As far back as 2002, research was showing that 70 per cent of people in drug services and 86 per cent in alcohol services had described or reported severe mental health problems in the previous year, said Dr Hauwa Onifade, a forensic psychologist at Turning Point involved in developing services with an integrated approach to co-existing mental health difficulties and substance use. Far too many in this client group were still failing to access the support they needed, she said.
Despite efforts to integrate services, there were ongoing barriers to bridging the gap. In many services there was ‘sequential delivery’, with clients told to address their substance issues before they could access mental health support, or parallel delivery – clients accessing both, but with difficulties in joining them up. Years of diminishing investment had taken its toll, while the transfer of public health functions to local authorities had also led to an ‘accountability gap’ across substance and mental health providers. ‘And of course COVID hasn’t made any of this any easier.’
High Risk
Turning Point had developed a substance use and mental health (SUMH) toolkit for professionals, condensing research and guidelines from PHE, NICE and elsewhere, she said. The organisation had also been working in Leicester, Leicestershire and Rutland on developing an integrated team, with a pilot launching during the COVID period following an audit of more than 3,000 clients. This had identified two significant groups where there were gaps in accessing treatment – populations involved in injecting drug use who were ‘frequent flyers’ at local hospitals and also presented with high levels of risk around mental health, including self-harm and suicide, and longer-term clients who, although there was little risk of self-harm or suicide, were in high levels of distress and unable to make changes in their substance use as a result.
‘We tend to focus on high-risk populations, almost to the detriment of the other group,’ she said. ‘And even with the high-risk populations we’re not necessarily working with them long-term, so they tend to fall into that pattern of re-presenting to services. A lot of services were involved in their care and a lot of people were aware of their difficulties, but they weren’t necessarily in treatment for very long.’
No Wrong Door
Turning Point’s integrated team had tried to implement the ‘no wrong door’ concept – that all services should have a fully open-door policy – along with a ‘huge focus on engagement and retention’, she told the seminar. There was also a need to focus on client needs rather than just diagnosis – ‘we found that when we focused on diagnosis alone we excluded a high number of clients who were struggling and in distress’.
Turning Point had also conducted a mapping exercise of all the services in the area that could meet the clients’ treatment needs. It found that specialist services for domestic violence, for example, would also work with people who had experienced those issues in the past, allowing the building of links to provide support while clients were on a waiting list. ‘Establishing those networks and looking at the wider availability of resources is really key,’ she said. ‘It’s astounding the number of peer support groups available’, and even organisations like Age UK could address issues of loneliness and provide interim support while clients waited to access other services. ‘So really broadening our idea of what intervention looks like for these client groups, which means we’re able to filter in a lot more options.’
Focusing on being able to deliver genuinely trauma-informed services was vital, alongside breaking down both stigma and professionals’ anxiety around their skill sets. Lack of clinical psychologists in third sector addiction services was a crucial issue, however – ‘I’m astounded by the number of services that don’t have psychologist input’ – and proper support for staff was also a key consideration. ‘If you’re working with people with those high levels of risk, as a professional you’ll likely need some support as well. Without that full structure and that supervision and training element, teams such as this would likely fall apart.’
But barriers didn’t just exist when it came to accessing treatment for co-existing conditions. There were also the legal barriers that prevented the use of substances that could provide potentially life-changing help for depression, anxiety, PTSD and other mental health issues.
Revolutionary
‘It was the first great revolution in psychiatry,’ said professor of neuropsychopharmacology at Imperial College London, David Nutt, of the widespread use of LSD therapy in the US in the 1950s and ’60s. There had been an ‘enormous clinical interest’ in LSD, and to a lesser extent psilocybin, with around 1,000 clinical papers and ‘overwhelmingly positive’ results describing safe and effective treatments.
For researchers and psychiatrists, psychedelics offered the opportunity to ‘ask questions of the brain that hadn’t been asked before, and potentially change brain function in a very positive way’, he said, and it was ‘remarkable’ how few adverse effects there had been. ‘Lower than you’d imagine for untreated populations at the time and certainly better than any treatment they were getting, which was essentially just barbiturates.’
It constituted a ‘remarkable period of enormous enthusiasm’, he stated. ‘But we don’t use them now, because in 1967 the US government decided to ban psychedelics because they thought they were encouraging the anti-Vietnam war movement.’ And – as ‘we’d always done in drug policy exactly what the US told us’ – the UK followed suit, as did the UN.
This meant an end to research, as it was almost always funded by governments, with even those researchers who could access funding from philanthropists unable to get hold of the drugs. It added up to ‘a genuine attempt by the US government and UN to eliminate all knowledge and almost all memory of the drugs, because they were seen as being so challenging to the status quo’.
