Opioid substitution

treatment (OST) service

self-assessment tool for
community drug services

Local authority area

Lead contact name

Email

Telephone/mobile
number

Role and
employing
organisation

Date of completion
Contents
Click to view:

Introduction
Background
Overview

S1. OST specific issues

OST specific issues

S2. Broader generic issues

Broader issues

Good practice
OST good practice pointers
Broader issues good practice pointers

Guidance
OST guidance
Broader issues guidance
Background

The OST service self-assessment tool for community services has been developed as part
of Public Health England's (PHE) OST good practice programme. It is designed to support
drug treatment providers and commissioners to provide the best possible treatment for and
with your OST service users in line with this clinical guidance.

The Drug misuse and dependence: UK guidelines on clinical management (also known as the ‘orange
developed as part
signed to support
treatment for and

t (also known as the ‘orange book’) outlines national guidance on best practice in drug treatment including OST.
Overview
About this tool
This self-assessment tool will help drug and alcohol treatment and recovery commissioners
service providers assess whether they are doing all they can to deliver OST in line with bes
practice.

Who should complete the tool?

A service manager or team leader (working with service commissioner w
useful or subject to capacity).

Who else should be involved in completing the tool?

There is no need to involve anyone else in the self-assessment audit but
might be helpful to discuss with other colleagues. This might include non-clinical colleagues
partner organisations, individually or in multi-disciplinary team (MDT) meetings. You can als
ask an external peer reviewer, for example, a drug and alcohol treatment and recovery
commissioner or service manager, to give you feedback on your draft. It may also be
appropriate to use feedback from service users about their experience of accessing and
receiving OST.

How long should completing the tool take?

This self-assessment focused on OST should take a service manager or
team leader around one day to complete.

How do I use this tool?

The tool is designed to be used on a computer screen, rather than printed off and filled in
manually. It is a quality improvement tool based around a simple questionnaire.

There are 2 sections for you to complete S1: OST specific issues and S2: Broader gener
issues. Each section has questions about a particular area of practice. When answering ea
question, consider whether or not you can demonstrate this practice in your organisation.

The first section is focused on OST specific areas of practice and the second section looks
broader generic areas of practice which are not specific to OST but could still have an impa
on OST outcomes.

To complete your OST service self-assessment, you need to:

1. Answer each question in S1 and S2 based on whether your service can demonstra
each area of practice. Using the dropdown menu, you can choose to answer 'yes', 'no' or
'partially'. Answer the questions honestly based on your knowledge of the service and evide
that you can provide to support your answer.

2. Make a note of examples you would use to evidence your answer. You can do this in
‘Evidence’ column.

3. Identify what actions to be taken to improve your OST service delivery. The good
practice tabs can be used to help identify appropriate actions. You can do this in the ‘Action
column. Pay particular attention to areas where your service does not have strong evidence
good practice to identify where there are gaps in current practice. What could you develop
further?

4. Ask an external peer reviewer to give feedback on the strength of your evidence and
plans for improvement. This is optional. An external peer reviewer with the relevant speciali
knowledge could be a drug and alcohol treatment and recovery commissioner or service
manager from another area. They can suggest other possible sources of evidence and mak
suggestions for appropriate actions to improve delivery in the ‘Peer review comments’ colum

The tool includes links to supporting resources including:

good practice pointers and examples of evidence to demonstrate good practice in that are
recovery commissioners and
iver OST in line with best

service commissioner where

lf-assessment audit but it

e non-clinical colleagues and
T) meetings. You can also
tment and recovery
aft. It may also be
nce of accessing and

ke a service manager or

printed off and filled in

uestionnaire.

and S2: Broader generic

tice. When answering each
e in your organisation.

he second section looks at

could still have an impact

service can demonstrate

e to answer 'yes', 'no' or
of the service and evidence

nswer. You can do this in the

ce delivery. The good

can do this in the ‘Actions’
not have strong evidence of
What could you develop

th of your evidence and your

with the relevant specialist
mmissioner or service
ces of evidence and make
review comments’ column.

good practice in that area

 OST specific issues
Good practice

Guidance
Key area Question Answer Evidence Action needed Peer review comments

1 Treatment system Are people who are accessing opioid drug treatment
information given information and advice about the following
treatment options: harm reduction, maintenance,
detoxification and abstinence?

2 Assessment and desired Are suitably comprehensive assessments carried

outcomes out?

3 Treatment and recovery care Are treatment and recovery care plans with agreed
planning and reviewing objectives drawn up, based on individual needs and
strengths?

Are review periods set out clearly in treatment and

recovery care plan?

Are regular OST medication (specific) reviews with

the prescriber held with service users?

4 Working with a Is there a regular multidisciplinary team meeting

multidisciplinary team accessible to all clinical staff, where case-specific
OST treatment options can be discussed, and which
includes a prescriber who can adjust prescriptions?

5 Competent staff Are staff suitably qualified, experienced and

confident to deliver high quality OST?

Have all staff delivering OST completed the Best

practice in Optimising Opioid Substitution Treatment
(BOOST) e-learning programme?

6 Staffing capacity Is the workforce capacity adequate in terms of

number to deliver a high quality OST service?

7 Choice of OST medications Does the system offer a range of OST medications,
adapted for changing needs, including for people
who do not benefit from OST medication initially
prescribed and may benefit from switching?

8 Optimal dose range Are doses of OST medication adjusted by the

prescriber according to optimal dose guidance, in
collaboration with the service user and drug
treatment and recovery worker?

9 Induction and monitoring Are OST prescribing induction procedures clear for
staff and service users?

10 Drug testing and illicit opioid Are local protocols in place that clearly
use on top communicate to staff and service users the role of
drug testing during OST?

Are treatment options adapted appropriately where

continued illicit opioid use occurs?

11 Detoxification support: Are a range of detoxification options available to

before, during and after service users as and when they are required?
detoxification

12 Injectables (where provided) In services where targeted injectable opioid

treatment (IOT) is available, are appropriately skilled
staff available in suitable settings?

13 Primary care prescribing and Are non-specialist prescribers (GPs, nurses or other
support to non-specialist non-medical prescribers) supported adequately?
prescribers

14 Supervised consumption Is supervised consumption used appropriately?

Are pharmacies providing a safe and confidential

setting for service users receiving supervised
consumption?

