Should we not be assessing the services suitability to treat women, and not the suitability of women, asks Florence Fowler, quality improvement lead at Phoenix Futures.
My name is Florence Fowler, and I am a Quality Improvement Lead at Phoenix Futures. I have worked in the Recovery Field for around 25 years however, on reflection, my desire to care for and assist disadvantaged others began at an early age and has matured with me.
The majority of my career has been working and managing our Phoenix Futures Substance Misuse Service provisions in prisons, specialising in the treatment model ‘Therapeutic Community’. My experience of prisons is that they have the potential to be great places for reform, rehabilitation, and ideal for treatment, to some extent, as there is a captive audience.
Yet despite being a captive audience, and a high percentage of crime associated with substance misuse access to residential treatment depended on the availability of treatment beds, funding, and individuals meeting the assessment criteria. The success of residential treatment in custody often prohibited further residential treatment post-prison, despite the stark differences in environment.
Towards the end of 2021, I was asked by our chief executive Karen Biggs to provide a report on the interventions we delivered to women as an organisation. This was in support of a women’s working group our chief executive is involved in.
I must admit when initially tasked to provide a report, I panicked thinking where do I begin, only to discover when compiling the report, how little I did know.
I knew that Phoenix Futures had worked with nearly 4,000 women across our community, housing, and rehab services last year, and that despite a CQC rating of outstanding our gender-specific residential rehab Grace House London closed due to funding constraints. So, what was on offer for women in our services?
Findings
The report explored a cross-section of services including: Supported Housing, Residential Services, Sheffield Residential Family Service, Community Services, Prison Services, Prison Family Services, and RtN (Recovery Through Nature).
Despite the fundamental differences of each service, geographical, design, criteria, etc., it very quickly became apparent that each service had a generic core approach and set of values that they applied when working with women.
All services were knowledgeable of the disadvantages that often affect women, such as mental health, domestic violence, poverty, caring responsibilities, prejudice associated with women who use substances and in particular those with children. Staff spoke with empathy reflecting the impact on health, access to treatment, and personal growth that these disadvantages can have on women, and expressed a strong desire to ensure that the inequality of women is not perpetuated in any way.
Services acknowledged their own limitations and expertise in their ability to support women, and all services had established a network of local and specialist providers to bridge any gaps in service provision.
Specialist roles in pregnancy care, women at risk, domestic abuse, and a specialist women’s treatment coordinator established in Derby City enabled pathways for women to be created, whilst our residentials created a safe space for women to feel at ease with themselves and others.
Generically, whether it was practical support of providing toiletries, accompanying women to activities to raise their self-esteem, or offering handheld support in meetings that determined a women’s ability to remain mum, Phoenix staff were there. The ‘can do’ attitude found in all areas of service spoke loud and clear that their optimistic view of success for women did not depend on funds, but more on a willingness to find a way.
In January the London Joint Working Group on Substance Use and Hepatitis C (LJWG) launched a new report on the case for a peer-based needle exchange in London – designed by, and run by, the people who know how these services can work best (see news, page 5).
Peers have lived experience of injecting drug use and use this to deliver education, services and advice on safer injecting practices to others. A peer-based needle exchange could still work with other services – such as drug treatment, health or housing advice – but would have this experience at its heart.
In 2020, 43 per cent of people who injected drugs reported sharing unclean needles and works, leading to a preventable rise in hepatitis C infections. This was the backdrop to LJWG’s idea to seek funding from Hackney Council as part of the national ADDER Accelerator (addiction, diversion, disruption, enforcement and recovery) project to explore how the idea could work in the London borough. If successful, it is hoped the service could become pan-London, and inspire similar projects further afield.
Service user voice
At the core of this research was a series of focus groups with people who inject drugs and peer workers, in order to build it around their experiences with current services as well as what they would want to see. Jason, a peer volunteer who has used services, said, ‘There were lots of ideas at our workshop, everyone had something to say and it was great to hear ideas. Why not have availability at night, or why can’t we have access at the needle exchange to other support – health, legal or housing?’
Needle exchange is vital to ensure that ‘the people who don’t get any service would get clean needles instead of just using what’s there’, Jason felt, but the peer side of it was important to him. ‘There’s a big difference between being given a needle exchange from a set worker and deciding what the service is yourself.’