In 2012, however, money finally became available from the Medical Research Council to study the use of psilocybin in treatment-resistant depression, dependent on an initial safety study. ‘But even that was easier than getting hold of the drug,’ said Nutt. ‘In the end, 32 months of our 36-month grant were spent on bureaucracy, which is all about protecting society from the dangers of magic mushrooms. It’s completely absurd.’
Pessimism bias
The study finally went ahead, involving 20 patients who had all failed to benefit from anti-depressants and CBT. ‘We gave them one dose, one trip of 25mg, and saw a halving of depression scores within a day.’ Even at six months there were still ‘huge’ effects, with some patients in remission after eight years. ‘It opened up the whole field, and now there are 40 different companies working in the field of psilocybin for depression.’
Psilocybin ‘changes the way people think’, he said, helping to remove the ‘pessimism bias’ involved in perpetuating depression. A subsequent ‘head-to-head trial’ of psilocybin versus the widely used SSRI antidepressant escitalopram found that psilocybin was ‘at least as good, and probably better’ on most measures, with ‘remarkably higher’ remission rates (www.drinkanddrugsnews.com/magic-mushrooms-may-be-as-effective-as-antidepressants).
While SSRIs worked by enhancing serotonin in the limbic system – ‘they are to depression what a plaster cast is to a broken leg’ – psychedelics worked in a different part of the brain by disrupting cortical thinking. This helped to break down negative thought patterns and increase wellbeing, without the blunting effect on the emotions that sometimes came with SSRIs.
Studies had now been widened to include areas like anorexia, OCD and pain syndromes, he said. These were ‘internalising disorders where people get locked into thinking patterns they can’t escape, and psychedelics can help them do that’. The drugs also worked well in treating addiction, he stressed, in that they helped to ‘break down the circuits that drive addictive thinking and habit behaviour’, and he was now involved in work looking at whether ketamine could be effective for behavioural addictions such as gambling or pornography.
Maximum benefit
MDMA was now likely to become approved therapy for PTSD in the US from the end of next year, he said. ‘They’ve done one phase 3 study, and the second one’s on its way – if it’s as good as the first I’m pretty sure it’ll get a licence, and hopefully we’ll then be able to use it in Britain. And maybe in the next three years we’ll be able to have psilocybin in the UK, depending on how the next phase 3 trial comes out.’ Psychotherapeutic support provided around the psilocybin dosing was essential, however. ‘I like the idea that we can bring psychotherapy and pharmacology together to maximise the benefits for people.’
‘As George Bernard Shaw said, “Those who cannot change their minds cannot change anything”, and I think what’s pretty clear is that psychedelics can change the minds of our patients. I’m hoping this research can also change the public’s and politicians’ minds about psychedelics and bring them back into medical practice, because it was absurd that they were taken from it. It’s actually the worst censorship of research and clinical practice in the history of the world. And we should rectify it now.’ DDN
The SUMH resource pack – working with people with coexisting substance use and mental health issues at www.turning-point.co.uk/reports
Oasis’ approach includes delivery of treatment in a women-only building, providing a physically and emotionally safe place for women to access support in an environment which recognises the prevalence of trauma and actively seeks to prevent re-traumatisation and promote recovery. Women report feeling more comfortable in a setting they know is women-only, sharing space with peers and drawing on shared connections, without risk of being in groups and settings with a partner, or ex-partner.
Case studies
Taking Control
Release are UK experts on drugs and drug laws and provide advice and advocacy. A non-government and non-profit organisation, they campaign for drug policies that respect
We are proud to work in partnership with many of the leading charities and treatment providers in the sector.
While all local authorities will receive additional funding as part of the government’s three-year £780m investment in treatment 
My work background before I went to prison was mainly machine driving, but also building and construction, warehouse jobs and driving jobs. I’ve had spells off from time to time due to factors going on in my life, whether it be drink, drugs, family issues, poor emotional management, or not being able to cope properly. But I’ve always worked, and I’ve always managed to get myself a job and have a bit of stability.
By 2000, I was completely out of control, barely hanging on to my job, and I went to the first of six treatment centres. When I left, I should have gone to a ‘dry house’, but I chose not to – I wanted to return to work. I returned to work five weeks after leaving and relapsed within a week. By 2001, my employer said, ‘We need to part company with you’.