15 Providing treatment and
harm reduction information
and resources to service
users and families, friends
and carers
16 Keywork
Are all service users and their families, friends and
carers provided with appropriate information about
OST and harm reduction?
Do all OST service users have a named keyworker
and receive regular high quality keywork input?

17 Psychosocial Interventions Is there a 'toolbox' of high quality psychosocial

approaches to support OST?

18 Continuity of care - prison Are procedures in place that ensure swift access to
release seamless support and continuation of treatment
upon release from prison?

19 Ageing cohort and those on Are treatment services aware of the specific issues
OST longer term that can affect older OST service users and how to
identify and respond effectively to these?

20 Use of non-opioid illicit
drugs, medication not as
prescribed and alcohol
Are interventions available that address other illicit
drug use (including benzodiazepines, cocaine and
crack, gabapentinoids, medicines used not as
prescribed, and z-drugs) and alcohol use on top of
OST?
21 Providing OST in hospitals If opioid-dependent patients are admitted to
hospital, are they assessed, provided with effective
treatment that maintains continuity with OST in the
community, and supported (back) into treatment
before discharge?
Broader Generic Issues

Broader issues
Good practice

Guidance
Key area Question Answer Evidence

1 Partnership stakeholder Is the provision of high quality OST supported

support for OST as part of locally by appropriate strategic leaders?
evidence-based drug
treatment system
2 Access Are referral pathways into drug and alcohol
treatment and recovery services clear and working?

3 Clinical governance Are clinical governance arrangements robust?

arrangements

4 Safeguarding Are safeguarding policies up-to-date, implemented

and monitored?

Are all staff trained around safeguarding adults and

children?

5 Record keeping Are record keeping policies adequate and

monitored?

6 Co-occurring mental health Do service users with a co-occurring mental health

conditions conditions receive adequate support for both drug
and mental health issues?

7 Service-user, families, Are service users and their families, friends and
friends and carers carers (where appropriate and with consent)
involvement involved in treatment and recovery care planning?

Are service users, families, friends and carers

involved in developing, reviewing and improving
service delivery?

8 Drug-related deaths Are local drug-related death reviews carried out to

identify any learning or changes required?

9 Non-fatal overdoses Is there an adequate response in place to review

and respond to non-fatal overdoses?