Archie Christian, national training and volunteer manager for The Hepatitis C Trust, helped run the focus groups: ‘There was a real positive outcome in sitting down, hearing and understanding the experiences of people who are in that community,’ he said. ‘And they realised it wasn’t just one of those simple “tick box” exercises. That produced an enthusiasm – that they were listened to, that they were understood and that they weren’t judged. I believe we could develop a programme of services where everyone involved in the production and delivery of the services, or the majority, have lived experience. Our actual service users or peers that no longer inject are still working within that community. Giving people opportunities to volunteer and pathways into employment can be transformational.’
Confronting stigma
Bad experiences with existing services was a common theme in the focus groups, and in the work peers from The Hepatitis C Trust do generally. ‘Having individuals trained who are actually present on the ground in the communities can overcome a lot of the barriers that they feel are presented to them in terms of from discrimination from some pharmacists and feeling that what they’re doing is problematic,’ said Archie.
Nathan Motherwell, a Hepatitis C Trust peer who organises needle exchange services in Kent, finds the issues the London focus groups raised are commonplace. ‘I think the problems with needle exchange are across the board very similar. If people are going into a pharmacy needle exchange, sometimes there’s shame and fear and stigma attached to it – sometimes they’re not treated very well. Another barrier is people often get their methadone scripts from places where they would be going for exchange, and they worry they’ll be asked “are you using on top?”’
A peer-based exchange could offer a way to upend this model. ‘Peers working with peers don’t present the same sort of barriers to the community who use injection drugs’, Archie argued. ‘Because of the way society looks at them, they sometimes feel like they’re a burden. You don’t have that if it’s members of the community providing the service. There’s no judgement, no being condescending. You have an opportunity to do something different where the ownership of the service delivery is from the peers. You are taking a different approach of encouraging development, giving people responsibilities. They feel responsible, they grow esteem.’
Accessibility
There was emphasis in the groups on openness, Archie reported, as well as links to other services: ‘It should be community-based, easy access, no limitations on the amount people can receive. A holistic approach to the whole person and services that are provided. At the very least, the needle exchange, if it was mobile, could signpost to a community service user hub where there’s access to more care, more opportunity and more support.’ There could be an important role for such a hub in supporting people who leave prison with accessing a wide range of holistic services.
Peers, service users and commissioners offered different perspectives on how much data to collect about service users, but it was acknowledged that this should be light-touch to avoid discouraging people. Nathan suggested that, ‘if you want to increase the uptake, the fewer details you take the better because we want them to have clean equipment’, but ‘a very basic bit of info doesn’t really damage it’, such as their initials and date of birth – ‘the ideal needle exchange is just making it more available’.
Wider prospects
The work has already led to some changes on the ground and if it works, it is hoped there could be scope to widen the approach. ‘We’ve seen that some things that have been mentioned in this process have led to changes from Hackney, and we’re talking about maybe a pan-London approach’, Archie said. ‘If we get the goodwill and the buy-in from the commissioners and the local health and justice services, and we look at treating this as a community and public health concern, we can make meaningful changes.’ This builds on existing work in New Zealand, Australia and elsewhere, he noted – ‘The report had lots of good examples of it working internationally.’
Elliot Bidgood is a policy adviser with the London Joint Working Group on Substance Use and Hepatitis C (LJWG).
Service user involvement, co-production, peer-led initiatives – whatever the terminology, we’re glad to see the renewed efforts to make the voice of experience a vital part of the infrastructure of services. Almost two decades ago when we started DDN, the two-year rule – a nebulous guideline about an amount of time required to be drug-free and therefore stable enough to enter full-time work, and grasped by many as a reason not to put service users on an equal footing – was a real barrier to admitting people back into employment and an equal status.
Now many organisations, including the Scottish Government, have realised the value of people with authentic experience in collaborating on the ‘national mission on drug deaths’ (page 5). The LJWG are among those to go further by making the case for peers as the best people for the job with the highest chance of attracting participation in these vital services (page 6). With the grassroots knowledge and experience embedded in major service providers (page 16) and a keen appetite for collaboration between partners in health, substance use, police and social care (page 20), the time is ripe for making focused, cost-effective – and representative – decisions that will transform the outlook for many.
Peter Furlong is Change Grow Live’s new national harm reduction lead. Here he talks about his career journey and the need to focus on saving lives.
