to use of alcohol per 100,000 population varies between 157 and 1675, with a median average of 423 in 2018/19.
- Successful completion of drug treatment (opiate users) varies between 1.6% and 12.2%, with a median of 5.8% in 2019.
- Successful completion of drug treatment (non-opiate users) varies between 11.9% and 66.8%, with a median of 33.5% in 2019.
- Successful completion of alcohol treatment varies between 17% and 56%, with a median average of 38.8% in 2019.
* All data from NHS Benchmarking Network projects is subject to change dependent upon permissions being receiving from provider organisations to have their data included in the map. The information reported reflects the data available as at 05/09/2022.
National Institute for Health and Care Excellence
The National Institute for Health and Care Excellence (NICE) use the best available evidence to develop recommendations and guidelines that guide decisions in health, public health and social care. These guidelines can also be directly relevant to the assessment and treatment of substance misuse.
NICE Quality Standards:
- Alcohol-use disorders: diagnosis, assessment and management of harmful drinking
- Drug use disorders in adults
NICE Clinical Guidelines for drugs:
- Drug Misuse Prevention: Targeted interventions
- Co-existing severe mental illness and substance misuse
- Needle and syringe programmes
- Drug misuse in over 16: opioid detoxification
- Drug misuse in over 16: psychosocial interventions
NICE Clinical Guidelines for alcohol:
- Alcohol interventions in secondary and further education
- Alcohol use disorders: diagnosis and management of physical complications
- Cirrhosis in over 16: ssessment and management
- Nalmefene for reducing alcohol consumption in people with alcohol dependence
- Alcohol use disorders: prevention
- Psychosis with coexisting substance misuse: Assessment and management in adults and young people
Other NICE Guidelines:
- Coexisting severe mental illness and substance misuse: community health and social care services
- Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings
NHS Long Term Plan
The NHS Long Term Plan (2023/24) set out that the NHS will:
- Develop new integrated models of primary and community mental health care will support adults and older adults with severe mental illnesses. A new community-based offer will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use.
- Hospitals with the highest rate of alcohol dependence-related admissions will be supported to fully establish ACTs using funding from their clinical commissioning groups (CCGs) health inequalities funding supplement, working in partnership with local authority commissioners of drug and alcohol services. Delivered in the 25% of worst affected hospitals, this could prevent 50,000 admissions over five years.
Public Health England (PHE)
Public Health England have developed a guide in line with the NHS Five Year forward for Mental Health to improve the provision for effective care for people with co-morbid mental health and substance misuse problems and/or conditions. PHE (2017 ) recommend that:
- Co-occurring alcohol/drug and mental health needs should be core business for both alcohol, drug and mental health services, supported by wider health and social care services.
- Commissioners and providers should agree a pathway of care and routinely measured outcomes which will enable collaborative delivery of care by multiple agencies in response to individual need.
- Every person with co-occurring conditions should have a named care coordinator to help coordinate the multi-agency care plan.
- People should be able to access the care they need when they need it and, in the setting that is most suitable to their needs.
- There should be a 24/7 response to people experiencing mental health and alcohol and drug use crisis, including intoxicated individuals, with episodes of intoxication being managed safely, and an agreed plan to help people access ongoing care and manage future crisis episodes.
- Commissioners should ensure that local pathways exist which enable people to access appropriate services e.g. for homelessness, domestic abuse or physical healthcare
- Services should be commissioned to help people to access a range of recovery support, and all stakeholders should recognise that recovery is a highly individual process which can often occur in fits and starts and may take many years
- Care pathways should meet the specific needs of people in prison, children and young people, older adults and other vulnerable groups.
- Factors in the delivery of effective care include a strong therapeutic alliance, therapeutic optimism, and care that reflects the views, needs and priorities on the person.
The Department of Health
The Department of Health (DoH) has developed a UK guideline for the Clinical Management for drug misuse and dependence. The DOH (2017)  has recommended that:
- The needs of all drug misusers should be assessed across the four domains of drug and alcohol misuse, health, social functioning and criminal involvement.
- All drug misusers receiving structured treatment should have consented to their treatment and recovery care plan, which should be regularly reviewed.
- Drug misuse treatment should involve a range of psychosocial treatment and support interventions, not just prescribing.
- A proactive, flexible organisational ethos that actively involves service users and carers can support an effective and engaging therapeutic treatment.
- All drug services need competence in identifying and addressing the effects of trauma on service users and the effects of intimate partner or other domestic violence.
- Aftercare support and pathways for rapid re-engagement in treatment are important to address risks of relapse and harm, and support recovery in the period after leaving treatment.
Care Quality Commission
CQC have recommended guidelines from their findings from the inspections completed on substance misuse services . CQC recommend that:
- Local authority commissioners should assure themselves that the services they commission are safe, appropriate and effective, particularly in relation to the competence of service providers to meet and safely manage complex needs and to support vulnerable people.
- Commissioners should ensure a range of services are available so they can meet the full range of needs, including complex need. This includes having clear quality governance processes in place with services from whom treatment is purchased on a place by place or ‘spot purchase’ basis.
- Residential detoxification services should be compliant with relevant clinical guidelines, including relevant National Institute for Health and Care Excellence guidance and the Department of Health UK Guidelines
CQC have also created a brief guide for substance misuse services for detoxification and withdrawal from drugs and alcohol. This can be found at CQC Substance misuse service guide.
NHS England (2018) have recommended guidelines for integrated substance misuse treatment in prisons. They recommend that:
- To provide an excellent, safe and effective service to all prisoner’s equivalent to that of the community.
- Care should be delivered by professionals and allied staff who are suitably competent, properly supervised and operating within a clear quality and clinical governance framework supporting safe and effective delivery.