10 Women including pregnancy Are the needs of women including pregnant women
adequately assessed and responded to?

11 Environment and Is the service safe, attractive and accessible?

accessibility

< RETURN TO CONTENTS

< PREVIOUS PAGE NEXT PAGE >

Broader Generic Issues

Action needed Peer review comments

NEXT PAGE >

< PREVIOUS PAGE NEXT PAGE >

 OST good practice
Go back to S1
Guidance
Key area
1 Treatment system
information
2 Assessment and desired
outcomes
3 Treatment and recovery care Are treatment and recovery care plans Treatment goals such as reducing or stopping OST, and detoxification are identified in treatment and
planning and reviewing
4 Working with a
multidisciplinary team
5 Competent staff
6 Staffing capacity
Question
Are people who are accessing opioid Printed materials and discussions with drug treatment and recovery workers are provided about:
drug treatment given information and
advice about the following treatment • harm reduction – needle and syringe programmes (NSP) and blood-borne viruses (BBV) service
options: harm reduction, maintenance,
detoxification and abstinence?
Are suitably comprehensive
assessments carried out?
with agreed objectives drawn up, recovery care plans. These plans include timescales for review.
based on individual needs and
strengths? Treatment and recovery care plans for people completing inpatient detoxification or residential
rehabilitation incorporate transfer of care back to community services for continued structured treatment
or for aftercare.
Are review periods set out clearly in
treatment and recovery care plan?
Are regular OST medication (specific) Medication reviews include dosing, type and suitability of medication and assesses whether progress
reviews with the prescriber held with reflects reduction, cessation or detox goals.
service users?
Is there a regular multidisciplinary
team meeting accessible to all clinical
staff, where case-specific OST
treatment options can be discussed,
and which includes a prescriber who
can adjust prescriptions?
Are staff suitably qualified,
experienced and confident to deliver
high quality OST?
Have all staff delivering OST
completed the Best practice in
Optimising Opioid Substitution
Treatment (BOOST) e-learning
programme?
Is the workforce capacity adequate in
terms of number to deliver a high
quality OST service?
Good practice pointers
• prescribing for maintenance and detoxification
• drug-free psychosocial and rehabilitation support availability
Assessment should be carried out according to the detailed guidance in the national clinical guidelines.
Service has a clear assessment tool that ensures relevant issues are addressed.
In brief, assessments include: a risk assessment, service user's current presentation and history in terms
of health (including BBVs); mental health; drug history; treatment history; overdose history; drug screen;
domestic abuse (DA); family responsibilities; employment; involvement in criminal justice system;
housing; strengths and 'recovery capital'.
Opioid dependence is confirmed using urine tests.
Reasons for seeking treatment are addressed and desired outcomes (abstinence, stabilisation, harm
reduction) discussed.
Trauma-informed processes ensure service users do not have to repeat trauma by repeated
assessments.
Assessments include women’s views around family planning, support suitable contraception, incorporate
the needs of unborn children and treatment options are discussed.
GP registration should be facilitated where required for all service users.
Plans target issues and build on strengths highlighted in the assessment. They include OST alongside
psychosocial interventions (PSI) and recovery support.
Segmentation of service user group and relevant interventions and pathways, which are phased and
layered, exist for each group
Regular reviews should be planned and undertaken including:
• ongoing review: part of every 1:1, structured appointment between the service user and their
keyworker
• specific review: planned reviews of particular actions and goals
• strategic review: comprehensive reviews of progress, within three months (and no later than six
months) of treatment entry for someone on OST, usually repeated at six-monthly intervals (but could be
more or less depending on progress/circumstances)
• multidisciplinary reviews including prescribers, GP or non-medical prescribers views
• Medication reviews include dosing, type and suitability of medication and assesses whether progress
reflects reduction, cessation or detox goals
Reviews make use of TOP tracker or other outcome tool to show progress.
Local case management systems are used to identify and prompt reviews that are pending or overdue
based on National Drug Treatment Monitoring System (NDTMS) data.
Staff have skills and confidence to have challenging discussions with service users about the goals of
treatment.
Review considers compliance with and need for supervised consumption, engagement with PSI and
health/social situation
Treatment and recovery care plan is adjusted as relevant based on the review.
Review considers compliance with and need for supervised consumption, engagement with PSI and
health and social situation.
Treatment and recovery care plan is adjusted as relevant based on the review
Multidisciplinary team (MDT) meetings review priority cases proposed by keyworkers, prioritising those
who have difficulties, complex health or social issues or are not benefitting from treatment.
Agendas make time for discussion of positive outcomes.
Keyworkers can access clinical support particularly prescribing expertise.
Relevant disciplines attend including a prescriber who can adjust prescriptions.
Meetings ensure psychosocial support and progress (including positive outcomes) are discussed,
alongside prescribing issues.
Case records are shared and discussed in meetings; there are clear decision-making processes and
records kept of decisions; and support is provided outside of the meeting from specialists who attend
such as prescribers, psychologists and nursing staff
Services allow time for this meeting to happen regularly.
Specialist prescribers with qualifications are available in service (acting as clinical lead - and have
availability to advise other prescribers).
Staff delivering OST have completed the Best practice in Optimising Opioid Substitution Treatment
(BOOST) e-learning programme.
PSI training is available for keyworkers.
Staff are competent in assessment, treatment and recovery care planning and reviews, familiar with
updates and clinical guidelines.
Training includes observed practice and reflective practice sessions.
Staff are knowledgeable about providing injecting equipment, basic wound care and bacterial infection,
and training is available.
Keyworkers have adequate skills and confidence to have optimisation conversations with service users.
Staff are trained and able to deliver advice on reducing overdose risk.
Staff are trained to deliver or refer for: hepatitis B vaccinations; hepatitis C testing and treatment; HIV
testing and treatment; injecting site health checks; safer injecting advice; tuberculosis (TB) testing and
treatment; stop smoking support; NSP; sexual health services; mental health support; GP registration;
liver disease treatment; and specialist midwifery support.
There is an appropriate mix of skills, experience and professional roles in the service to meet the needs
of service users.
Staff have manageable caseloads which allow them to focus on the needs of individual service users on
their caseload. This involves:
• segmenting the treatment population according to where clients are in their treatment journeys and
how much involvement they need
• determining caseloads according to service factors like staff mix, travel time, the nature of
interventions provided
• allocating cases to ensure that all staff have a mix of high and low complexity and need for
involvement, according to their competence and capacity
There is a service training plan in place to address gaps in the skills of the workforce.
Staff competence and development is addressed in appraisals and individual staff training and
development plans.
 7 Choice of OST medications
8 Optimal dose range
9 Induction and monitoring
10 Drug testing and illicit opioid Are local protocols in place that clearly • Protocols on testing and use on top are used, reviewed and updated. Protocol training for staff is in
use on top
11 Detoxification support:
before, during and after
detoxification
12 Injectables (where provided) In services where targeted injectable Staff are competent (and licensed, supervised and supported to prescribe) and specific training is
opioid treatment (IOT) is available, are available.
appropriately skilled staff available in
suitable settings?
13 Primary care prescribing and Are non-specialist prescribers (GPs,
support to non-specialist nurses or other non-medical
prescribers prescribers) supported adequately?
14 Supervised consumption
15 Providing treatment and
harm reduction information
and resources to service
users and families, friends
and carers
Does the system offer a range of OST Availability of:
medications, adapted for changing
needs, including for people who do not • methadone solution (and tablets for special circumstances)
benefit from OST medication initially
prescribed and may benefit from
switching?
Are doses of OST medication adjusted Service-wide audit triggers individual service user review where low or high doses are flagged.
by the prescriber according to optimal
dose guidance, in collaboration with
the service user and drug treatment
and recovery worker?
Are OST prescribing induction
procedures clear for staff and service
users?
communicate to staff and service
users the role of drug testing during
OST?
Are treatment options adapted
appropriately where continued illicit
opioid use occurs?
Are a range of detoxification options Prescribers are operating as per the scope of their role, qualification and training.
available to service users as and when
they are required?
Service users are closely monitored and reviewed, and provided with clinical support.
Is supervised consumption used
appropriately?
Are pharmacies providing a safe and
confidential setting for service users
receiving supervised consumption?
Are all service users and their families, Information is provided for families, friends and carers so they can support service users (where
friends and carers provided with
appropriate information about OST
and harm reduction?
• buprenorphine tablets or wafers (and depot injections if supported by local policy and practice)
• injectable and other opioids (if supported by local policy and practice)
Audit data is compared against optimal dose suggested by the British National Formulary (BNF) and
National Institute of Health and Clinical Excellence (NICE).
Regular review of NDTMS (or local) data on dose using local case management systems provides