After working for Change Grow Live for more than 12 years in various roles I am now starting in the new role of national harm reduction lead, and I fully share the organisation’s ambition and commitment to ensuring harm reduction is a priority in our response to the new UK drug strategy. Reducing harm and drug-related deaths must be at the forefront of our minds.
I hope that the debate around abstinence vs harm reduction has run its course, as both approaches can play an important role in drug and alcohol treatment. As we respond to meeting the objectives set out in the strategy, I would like to see harm reduction beliefs and practice at the heart of treatment services, alongside the confidence and hope that abstinence is possible if chosen as a treatment goal. Harm reduction interventions and meaningful support towards abstinence can of course sit within the same continuums of care, with many of the Dame Carol Black report’s recommendations reminding us of the need to revisit areas lost to disinvestment or policy changes.
Early days
Starting as a volunteer for Merseyside Drugs Council (MDC) in 1996, I knew I that wanted to learn more about drugs and hopefully help some people close to me with their challenges around substance misuse. This was particularly driven by the arrival of cheap brown powder heroin in the ’80s and crack cocaine in the ’90s. My thoughts and feelings about drug and alcohol treatment at that time included anger and frustration, and of course compassion for the people involved – this anger largely stemming from seeing some people very close to me not getting the support or treatment they needed. This included losing an uncle to an avoidable death from him contracting HIV through his injecting drug use – in the early ’80s his illness was treated like a shameful event surrounded by mystery. I came to the stark realisation that better, more humanistic basic treatment and access to clean injecting equipment could have helped prevent his death.
My own rapid affiliation with harm reduction approaches and interventions was again led by poor treatment access in the ’90s. It was common to see five-year waiting lists to access specialist substitute prescribing when I began volunteering in Merseyside. Keeping people as safe as possible from all of the harms associated with drug use at the time centred around increasing access to clean injecting equipment, and safer injecting advice. It also involved promoting then-new messages around the risks of BBVs and sharing paraphernalia, as well as outreach methods to seek out people who did not have access to basic health care and support. As an outreach worker and non-clinician, I often found myself sitting with people who had to share drugs to avoid withdrawal, or were forced to attempt self-detox with no clinical support. By default I was providing advice and guidance on things like their injecting practice, more hygienic drug use, and promoting peer-to-peer support and advice when possible.
From volunteering I started work in the well-known Maryland Centre in Liverpool, where I had the opportunity to learn from some great people in the field. I also worked with the activists who established the now globally famous ‘Mersey model’ of harm reduction and went on to train others in what I see now as an approach grounded in the Hippocratic Oath of ‘first do no harm’.
Harm reduction heroes
Some of these harm reduction heroes, such as Professor Pat O’Hare, Alan Parry and Alan Mathews, led the way in the late ’80s, and much of my own learning came from great tutors and influencers such as Alan McGee, Jon Dericott, Andrew Bennet, and many more. The Maryland Centre opened up a whole new world of learning for me. It taught me about working with the most marginalised and vulnerable groups of people, the many benefits of needle and syringe programmes, street outreach work, low-threshold prescribing and HIV prevention. This experience has stayed with me throughout my career.
For the next 20-plus years I have worked in the third sector in various roles. Thankfully, I’ve seen significant positive changes and improvements in the delivery and quality of drug and alcohol treatment in the UK. My excitement and ambition for the new role of national harm reduction lead in Change Grow Live are huge, as is the organisation’s commitment to reducing drug-related deaths and improving quality of life for people who use substances. We are determined to ensure that people across the sector and partner agencies are informed, confident and competent in offering harm reduction interventions where every contact counts.
We are committed to invaluable cross-sector workstreams such as providing more life-saving naloxone, encouraging more people into treatment, and more outreach, especially for people living alone or isolated from support. More and more evidence points towards the harm that untreated or undiagnosed long-term health conditions can bring to people who use drugs or alcohol, and we want to ensure that people are able to access the mainstream healthcare treatment they deserve.
Meeting ourselves where we are
The terminology and language we use to describe approaches and strategy often changes. I personally like ‘meeting people where they are’ in their own journey and ensuring we provide individualised interventions for each person’s presenting needs.
