Guidance

Substance misuse: providing remote and in-person interventions

Updated 25 October 2023

Applies to England

Introduction

The increase of remote interventions in the pandemic

Alcohol and drug treatment services were subject to restrictions and limitations early in the 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.

Research commissioned by the National Institute of Health Research on remote models of service delivery by drug and alcohol services in Leeds during the COVID-19 pandemic found that some of the changes to practice helped with service user satisfaction. This may have improved some people’s engagement with treatment.

Remote options may also be useful for initial contacts with some groups who would not otherwise come to a substance misuse service, including people who only need lower-level interventions (like brief interventions, webchat and online advice). However, deaths in treatment data suggests that it’s likely that treatment became less safe or effective for many dependent people in structured treatment. And this may be the case even for service users who report only experiencing benefit from treatment. There are also considerations for domestic abuse and child and adult safeguarding that mean remote service delivery is not always appropriate.

Now the restrictions and limitations that made remote service delivery necessary no longer apply, it is important that services prioritise safety and safeguarding considerations whenever they have concerns about a person.

Where you have assessed remote components of treatment as appropriate and safe for a person, you must regularly reassess these for risks and benefits. And you must deliver interventions in line with clinical guidance. Remote service delivery should also never entirely replace in-person contact for anyone  in structured treatment.

Deaths of people in treatment

Substance misuse treatment for adults: statistics 2021 to 2022 shows that 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 stresses related to restrictions on people’s freedoms and to changes in healthcare practice made necessary by the pandemic. These include changes to drug and alcohol treatment provision, such as reduced availability of in-person appointments and interventions that require in-person contact, like inpatient detox.

For people in opioid substitution treatment (OST), increased deaths may be linked to reduced supervised consumption or daily dispensing of OST medications (mainly methadone). Methadone deaths among people who are not in treatment have also increased, possibly as a result of more methadone being diverted from treatment.

Purpose of this guidance

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.

Assessment

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 important addiction indicators, as well as signs of mental and physical health or social problems. Addiction indicators include:

• yawning
• coughing
• sneezing
• raised blood pressure
• dilated pupils
• cool, clammy skin
• diarrhoea
• nausea
• fine muscle tremor

An initial in-person meeting also provides an opportunity to develop rapport, which may be less effective if done remotely.

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 with an online form or phone call and then meeting in-person to assess the person and start to build a relationship.

Keyworking

For some people already in treatment, having some remote keyworking sessions can be beneficial. Keyworkers must ensure the service user has an adequate internet connection and device, such as a smartphone or laptop with camera. They will also need a private space to enable good quality interactions and interventions.

How often you should hold regular keyworking sessions in-person or remotely will depend on individual need. For some service users, it might be suitable to use remote communication for most regular keyworking sessions. But you will also need to have some intermittent in-person contact to assess their mental and physical wellbeing and to maintain a relationship with them.

For vulnerable service users, including most opiate users, whose mental and physical health are at greater risk of deterioration, you need to have frequent in-person check-ins.

You should continuously monitor the appropriate balance of in-person and remote keyworking sessions, because a person’s situation can change throughout their treatment.

Reviews

You should always conduct care plan reviews and other major reviews in-person so you can carry out a comprehensive assessment of the service user’s current physical and mental health and social circumstances.

Drug misuse and dependence: UK guidelines on clinical management (the ‘orange book’) already makes it clear that where treatment includes OST:

… strategic reviews should be within three months of treatment entry (and no later than six months). They can then be repeated at six-monthly intervals, although this frequency may be increased or reduced based on individual need.

The guidance Treating drug dependence recovery with medication says that these strategic reviews will be:

… earlier and more frequently for patients who are early in their treatment, who are on treatments of short-term duration, whose condition is complex, comorbid or problematic, for whom treatment is not producing the expected benefits, and at times of personal transition or changes in setting and situation.

Strategic reviews need to be in-person. If a person cannot or will not attend the service, you should consider home visits or meeting off-site for the review. Other reviews (recovery and care plan reviews and ongoing clinical reviews between the patient and their keyworker) will likely be even more frequent. So, you should assess which of these reviews should be in-person to help you provide effective assessment and support.

It is good practice to have local standards that ensure the frequency of in-person reviews is matched to levels of risk.  

OST and supervised consumption

You will need to have in-person meetings before starting someone on OST and when significantly increasing their dose of medication.

 The General Medical Council guidance on remote consultations explains when it is safe to prescribe remotely and when it is not.

OST patients may be particularly vulnerable. It’s important that you have frequent in-person keyworking sessions to identify and respond to people’s physical and mental health issues. It will not usually be appropriate to rely mainly on remote contact for keyworking sessions with OST patients.

You should assess the need for supervised consumption of medication at the start of treatment and regularly after that through in-person appointments and drug testing. The orange book 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 their home environment is suitable for safe storage of medicines.