service-wide picture of how doses compare to optimum as per guidance.
Systemic causes for non-optimum doses are investigated and action plans put in place where
appropriate.
Progress of individual service users is monitored, and dose is adjusted when required.
Service users are active partners in individual prescribing decisions.
If service user reports experiencing withdrawal symptoms later in the day, assess whether service user
is a 'fast metaboliser'. If so, consider optimising the dose, splitting the dose or both.
'Tell the story' using qualitative feedback (including individual recovery stories) to share good practice
across the workforce and inspire other service users to consider the benefits of optimisation.
Titration procedures and protocols are in use.
Regular monitoring happens, clarity about decision-making (adjusting dose) demonstrated in file records.
Information is available for service users on what to expect and how titration works.
Goals of OST for individuals, in terms of reducing or stopping use, are discussed with service user and
recorded on file.
place. Protocols have clarity about the role of testing in cases where criminal justice system or
safeguarding plans require it
• TOP is used to demonstrate use on top and track progress over time
• Testing is available and incorporated within treatment plans and reviews. Testing is linked to
incentives (contingency management (CM)) where a formal CM programme is in place
• Service-wide systems are in place to identify service users who use on top, and offer them individual
medication reviews
• Service users are provided with clear information on the role and frequency of testing. Safety
considerations are explained and links to supervised consumption arrangements and treatment decision-
making are made clear.
For service users who continue to use heroin on top:
• Review dose against optimal range: would the service user benefit from a higher dose?
• Provide encouragement to engage with PSI
• Assess whether service user is a 'fast metaboliser'. If so, consider increasing dose and/or splitting
dose
• Consider social situation and other drug/alcohol use: is this affecting the service user's ability to resist
use on top?
• Ensure low threshold prescribing is available (without the expectation that individuals are abstinent),
and other barriers to service access are reduced as far as possible.
Regular training and support for prescribers is available.
Updates and local protocols based on clinical guidelines (‘orange book’ and NICE) are provided.
Regular professional supervision and appraisal are undertaken.
Monitoring arrangements and communications between primary care and the specialist service are clear
and supported by a communications protocol.
Observation of injecting is standard and harm reduction advice is offered.
Settings are licensed and safe/suitable for daily and more frequent injecting.
Pathways into and out of treatment options are clear and work well.
Take-home doses are only of oral medications.
Prescribers are operating as per their scope of their role, qualification and training.
Regular training and support for prescribers is available.
Updates and local protocols based on clinical guidelines (Orange book and NICE) are provided.
Regular professional supervision and appraisal is undertaken.
Monitoring arrangements and communications between primary care and the specialist service are
clear, and a communications protocol is used between specialist and primary care services.
Supervision is required initially for a period of time to allow monitoring including ongoing risk
assessment, then reviewed regularly by the prescriber. Supervision should not be used as a sanction.
Duration of supervision depends on assessed clinical need and not applied in an arbitrary way.
Take-home medicine is provided when compliance is assured in consultation with the multidisciplinary
team, pharmacist, and the service user.
Clear communication lines exist between pharmacy, prescriber and keyworker.
Monitoring is ongoing.
Peer-led surveys of supervised consumption experience are carried out and service-users are aware of
their right to request a review.
Pharmacy premises provide a level of confidentiality and privacy that is acceptable to service users.
Minimum standards are applied in pharmacy contracts.
appropriate and with consent).
Information covers the rationale and benefits of treatment, expectations of service users, what they can
expect, risks during induction, support available, risks associated with using central nervous system
(CNS) depressants, explanation of titration and effects of adjusting dosage.
Safeguarding information is provided in relation to children and safe storage. Supervised consumption
expectations.
Overdose awareness and prevention, wound awareness and naloxone training is offered to service
users.
Supply of take home naloxone and training for carers and service users.
Service user education is provided about medicines and interactions.
16 Keywork
17 Psychosocial Interventions
18 Continuity of care - prison
release
19 Ageing cohort and those on Are treatment services aware of the
OST longer term specific issues that can affect older support these needs
OST service users and how to identify
and respond effectively to these?
20 Use of non-opioid illicit
drugs, medication not as
prescribed and alcohol
21 Providing OST in hospitals
Do all OST service users have a named Information is provided for families, friends and carers so they can support service users (where
keyworker and receive regular high
quality keywork input?
Is there a 'toolbox' of high quality
psychosocial approaches to support
OST?
Are procedures in place that ensure
swift access to seamless support and recovery and community drug treatment services.
continuation of treatment upon release
from prison?
• Staff are trained to identify health issues and respond. Health and social care pathways are in place to
• Clear pathways exist for specialist help for: liver disease, respiratory disease, mental health including
dementia, menopause and chronic pain
Are interventions available that
address other illicit drug use
(including benzodiazepines, cocaine
and crack, gabapentinoids, medicines
used not as prescribed, and z-drugs)
and alcohol use on top of OST?
If opioid-dependent patients are
admitted to hospital, are they
assessed, provided with effective
treatment that maintains continuity
with OST in the community, and
supported (back) into treatment before
discharge?
< RETURN TO CONTENTS
appropriate and with consent).
Information covers the rationale and benefits of treatment, expectations of service users, what they can
expect, risks during induction, support available, risks associated with using central nervous system
(CNS) depressants, explanation of titration and effects of adjusting dosage.
Safeguarding information is provided in relation to children and safe storage. Supervised consumption
expectations.
Overdose awareness and prevention, wound awareness and naloxone training is offered to service
users.
Supply of take home naloxone and training for carers and service users.
Service user education is provided about medicines and interactions.
Staff and service users are aware that OST outcomes benefit from evidence-based psychosocial
interventions (PSI): motivational interviewing, contingency management, behavioural couples therapy,
cognitive behavioural therapy (CBT), behavioural activation, CBT for depression, and anxiety-based
guided self-help interventions.
Groups, individual counselling or both are available where progress is monitored and when needs
change, interventions can change.
PSIs are manualised, or delivered by workers with sufficient skills and training.
Observed practice is used as part of monitoring and skill development.
Psychological expertise, such as clinical psychologists, exist within the workforce to oversee governance
of PSIs.
Seamless and swift initiation or continuation of OST is available, along with effective referral to aftercare,
Clear protocols are in place for continuation of OST following release from prison including for Friday
releases.
Prison-based services should provide pre-release education on overdose risks and prevention and
community services check understanding, reinforce message and offer refresher.
Providers in prisons inform the community drug service of planned release dates for all leavers with an
ongoing treatment need particularly high risk individuals and those released at short notice (for example,
from court)
Prisoners on OST are trained to administer take home naloxone prior to release and are provided with
naloxone as they leave custody. Community treatment providers check that prison leavers have received
a kit and provide one if not.
The community treatment offer meets the needs of prison leavers (including swift provision of OST) and
healthcare providers in the main feeder prisons are aware of this. Prison-based providers have the
information they need to describe to service users the treatment and recovery services available to them
after release.
• There is integrated working between prison and community treatment providers to improve
engagement in treatment via in-reach provision and/or drawing on mutual aid, peer and family support
networks to support release plans
• Staff and service users are aware of issues related to polypharmacy and the potential need for
reduced dose OST, prescribed medicines dependence, drug interactions and increased risk of falls, and
are able to address these
• Reduced accessibility due to age-related disability is addressed, and support such as bereavement
support is provided
• There is an integrated model of delivery with other health/social care services
Advice and information is available on all drug group interactions including the risks associated with
poly-drug use including benzodiazepines, cocaine and crack, gabapentinoids, medicines used not as
prescribed, z-drugs and alcohol; how to reduce these risks and the potential effects on OST treatment
outcomes
PSI is available to address poly-drug use.
Alcohol screening and brief advice is routinely provided and treatment is offered for alcohol dependence.
Comprehensive assessment includes prescribed medicines.
Keyworkers are trained and confident in addressing prescribed or poly-drug use.
Drug service and hospital staff hold regular liaison meetings.
Drug service staff provide in-reach to local hospitals.
Drug services train hospital staff in the needs and treatment of people who use drugs.
Keyworkers or prescribers and hospital staff liaise over individual patient admissions.
Hospital staff understand and follow best practice in this area, described in section 7.5 of the national
clinical guidelines.
Pathways into drug treatment are in place.
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Evidence that might demonstrate good practice