The sector has changed a lot over the last few decades, and harm reduction has not always been as much of a focus as it should have been. Noticing the sector’s changing shape, with budgets increasing then shrinking with treatment targets/outcomes changeable and more focused on discharges, and the casualties of staff development, training and key competencies around some harm reduction interventions have not always been as high as we would envisage or aim for.
We must look at the UK and the rest of Europe’s approaches to harm reduction, learn what we can from the pandemic, and take on board the recommendations of the Dame Carol Black review. Then we can refocus and revitalise our collaborative approach to harm reduction principles and help to improve the experiences of the people who use our services.
The pandemic stopped us all in our tracks. Every day new situations tested our ability to keep vulnerable service users safe. The very harm reduction principles that have improved our practice over time became more important than ever, and demonstrated the real importance of safe clinical practice.
The new UK strategy allows us the financial and strategic re-investment to ensure the support we offer is grounded in the guiding principles of reducing the harms associated with drugs and alcohol, and helping people to change the direction of their lives.
Peter Furlong is national harm reduction lead for Change Grow Live
In the first of a two-part article looking at the impact of menopause on colleagues and service users, Helen O’Connor talks about the importance of creating menopause-inclusive workplaces.
Women make up 51 per cent of the UK workforce, with women over the age of 50 being the fastest growing segment. This is also the age at which women will commonly experience menopause transition as oestrogen levels decline, although it can also happen for younger women, transgender, and non-binary people too and the perimenopause and symptoms can begin some years before.
Some women experience the impact of oestrogen diminishment during their menopause as a ‘cliff edge’ that significantly affects their physical and mental health. About eight in ten women will experience noticeable menopause symptoms, of which 45 per cent will find their symptoms hard to deal with, both in and out of the workplace. It can also affect their relationships and may occur alongside other challenging life events, such as an ‘empty nest’, divorce, or caring for elderly relatives.
These problems can be exacerbated by a lack of understanding about the menopause and how to support people who are experiencing a difficult menopause transition at work, or when it is treated as something embarrassing, taboo, or a joke.
Results of several different surveys indicate that this has a direct impact on work life and retention of colleagues:
10 per cent have considered leaving work because of the menopause
55 per cent said the menopause impacted negatively on their work life and productivity
59 per cent took time off due to menopause symptoms
60 per cent said their workplace offered no menopause support
Issues can include conflict and tension between colleagues about room temperatures; difficulties attending meetings or running groups and keyworking sessions in confined spaces that exacerbate hot flushes; high sickness absences and the stress of meetings to discuss them; emotional problems at work including anxiety, and changes in performance because of lack of sleep and a loss of focus. Add to this the frustration that can come from trying to get help and appropriate treatment from a GP and how it might also be affecting one’s personal life, and this can be an incredibly difficult life event to navigate.
Seeing an opportunity to enhance our workforce health and safety policies to directly address the menopause, I volunteered to lead on shaping WDP’s menopause policy and toolkit. Our people and culture team were really enthusiastic and encouraging of this direction and of my involvement, and I value being part of a responsive and supportive organisation that welcomes organisation-wide initiatives and ownership of them to originate from those working within services.
After consulting other organisations’ policies and guidelines, and menopause advocates and experts, I drafted our (Peri)menopause at work policy, which was put out for a staff consultation that was open to everyone at WDP. We launched the policy internally on World Menopause Awareness Day 2021 and situated it within our new pay and reward structure, outlined by our CEO Anna Whitton in a previous issue of DDN (November, page 20).
When we put our (Peri)menopause policy out for staff consultation, a colleague within our team at WDP Merton commented: ‘I’m currently in the process of managing my own menstrual/hormonal related issues and their impacts and it feels very reassuring to be in an environment that is progressive in its ways of approaching these topics.’
This policy and the associated toolkit of information and resources, together with briefings and training that will be rolled out over the next few months, are intended to help everyone understand and appropriately support people who are experiencing difficulties with menopause symptoms.
Of course, it’s not up to us to ‘diagnose’ colleagues who may be experiencing menopause transition symptoms, and whether someone wishes to discuss them is up to them. But we do want to help managers and other colleagues to be able to support their team members who are experiencing difficulties at work, by increasing their knowledge of menopause and how to hold positive supportive conversations about it.
