In June 2014 the Ana Liffey Drugs Project (ALDP) published a position paper proposing the provision, on a three-year demonstration basis, of a low-threshold residential stabilisation service (LTRSS). The paper outlines the concept of LTRSS and how this differs from current services as well as describing how the service would operate and the steps required to begin implementation.1

Definition of LTRSS

The overall aim of an LTRSS is to provide a ‘genuine person-centred service, catering for those with greatest need’. The paper describes LTRSS as follows:

• low threshold – barriers to entry are kept as low as possible;
• residential – medically-led inpatient programme, with psycho-social support and follow-up care;
• stabilisation – stabilising the individual’s drug use, as well as providing detoxification (if appropriate) and referral to community or residential services;
• access to the service based on individual need, as measured by a comprehensive assessment tool; and
• time-bound (no more than a 28-day stay), but flexible to meet the client’s needs.

The proposed new service is described as differing from services currently available in Ireland in that it is open access, based on a holistic assessment of need and not determined by the individual’s drug use. There would be no cost to the client. Outcomes would not be solely clinically based but would also focus on enhanced stability.

Rationale

A number of local and national policy documents which support the development of LTRSS in Ireland are cited in the position paper. In particular, the feedback from the consultation process for the current National Drugs Strategy (2009–2016) and the strategy itself highlighted the need for services tailored to the needs of individuals and also the need to enhance all aspects of treatment, stabilisation and harm- reduction services.

While there is a general recognition of a need for expanded residential treatment options, the paper argues that services for polydrug users require particular attention. Polydrug use is a significant factor in drug-related deaths and as Ireland has one of the highest rates of drug-related deaths in Europe, there is a very strong rationale for the development of residential services which are not restricted to single drug use and which are responsive to the chaotic lifestyles of polydrug users. The paper states that polydrug users’ access to the majority of existing residential stabilisation and detoxification services is restricted, and that an LTRSS would provide a more flexible treatment model adapted to the needs of this particular at-risk group.

At the same time, the paper recognises that the client’s presenting needs, as opposed to the potential clinical outcome, should be the primary determinant of service provision. The paper lists patient characteristics that can help determine whether a client is likely to benefit from in-patient provision. These include:

• dependence on more than one drug,
• physical complications,
• co-morbidity,
• history of complications during previous withdrawals,
• chaotic polydrug use,
• pregnancy,
• failed outpatient withdrawal, and
• inability to cope with out-patient withdrawal owing to isolation, homelessness or lack of support.

The proposed LTRSS would target those presenting with these characteristics through a comprehensive assessment process.

Principles

The LTRSS would provide a 24-hour, seven-days-a-week programme based on the following principles:

• Access based on the person’s need at the time of presentation: when a bed becomes available, the person with the greatest need would be offered a place; there would be no waiting list. (See next section for a fuller explanation of this principle.)
• Limited length of stay: maximum stay of approximately 28 days depending on need; the goal would be stabilisation with an option for detoxification.
• Type or level of drug use not a barrier to entry: Polydrug users and those with comorbid mental health issues will not be excluded except where the individual’s mental or physical health is a barrier to their receiving the stabilisation service.

Proposed service

Clients would be able to self-refer. An initial detailed assessment would be conducted following which a case would be brought to a team meeting to determine whether a client requires admission and the level of priority they should be given. If no bed is available, the client would be asked to come back on a daily basis until a bed is available.

Prior to admission, a structured care plan would be developed with the client, setting out clear goals for the treatment episode. All clients would be seen by the service’s GP prior to admission, to ensure that clinical risk is appropriately assessed, medical history is complete and any necessary adjustments have been made to the care plan.

During their stay clients would be regularly monitored to ensure they are medically stable. The service would be overseen by a GP. Discharge would usually be to a residential treatment facility. However, discharge to day programmes, family or other structured supports would also be possible.

Next steps

The ALDP is currently seeking funding and a premises to operate the service on a demonstration basis for three years beginning in 2017.

1 Ana Liffey Drug Project (2015) Ana Liffey Drug Project position paper on the provision of low threshold residential stabilisation service (LTRSS )in Ireland. Dublin: Ana Liffey Drug Project. https://www.drugsandalcohol.ie/24100/