The team brandish naloxone kits when they’re out and about – a conversation starter as well as a vital harm reduction intervention. They wear their naloxone shirts and are proud to spread the word as Medway naloxone peers. On their route down the high street they stop to talk to two young men who are willing to hear more and engage in answering some questions – ‘What are the main causes of an overdose? When are the high-risk times? What are the signs and symptoms of an overdose? What should you not do in an overdose situation…?’ The men carry on their way with naloxone kits and the knowledge and confidence to use them, saying they ‘learned something very useful’.
As they work through an agenda that covers their progress over the last few months they realise their partnership working is paying off and results are tangible – for clients and for the team members themselves. The growth and development of the peer group is an important part of this story.
Jo Payne, volunteer and building recovery coordinator, has worked with Open Road since 2018 and has seen the peer support develop as the partnerships have evolved. The peer projects now reach into all areas of work – outreach, naloxone, sexual health, the hep C clinic, rough sleeper initiatives with the council, the Ladies’ Night project with sex workers. With 24 peer mentors, ‘it’s known as a safe place to be,’ she says. Furthermore, ‘peer mentor support has become integral to services’ and peer mentors regularly work at Turning Point, co-facilitating groups.
Gambling and lottery advertising will no longer be able to use content ‘likely to be of strong appeal to children or young persons’, the Committee for Advertising Practice (CAP) has announced, especially that associated with youth culture. This means that prominent sports personalities, celebrities and social media influencers will no longer be able promote gambling brands if they strongly appeal to those under 18.
A letter from a prisoner had pointed out that any attempt to tackle alcohol and drug-related deaths in custody would need to address ‘many aspects’ of prison life. ‘It’s the overall context in which people are living, and of course this has been exacerbated massively by COVID. The kind of desperation we’ve been seeing, the crushing boredom, living 23 hours a day in a six-by-nine cell often shared with a stranger.’ It was clear why people would turn to ‘any substance’ to try to block this out, she said. Unless someone had gone through it they could ‘never comprehend’ it, the letter had stressed.
Housing Matters
More than half of the people who changed from buprenorphine to Espranor remained on the same dose at the point of switching (Figure 2), and a large proportion of people remained on the dose they started Espranor on after 28 days of treatment (Figure 3). A larger proportion of people required a dose change within 28 days of starting Espranor treatment if they changed dose at the point of switching from sublingual buprenorphine, and if people needed to change dose after starting Espranor they were more likely to need a dose increase than decrease.
An outreach worker reports that people find Espranor less intrusive when doses are being supervised, and that Espranor feels more dignified as people do not have to stand in the pharmacy for a long time waiting for the dose to dissolve. They also echo service user feedback that Espranor tastes better. Staff report reduced diversion risk as a key benefit, and they are more assured that people are taking their prescribed dose. 
The group, which is chaired by Humankind, has already submitted a letter to the Office for Health Improvement and Disparities (OHID) outlining the minimum provision for women that should exist in every service. 
The highest number of deaths occurred in the 35-39 age group, followed closely by the 40-44 age group. The age profile of overdose deaths followed the same pattern, but with a more pronounced peak in the 35-39 age group. The data suggests that those aged 50 and over are more likely to die from a physical health condition than an overdose – in the 50-plus age group 19 per cent of deaths were due to overdose, compared to 39 per cent of deaths in those aged 35-49.
Physical health conditions were highly prevalent in the cohort that died, with 81 per cent of people (251) having at least one such condition – 60 per cent (186) had two or more. The most commonly occurring conditions were chronic obstructive pulmonary disease (COPD) at the time of death. In this study 243 decedents were under the age of 50. Of these 191 had at least one long-term health condition such as COPD, liver disease, or a heart condition, and 155 had an identifiable mental health condition, such as anxiety and depression disorders, personality disorder, PTSD or psychotic illness. Poor physical health and life-limiting conditions will continue to be a challenge to the sector. Three quarters of the people who died had also had at least one hospital admission in the previous 12 months – a significant red flag and a clear indicator of risk regardless of reason for hospital admission.
A partnership between Derbyshire Healthcare NHS Foundation Trust and ImpACT+, the specialist respiratory/COPD team based at the Royal Derby Hospital, was created to address a recognised need for access to specialist respiratory care for those using our services. This service is now delivered from within two of our treatment bases. More people have been diagnosed and commenced on treatment regimes, with one case of TB identified and treated. Many with symptoms but undiagnosed have been identified and received appropriate investigations for symptoms they had previously not addressed or been unable to access their GP to discuss. One client was identified to be suffering from a range of conditions including a DVT and heart failure and is only alive today because the health improvement nurse had access to the specialist team who were able to act accordingly on her concerns.
Engage and re-engage
The intimidating men-only environments of betting shops meant that problem gambling was largely a male problem, but the rise of online gambling has changed all that. 