However, take-home medication regimens are not often appropriate for service users who continue to use illicit opioids or who use other substances at levels that compromise the effectiveness or safety of their treatment. Also, the potential for diverting OST medications poses additional danger to other people who are at risk of opioid overdose.

OST prescribers have a responsibility to remain reasonably assured that service users are sticking to their treatment plan. This will usually be best accomplished through frequent in-person keyworking sessions, reviews and drug testing. You should reintroduce supervised consumption if it will help the person to stop taking other drugs.

Medically assisted withdrawal for alcohol

Community medically assisted withdrawal for alcohol dependence should be delivered through in-person meetings, in line with the National Institute for Health and Care Excellence (NICE) clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence.

Physical and mental health interventions

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 often 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 comes in for a more thorough check-up.

Needle and syringe services

During the pandemic, some drug services started online ordering and postal delivery of injecting (and other) equipment to people who inject drugs. 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 people will benefit from continuing this option.

However, postal NSP should not replace physical NSP entirely and you should encourage people to visit NSP in-person at least some of the time. In-person meeting with NSP staff has benefits for service users, including:

• identifying and treating injecting wounds or infections
• testing for blood-borne viruses (BBVs)
• providing hepatitis B vaccinations
• referring to treatment for hepatitis C or HIV
• providing guidance on safer injecting

Hepatitis C tests

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:

• engaging people who might benefit from signposting to drug treatment identifying and treating injecting wounds or infections
• testing for or vaccinating against other BBVs
• referring to treatment and providing peer or other support to attend appointments providing guidance on safer injecting and NSP

Young people in treatment

Like adult treatment, young people’s treatment practitioners replaced in-person meetings with regular online contact for many service users during the pandemic.

Research by the Early Intervention Foundation on COVID-19 and early intervention found that many young people said they were not able to freely discuss issues on the phone with workers while they were in their family home.

Like adults in treatment, remote contact time can be beneficial for some young people, but it should not entirely replace in-person meetings. You should consider offering 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.

Families and child safeguarding

Many children and young people, parents and carers who engage with treatment and social care have responded well to remote service provision. However, to provide effective support to families and children, most cases need to have at least some in-person appointments.

This was demonstrated by research by the Children of Alcohol Dependent Parents (CADeP) programme. The Tavistock Institute, which evaluated the CADeP programme, reported in their Life during COVID times post that there were challenges to offering only remote support during the pandemic, which included:   

• younger children not having unsupervised internet access or a smartphone
• children and parents not having a safe space in the home where they could talk openly or engage fully in therapeutic activity
• young people finding it difficult to explore thoughts and feelings about their parent or carer’s drinking or drug use within hearing distance of them
• some parents and children hiding problems that were not revealed until they reached crisis point

You should carry out regular in-person reviews of child living arrangements with adult and young people’s service users, at least at each treatment review. You should also recognise that family situations can change. Treatment reviews should include at least some in-person visits to the home. If you feel that a service user is using remote treatment appointments to prevent you from assessing their parenting capacity or their child’s wellbeing, you should immediately refer to children’s social care services and make a home visit if possible.

Pregnant and postnatal women are particularly vulnerable, so you should offer them in-person appointments or home visits instead of remote sessions.

Domestic abuse

Alcohol and drug service staff should understand the statutory definition of domestic abuse and related guidance, set out in Domestic Abuse Bill 2020: factsheets. You should consider what that means for the service users you see in-person and remotely.

Services should follow the NICE public health guideline Domestic violence and abuse: multi-agency working and routinely enquire about domestic abuse. However, you should be aware of coercive control and should be trained to avoid talking about domestic abuse in telephone and video appointments, where a perpetrator might be listening and where a victim may be unable to discuss any issues honestly.

Injecting equipment and medicines 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 person, 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.

Under-reporting of domestic abuse is common, and services need to ensure that remote working does not prevent someone from disclosing domestic abuse. For example, you will need to share information on domestic abuse support that was previously displayed in treatment services (like posters, leaflets and business cards) safely and sensitively to all service users receiving remote support. You should also consider how you can offer the victim an opportunity to be away from the perpetrator. For example, requirements to attend in-person reviews can be a good opportunity to speak to the victim in private.

Group meetings and mutual aid

During the pandemic, mutual aid services (like Alcoholics Anonymous, Narcotics Anonymous and SMART Recovery) and peer-led lived experience recovery organisations (LEROs) made huge efforts to continue supporting members, by replacing in-person meetings with online and telephone appointments.

Most mutual aid services have returned to having mainly in-person meetings, but there is more use of online-only or hybrid meetings than before the pandemic. 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 offering remote meetings need to consider new ways of reaching out to newcomers and supporting them. For example, you can use social media to inform members about how to connect to virtual meetings, and put 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.