Evidence of discussions about local arrangements for provision of all treatment options by local services
(case notes about discussion)

Examples of printed or other information given to service users about the treatment options available

File audit of assessments and assessment processes in services undertaken

Action plans based on audit findings

Evidence of specific equality issues being addressed in assessments, treatment and recovery care
plans, and service model

Evidence of trauma-informed care processes

Keyworkers use the Treatment Outcomes Profile (TOP) as a clinical tool to support the treatment and
recovery care planning process. It can help to structure conversations with service users and set
treatment and recovery goals.

Pharmacy supervised consumption records and urine drug samples are used to prompt discussions with
the service user.

A review reminder system is in place.

Staff training and support is in place, specifically focusing on reviews and difficult discussions.

Observation is used as supervision tool and ensures appropriate level of service user involvement in
reviews.

Service user forum or surveys to enable service user experience of review to inform practice.

Terms of reference for meetings.

Minutes and agendas showing attendance, structure, and evidence-based decision-making around
prescribing and treatment and recovery care plans.

Independent observation of MDT and feedback.

Training needs analysis undertaken and training plan developed. Training needs analysis includes
health assessment, interventions and referrals and harm reduction skills for all staff.

Training records.

Audit of supervision records with a specific focus on OST optimisation of caseload.

Audit of continuing professional development (CPD).

Audit of case notes.

Observed practice.

Review carried out of caseload numbers and complexity.

Review carried out of skills of workforce and training and recruitment plans address identified gaps.

Action taken to address staff vacancies.

Ongoing review of caseload management system (weighting) and staff capacity.

Audit of medicines available for OST, and records of uptake of each.

Service user surveys cover prescribing issues.

Prescribing audit.

Up-to-date protocol and procedures form part of relevant staff training.

Service user surveys and feedback from forums cover prescribing issues. Where possible, surveys
should be service user led.

Case file audits.

Printed information on induction and titration for service users is available in an accessible format.

Up-to-date, comprehensive, drug testing protocols exist.

Training in place for staff.

Case file audits consider testing.

Detox protocols exist and are up-to-date.

Training for staff.

Regular audit of practice including case files.

Monitoring data shows waiting times for detox.

Records show PSI and recovery support are provided post detoxification.

Service user feedback or survey covers detox experience.

Naltrexone policy exists and is up-to-date.

Where IOT is provided there are:

• records of staff qualifications and training

• audits of case files for monitoring treatment, reviews and ensuring PSI support is provided

• protocols and minimum standards for injecting settings are in place and up-to-date

Review of initial training, updates and support provided to practitioners.

Non-medical prescribers (NMP) access support from the National Substance Misuse Non-Medical
Prescribing Forum (NSMNMPF).

Feedback from non-medicalor non-specialist staff invited and acted on.

Protocols are in place and working.

Initial and refresher training are provided for pharmacists.

File records of communications with pharmacies show adequate liaison.

Records of service user requests for review and experience of supervised consumption.

Copies of information provided to service users and their families, friends and carers.

File audits including review of safeguarding and safe storage discussions.

Service user, families, friends and carers feedback and surveys.

Naloxone kits distributed to in and out of treatment populations.

Training and supervision for keyworkers.

Skills and training needs analysis covers keywork skills.

Audit of case files for keywork input including frequency and content.

Observation of treatment as a form of supervision and audit

Commissioners ensure an appropriate range of PSI in service specification and monitor their provision
through performance reporting data.

Service review includes:

• skills audit and training analysis and plan
• observation and feedback records
• file audit

Service user feedback and surveys.

Meeting records between agencies.

Protocols and referral pathways are reviewed and updated.

Audit of prison referrals and engagement in treatment rates.

Use of NDTMS (and local data) to identify evidence of engagement.

Protocol in place and up-to-date.

Records of medicines review and options for older and longer term service users.

Records of referral for health and social care issues.

Joint working protocols with adult social services including disabilities, mental health and older people’s
teams.

Records of training on age-related issues.

Case file audit.

Printed information for service users.

Staff training records.

Notes of liaison meetings.

Patient notes include a record of individual liaison.

Patients report good treatment in hospital (few complaints).

Go back to S1
OST guidance
Key area
1 Treatment system
information
2 Assessment and desired
outcomes
3 Treatment and recovery care Are treatment and recovery care plans
planning and reviewing with agreed objectives drawn up,
based on individual needs and
strengths?
4 Working with a
multidisciplinary team
5 Competent staff
6 Staffing capacity
7 Choice of OST medications
8 Optimal dose range
9 Induction and monitoring
10 Drug testing and illicit opioid Are local protocols in place that clearly
use on top
11 Detoxification support:
before, during and after
detoxification
12 Injectables (where provided) In services where targeted injectable
13 Primary care prescribing and Are non-specialist prescribers (GPs,
support to non-specialist
prescribers
14 Supervised consumption
15 Providing treatment and
harm reduction information
and resources to service
users and families, friends
and carers
Question
Are people who are accessing opioid
drug treatment given information and
advice about the following treatment
options: harm reduction, maintenance,
detoxification and abstinence?
Are suitably comprehensive
assessments carried out?
Are review periods set out clearly in
treatment and recovery care plan?
Are regular OST medication (specific)
reviews with the prescriber held with
service users?
Is there a regular multidisciplinary
team meeting accessible to all clinical
staff, where case-specific OST
treatment
Are optionsqualified,
staff suitably can be discussed,
and which includes
experienced a prescriber
and confident who
to deliver
can adjust
high qualityprescriptions?
OST?
Have all staff delivering OST
completed the Best practice in
Optimising Opioid Substitution
Treatment (BOOST) e-learning
programme?
Is the workforce capacity adequate in
terms of number to deliver a high
quality OST service?
Does the system offer a range of OST
medications, adapted for changing
needs, including for people who do not
benefit from OST medication initially
prescribed and may benefit from
switching?
Are doses of OST medication adjusted
by the prescriber according to optimal
dose guidance, in collaboration with
the service
Are user and drug
OST prescribing treatment
induction
procedures clear for staff and service
users?
communicate to staff and service
users the role of drug testing during
OST?
Are treatment options adapted
appropriately where continued illicit
opioid use occurs?
Are a range of detoxification options
available to service users as and when
they are required?
opioid treatment (IOT) is available, are
appropriately skilled staff available in
suitable settings?
nurses or other non-medical
prescribers) supported adequately?
Is supervised consumption used
appropriately?
Are pharmacies providing a safe and
confidential setting for service users
receiving supervised consumption?
Are all service users and their families,
friends and carers provided with
appropriate information about OST
and harm reduction?
16 Keywork Do all OST service users have a named
keyworker and receive regular high
quality keywork input?