- Screening, assessment and treatment for problem drug and alcohol use should address the wide range of substance use/misuse, and other, often related, physical and mental health needs identified, and should address any identified disability
- Treatment should be regularly reviewed. There should be access to suitable psychosocial interventions to support treatment and recovery. Where medication is indicated, its provision should be suitably optimised, particularly in those with difficulties achieving stability.
- Clinicians should be able to adapt evidence-based treatments from the wider community where appropriate to the prison estate and regime, and be able to work with security staff and supply reduction and safer custody initiatives to help reduce harm and to manage risk, particularly the risk of death in custody and self-inflicted harm.
Around one in five people (21%) reported drinking more frequently since the lockdown, suggesting that around 8.6 million UK adults had changes in their drinking habits (Alcohol Change, 2020). More than half of adults and over two thirds of young people said that their mental health has gotten worse during the period of lockdown restrictions, with a third using alcohol or illegal drugs, with 18–24-year-olds using this coping strategy more than over-25s (Mind, 2020). Due to the comorbidity between mental health and substance misuse, it is likely this will impact the need for substance misuse services.
The Strategy Unit (2020) has undertaken work to predict the potential increase in demand for substance misuse services. The Strategy Unit has predicted a 592.3% increase in overall demand between 2021 and 2023 and has estimated a surge of 26,415. In particular, domestic abuse victims are likely to be the largest population source for the surge, above that of the general population. Additionally, the general population are likely to make up 8611 of the surge amounts, identifying that the need for substance misuse services will have a dramatic increase following COVID-19.
Impact on demand
Data in regard to the demand and activity of substance misuse services is very sparse for the time-period that the COVID-19 pandemic hit the UK and England. However, with 8.6 million people drinking at a higher risk during 2020 and 39% of people in recovery from addiction and having a relapse in their recovery (Alcohol Change UK, 2020 ), this may contribute to the rise in new presentations to substance misuse services, as seen figure 1 which shows the community adult treatment performance reports in England (National Drug Treatment Monitoring System, 2021).
Figure 2 shows that after the initial lockdown, there were a rise in new presentations to services, with alcohol services seeing the largest influx of new presentations from 2,380 in April to 10,568 in August 2020. A high number of new presentations (not previously known) suggests that people within the community are not accessing substance misuse services until they reach to a point where they need support.
Figure 2- The number of presentations (patients) to substance misuse treatment (opiate, non-opiate, non-opiate and alcohol or alcohol only) in England (2020-21)
Impact on service
COVID-19 pandemic has presented challenges for substance misuse services. In 2020, The Department of Health and Social Care and Public Health England (2020) released guidance for commissioners and providers of services in for people who use drugs and alcohol in England. This impacted the service through:
- Arrangements for prescribing and dispensing of medicines used in drug and alcohol treatment were previously changed to take account of service and pharmacy closures, staff unavailability, patients having to maintain social distance or self-isolate.
- Face-to-face contact should be avoided where it would be unsafe or unnecessary; telephone or other remote or virtual support should be provided as an alternative.
- This had some negative effects on older adults in alcohol treatment, The ability of older clients to access online resources was limited for a number of reasons, including not having access to technology or the Internet, not knowing how to use technology, health barriers or learning difficulties, or anxiety around online support (Seddon et al., 2021)
Needle and syringe programmes
Whitfield, Reed & Webster (2020)
- In April 2020, 105 (91%) of the 115 sites in England providing Needle and Syringe Programmes (NSP’s) services that could be contacted remained open with social distancing measures in place. Of these sites, 45% had reduced hours or had additional access restriction in place.
- Monitoring of NSP activity data shows that the number of clients, visits, and number of needles all dropped substantially between March and April 2020.
- Number of clients dropped by 36% (662 clients per week to 426)
- Number of visits dropped by 36% (1,424 visits per week to 913)
- Number of needles provided dropped by 29% (59,026 needles per week to 41,772)
- Since 16th March 2020, these have both been down by around one-third on the comparable periods in 2019 (number of clients by 34% and number of visits by 32%).
Croxford et al (2021)
- One in five people who inject drugs reported difficulties in accessing HIV and hepatitis testing, and one in four reported difficulties in accessing equipment for safer injecting.
- Number of people aged 15 to 64 using opiates or crack per 1,000 population
- Number of alcohol dependent adults per 1,000 population
- Proportion of people referred for drug treatment waiting more than 3 weeks
- Proportion of people referred for alcohol treatment waiting more than 3 weeks
- Admissions due to alcohol for all ages per 100,000 population
- Admission episodes for mental and behavioural disorders due to use of alcohol per 100,000 population
- Successful completion of drug treatment - opiate users
- Successful completion of drug treatment - non-opiate users
- Successful completion of alcohol treatment
- Depression prevalence (18+)
- Index of Multiple Deprivation - proportion of Lower Super Output Areas (LSOAs) in the most deprived 10% nationally
- Severe Mental Illness (SMI) prevalence
- Total CCG spend on mental health (all ages) per 100,000 registered population (£)
- CCG spend on mental health (all ages) as a percentage of CCG base allocations
All data from NHS Benchmarking Network projects is subject to change dependent upon permissions being receiving from provider organisations to have their data included in the map. The information reported reflects the data available as at 26/03/2021.
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Content reviewed and updated 05/09/22
Case study examples of best and innovative practice
Sandwell and West Birmingham Hospital - alcohol care team
The Sandwell and West Birmingham Trust alcohol care team was introduced as part of their care pathway to support admissions to emergency departments and provide guidance for symptom-triggered withdrawal in patients.
National Institute of Mental Health - scale-up hubs
The National Institute of Mental Health (NIMH) developed a network of global research Hubs called ‘NIMH Scale-Up Hubs” to increase the reach, accessibility, quality, costs and effectiveness of mental health services.