17 Psychosocial Interventions Is there a 'toolbox' of high quality

psychosocial approaches to support
OST?

18 Continuity of care - prison Are procedures in place that ensure

release swift access to seamless support and
continuation of treatment upon release
from prison?

19 Ageing cohort and those on Are treatment services aware of the

OST longer term specific issues that can affect older
OST service users and how to identify
and respond effectively to these?

20 Use of non-opioid illicit Are interventions available that

drugs, medication not as
prescribed and alcohol
21 Providing OST in hospitals
address other illicit drug use
(including benzodiazepines, cocaine
and crack, gabapentinoids, medicines
used not as prescribed, and z-drugs)
and alcohol use on top of OST?
If opioid-dependent patients are
admitted to hospital, are they
assessed, provided with effective
treatment that maintains continuity
with OST in the community, and
supported (back) into treatment before
discharge?

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ce
Guidance, reports and resources

1. National Institute of Health and Care Excellence (NICE), Drug use disorders in adults, Quality standard statement QS23, 2012, statement 5.

2. NICE, Drug misuse in over 16s: psychosocial interventions, NICE clinical guideline CG51, 2007, section 1.1.1.1.

Clinical guidelines, sections: • 2.2 Assessment, planning care and treatment • 2.7.13 Provide trauma-informed care

PHE, Routes to recovery from substance addiction: mapping user manual, 2013, chapter 1.
1. PHE, Medications in recovery: best practice in reviewing treatment, 2013, chapters 1 and 2.

2. NTA, Medications in recovery: re-orientating drug dependence treatment, 2012, chapter 4 ‘The phasing and layering of treatment’.

3. PHE, Optimising opioid substitution treatment: turning evidence into practice, 2014.

4. Clinical guidelines, sections: • 2.2.4.2 Treatment planning • 3.3.3 Segmentation

Clinical guidelines, section 2.2.4.3 ‘Review of treatment and recovery care plans’.

Clinical guidelines, section A2.1.5 ‘ Staff competencies’.

Best practice in Optimising Opioid Substitution Treatment (BOOST) e-learning programme page

There is no current PHE guidance on caseloads. If you need help with this part of the assessment,
please contact your regional PHE team.

1. PHE, Optimising opioid substitution treatment: turning evidence into practice, 2014, chapter 5.

2. Clinical guidelines, section 4.3 ‘Choosing an appropriate opioid substitute’

1. British Medical Association and the Royal Pharmaceutical Society , British National Formulary (BNF)

2. Clinical guidelines, section 4.4 ‘Induction onto methadone and buprenorphine substitution treatment’.
1. Clinical guidelines, section 4.4 ‘Induction onto methadone and buprenorphine substitution treatment’.

2. NICE, Methadone and buprenorphine for the management of opioid dependence, NICE technology appraisal guidance TA114, 2007

1. Clinical guidelines, sections: • 2.4 Drug testing • 4.6 Assessing and responding to failure to benefit • Table 3: Responses to drug and alcohol misuse on top of an opioid prescription, page 109

2. PHE, Optimising opioid substitution treatment: turning evidence into practice, 2014, section 7 ‘Biological testing to monitor compliance and reinforce change’

1. NICE, Drug misuse: Opioid detoxification, 2007

2. Clinical guidelines, section 4.8 ‘Opioid detoxification’
3. NICE, Naltrexone for the management of opioid dependence, NICE technology appraisal guidance TA115, 2007
1. Clinical guidelines, section 4.7.5 ‘Injectable opioid treatments’
2. PHE, Injectable opioid treatment: commissioning and providing services, 2021
3. Regional Medicines Optimisation Committee (RMOC), RMOC Buprenorphine Long-acting Injection Guidance, 2021

1. Royal College of General Practitioners (RCGP), Drugs: Management of Drug Misuse (Level 1) e-learning

2. National Substance Misuse Non-Medical Prescribing Forum (NSMNMPF)

3. RCGP/RCPsych, Delivering quality care for drug and alcohol users: the roles and competencies of doctors. A guide for commissioners, providers and clinicians, 2012

4. PHE, Non-medical prescribing in the management of substance misuse, 2014

1. Clinical guidelines, section 4.5 ‘Supervised consumption’

2. PHE, Optimising opioid substitution treatment: turning evidence into practice, 2014, section 6 ‘Supervised consumption: monitoring safety and providing support’

1. PHE, Routes to recovery from substance addiction: mapping user manual, 2013, Chapter 4
2. Clinical guidelines, sections: • 2.7.12 Support and involve carers • 4.4.5.4 Provision of information

3. Harm Reduction Works website

4. PHE, Widening the availability of naloxone, 2015
5. Addiction Professionals Educational Resources, Naloxone saves lives e-learning
6. PHE, Wound aware: a resource for commissioners and providers of drug services, 2021
Clinical guidelines, sections: • 2.2.4 Treatment and recovery care planning and keyworking • 2.2.4.1 Content of keyworking

1. PHE, Routes to recovery from substance addiction: mapping user manual, 2013
2. NICE, Drug misuse in over 16s: psychosocial interventions, NICE clinical guideline CG51, 2007
3. Clinical guidelines, Chapter 3 ‘Psychosocial components of treatment’
1. Clinical guidelines, sections: • 5.3.5 Interfaces between treatment and the criminal justice system • 5.4.13 Continuity of treatment

2. PHE, Continuity of care for prisoners who need substance misuse treatment, 2018
1. Clinical guidelines, sections: • 7.11 Older people • 7.11.4 Older patients on long-term OST

2. Royal College of Psychiatrists, Our invisible addicts, 2nd edition, 2018

Clinical guidelines, section 6.5.3.1 'Heavy drinking on top of OST' (Table 3, page 109: Responses to
drug and alcohol misuse on top of an opioid prescription)

Clinical guidelines, section 7.5 ‘Hospitalisation’

NEXT PAGE >

 Broader issues good practice
Guidance
Go back to S2
Key area
1 Partnership stakeholder
support for OST as part of
evidence-based drug
treatment system
2 Access
3 Clinical governance
arrangements
4 Safeguarding
5 Record keeping
6 Co-occurring mental health
and drug and alcohol use
conditions
7 Service-user, families,
friends and carers
involvement
8 Drug-related deaths
9 Non-fatal overdoses
Question
Is the provision of high quality OST
supported locally by appropriate
strategic leaders?
Are referral pathways into drug and
alcohol treatment and recovery
services clear and working?
Are clinical governance arrangements There is stable, engaged local clinical leadership.
robust?
Decisions are taken about local audit priorities. This could include for example prescribing policies,
dosing, testing, supervised consumption, adequacy and competence of workforce, staff education and
training, and risk management.
Are safeguarding policies up-to-date,
implemented and monitored?
Are all staff trained around
safeguarding adults and children?
Are record keeping policies adequate
and monitored?
Do service users with co-occurring
mental health conditions receive
adequate support for both drug and
mental health issues?
Are service users and their families,
friends and carers (where appropriate
and with consent) involved in
treatment and recovery care planning?
Are service users, families, friends and
carers involved in developing,
reviewing and improving service
delivery?
Are local drug-related deaths reviews
carried out to identify any learning or
changes required?
Is there an adequate response in place Service managers and practitioners across relevant agencies meet and review non-fatal overdose cases
to review and respond to non-fatal
overdoses?
Good practice pointers
Active support from director of public health and other senior leaders such as probation, children’s
services, adult safeguarding, police, clinical commissioning group (CCG), integrated care system (ICS)
and primary care networks (PCN).
Referral pathways into drug and alcohol treatment and recovery services are clear and regularly
reviewed and updated.
Referral numbers into drug and alcohol treatment and recovery services, from various sources, are
audited annually to ensure the pathways are effective.
Audits are conducted and action plans developed which cover areas audited.
There is a named clinical governance lead.
Practice is audited (and, where needed, improved) against recommendations in the NICE suite of drug
misuse guidance and quality standards, and national clinical guidelines (2017).
Supervisors have the appropriate competences to supervise all the techniques or interventions being
used by the practitioners they are supervising.
Quality of supervision content and format is reviewed and staff feedback is sought to support
improvement.
Safeguarding policies and standard operating procedures for adults and children are up-to-date and
safeguarding training is mandatory for all staff.
Two separate trackers used (adults and children) which are taken to the weekly multi-disciplinary team
meeting for discussion, escalation or de-escalation (as per CQC requirements).
Audit of assessment and referrals in respect of safeguarding issues.
Checks are made about safe storage of take home medicines including for example use of locked
cabinet, storage out of reach.
Domestic abuse is included in assessment and referrals recorded in case notes.
Policy and training in place.
Case file checks conducted as part of supervision.
Joint working protocols, joint case management, standard operating procedures and information sharing
agreements exist between agencies.
Suicide awareness and prevention training is mandatory in drug and alcohol services.
Mental health awareness training is mandatory in drug and alcohol services.
Drug and alcohol awareness training is mandatory in mental health services.
Staff are aware of the principles of 'No wrong door' and 'everyone's job'.
Workers who are dedicated or lead on service user, familiy, friend and carer support exist in services.
Service user forums, representatives, and involvement policies are in place and reviewed.
Service user-led quality improvement approaches exist (such as surveys) and are part of service user
and family and carer involvement strategies. For example a peer-led survey of experiences of
supervised consumption.
An effective local drug-related death (DRD) review process and lead officer is in place for local areas to
understand their population most at risk of DRD, and to implement effective interventions to prevent
future deaths.
The DRD review identifies ways to improve services, remedy system failures, develop opportunities for
shared learning, and challenge, and change practice.
A meeting is held to discuss cases, with an agreed format.
Local services give account of their input in the case and take responsibility for any relevant areas that
need improvement.
There is multi-agency input to the meeting where relevant.
The meeting members include all agencies relevant to the case. This could include: commissioners,
coroner, relatives or carers, pharmacy, GP, hospital, mental health, drug treatment services, adult
safeguarding, police, ambulance, children’s services, homeless services, midwifery, probation, prisons
and others.
Actions agreed at the DRD review meeting are monitored and followed up where necessary.
Learning is shared.
and apply learning to current practice.
Fast track referral to treatment available or review of treatment for those who have experienced a recent,
near fatal overdose.
10 Women including pregnancy Are the needs of women (including Women are offered a choice of female case worker; and female-only groups.
pregnant women) adequately assessed
and responded to? Domestic abuse training for staff and in risk assessment, and links to domestic abuse support services.

All initial contacts explain the practicality of how child safeguarding including protection policies operate.

Midwifery services have specialist support available for drug users and pathways are in place.

Staff in pregnancy-related services complete drug and alcohol awareness training and have access to
evidence-based information on how to manage drug and alcohol use during pregnancy and the
challenges that exist for those using these substances in accessing antenatal care.

Support during labour and birth, advice on breastfeeding and postnatal support are available.

Links to sexual health services are effective, and support is provided for sex workers (female or male).

11 Environment and Is the service safe, attractive and Service feels welcoming and attractive to new service users.
accessibility accessible?
The service is available from locations that are safe and appropriate.

The atmosphere in the service is well organised and calm.

The service can be accessed at a time that is convenient to different cohorts of service users.

Friendly reminders about upcoming appointments are given.

Staff are friendly, professional and informative to service users.

Privacy and dignity is respected.

Toilets are available and waiting rooms are comfortable.

The public areas and facilities are clean and well maintained.

Staff and peer support workers or volunteers are visible.

Information leaflets are available and kept updated.

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Evidence that might demonstrate good practice

Statements of support from partner agencies.

Partner agency attendance and involvement in drug strategy groups and in development of local
treatment plans.

Clear and well used referral pathways and joint protocols between agencies exist and are demonstrated
as effective by monitoring data.

Evidence that shows directors/senior management assist to clear blockages, develop effective pathways
and release resources.

Audit of referrals into service from various sources.

Review of protocols and pathways where referrals are found to be lacking.

Service user and carer feedback and surveys

Named clinical lead.

Records of audits being conducted regularly as part of standard service management. These could be
linked to commissioners monitoring reports using NDTMS data.

Involvement of clinical governance lead.

Care Quality Commission (CQC) inspection report.

Up-to-date safeguarding policies and mandatory training available.

Audits take account of referrals to domestic abuse services, children's services and safeguarding teams.

Risk assessments and risk management plans are clearly shown in case file checks.

Service user surveys and feedback.

Joint working protocols in place with external agencies.

Audit of case files.

Record keeping requirements form part of mandatory training.

Updated joint protocol in place signed up to by drug treatment and mental health services.

File records show formal and informal liaison, referrals and assessments, joint recovery plans, and
regular reviews involving drug service and mental health service.

Attendance records of suicide awareness and prevention, and mental health training. Evidence of drug
and alcohol training for mental health services.

Service user and carer feedback and surveys.

Records including minutes from service user and carers forums.

Consultation exercises.

Case note reviews show family, friend and carer involvement.

Audit of family, friend and carer involvement questionnaires.

Minutes of DRD reviews.

Records of agreed structure or agenda, attendance and action notes including named individuals to take
actions forward.

Progress on action points from the meeting are fed back to the review meeting members.

Evidence that the findings of every DRD review meeting is sent to an up to date list of stakeholders.

Evidence of learning being shared with stakeholders.

Minutes of overdose review meetings.

Reviews of treatment plans and amendments in intensity of interventions offered.

Action plans to address overdose risks, within service.

Review of overdose cases to assess waiting times into treatment.

Joint protocols with midwifery, health visitors, safeguarding teams, children's services, domestic abuse
services exist and are used.

Records of referrals to the above services on file.

Communications and records of joint work/assessments are on file.

Clear printed information is provided on child safeguarding, and records of safeguarding discussions are
on file.

Joint training is in place on working with pregnant women who use drugs.

Assessments show appropriate areas (for example pregnancy or safeguarding) and treatment and
recovery plans show referrals and joint work.

There is evidence that service ‘walk arounds’ have been undertaken which are linked to improvement
action plans.

Evidence that walk arounds include staff, service users, carers, board members and/or impartial peer
reviewers.

Service user and carer consultation exercises include questions about the environment, staff interactions
and what might improve the attractiveness of the service.
Go back to S2
Broader issues guidance
Key area Question

1 Partnership stakeholder Is the provision of high quality OST

support for OST as part of supported locally by appropriate
2 evidence
Access based drug strategic
Are leaders?
referral pathways into drug and
treatment system. alcohol treatment and recovery
services clear and working?
3 Clinical governance Are clinical governance arrangements
arrangements robust?

4 Safeguarding Are safeguarding policies up-to-date,

implemented and monitored?

Are all staff trained around

safeguarding adults and children?

5 Record keeping Are record keeping policies adequate

and monitored?
6 Co-occurring mental health Do service users with co-occurring
and drug and alcohol use mental health conditions receive
conditions adequate support for both drug and
mental health issues?

7 Service-user, families, Are service users and their families,

friends and carers friends and carers (where appropriate
involvement and with consent) involved in
treatment and recovery care planning?
Are service users, families, friends and
carers involved in developing,
reviewing and improving service
delivery?

8 Drug-related deaths Are local drug-related deaths reviews

carried out to identify any learning or
changes required?

9 Non-fatal overdoses Is there an adequate response in place

to review and respond to non-fatal
overdoses?

10 Women including pregnancy Are the needs of women (including

pregnant women) adequately assessed
and responded to?

11 Environment and Is the service safe, attractive and

accessibility accessible?

< RETURN TO CONTENTS

ues guidance
Guidance/reports

Home Office, 2017 Drug Strategy, 2017, page 29

NTA, Auditing drug misuse treatment, 2008

1. Clinical guidelines, appendix A2 ‘Quality governance’

2. NTA, Medications in recovery: re-orientating drug dependence treatment, 2012

Clinical guidelines, sections: • 2.2.2.2 Assessment of risk • 2.2.5 Risk management and actions to reduce harm • 2.8 Intimate partner violence and domestic abuse • A2.2 Confidentiality and safeguarding

Local service policies

1. PHE, Better care for people with co-occurring mental health and alcohol/drug use conditions: a guide for commissioners and service providers, 2017

2. Revolving Doors Agency, Capability Framework: Working effectively with people with co-occurring mental health and alcohol/drug use conditions, 2019

3. Revolving Doors Agency, ‘Better Care for People with Co-occurring Mental Health and Alcohol/Drug Use Issues’ e-learning

4. Clinical guidelines, section 7.9 ‘Coexisting problems with mental health and substance use’

1. PHE, Service user involvement: A guide for drug and alcohol commissioners, providers and service users, 2015

2. Clinical guidelines sections: • 2.7.11 Involve service users • 2.7.12 Support and involve carers

1. NTA, Drug-related deaths: setting up a local review process, 2010

2. PHE, Understanding and preventing drug related deaths: The report of a national expert workinggroup to investigate drug-related deaths in England, 2016

Clinical guidelines, section 2.2.4 ‘Treatment and recovery care planning’

Clinical guidelines sections: • 2.8 Intimate partner violence and domestic abuse • 2.7.9 Address equity of access, vulnerable groups and cultural considerations • 7.6 Pregnancy and neonatal care • A2.2 Confiden

NHS England, The Fifteen Steps Challenge - Quality from a patient’s perspective: A toolkit for clinics and outpatient settings, 2017

Ashton, Mike. ‘Manners matter’ series, collected on Drug and Alcohol Findings website, 2004-06