A quote from Kellogg’s, who recently announced how they would be providing more support to staff experiencing the menopause, expresses what we are trying to achieve: ‘We want to create a culture where people feel psychologically safe, so we’ll encourage colleagues to be allies to others impacted by these issues.’
The second part of this article will look at how we can improve our understanding of the possible impact of the menopause on our service users and how it can affect their recovery.
Emotional support
In the second of a two-part article, Helen O’Connor talks about the importance of understanding the potential impact of the menopause on service users and how it can affect their recovery.
‘It really reminded me of when I was using, and I really hated it…’ This quote is from a 2020 TV interview with Davina McCall, who has been open about her history of addiction and has more recently put menopause in the public eye by sharing her experience of the symptoms associated with her own menopause.
As we consider the impact of menopause on our colleagues, we can also improve our understanding of the possible impact of the menopause on our service users. According to the Office for Health Improvement and Disparities (OHID), across our sector 32 per cent of service users are women, and at WDP the largest segment of our women service users is the 35-54 age group, the period where someone is most likely to go through the menopause. How they experience the menopause and how they are supported during it could affect their recovery and mental health.
Perimenopausal women are twice as likely to have depressive symptoms or depression than premenopausal women and suicide rates in women of menopausal age have increased by 6 per cent in the last 20 years despite rates for older women (55+) falling by 28 per cent across the same period. A difficult menopause can affect relationships and often occurs alongside other difficult life events or transitions such as an ‘empty nest’, divorce, or being a carer for elderly relatives.
If a person’s GP does not identify the symptoms they are describing (depression, anxiety, sleep issues, ‘brain fog’) as being related to the perimenopause, or offer appropriate treatment, that can also be confusing, frustrating, and upsetting.
All of this indicates that the menopause is another factor to consider when assessing risk and developing care plans. This could include looking at how symptoms of the menopause, combined with active substance misuse, might lead to an increase in use as a way of managing moods, increase the risk of suicide or self-harm for some service users, or how menopause symptoms and concurrent life events might introduce an increased risk of relapse for service users who are abstinent.
Hannah Lidsell, an experienced coach and addiction specialist, also feels passionately about these issues. ‘Using substances to try and manage debilitating menopausal symptoms, such as anxiety, heart palpitations and hot flushes, can actually exacerbate them,’ she says. ‘Once you throw in health inequalities, stigma, and unequal access to services, you have the perfect storm for increased use/lapse/relapse.’
In Merton, our service users can access a specialist menopause service. Esha Saha, consultant gynaecologist and lead for this service at St George’s NHS Trust, believes that ‘asking for help or taking HRT (hormone replacement therapy) whilst undergoing the menopause transition should not be considered as a last resort’. She recommends that women are encouraged to use tools such as the Menopause Quality of Life Scale (MENQOL) to prepare for a discussion with their GP about how their symptoms are affecting their quality of life. It allows them to both validate and score the severity of their symptoms which should be the springboard for a discussion with their GP about the best way to manage their menopause transition. If clinicians, keyworkers, and other professionals are more informed and confident about discussing the relationship between drug and alcohol use and menopause, they can educate service users and signpost them to this tool and other support available.
Fortunately, more information and resources that can improve our understanding of, and empathy for, how symptoms of the menopause transition might affect the individuals we work with are available than ever before. WDP has created a handout of these resources and is combining them with staff lunch and learn sessions to increase confidence about having discussions with service users. The Menopause Charity also offers training for healthcare professionals, some of which is free of charge.
Considering the impact and effects of the menopause should sit within a person-centred and holistic view of the individual. Experiences of menopause can vary – some will have a difficult time with life-changing symptoms whilst others report menopause as being a time of personal growth, or simply a relief and freedom from painful periods.
As we commit to engaging more women into treatment at any age, WDP welcomes the creation of the cross-party Menopause Taskforce, alongside the development of the first ever Women’s Health Strategy for England, given our role in supporting people to improve their physical and mental wellbeing, through achieving recovery from problematic substance use.
The drug strategy had the potential to revitalise the sector, heard January’s meeting of the Drugs, Alcohol and Justice APPG – but now it was time to deliver. DDN reports.
Click to read it in DDN Magazine
The government’s new drug strategy came after a decade of major disinvestment, an ideological drive towards localism, and a marketisation of the way services are commissioned and funded, Collective Voice director Oliver Standing told the online meeting of the All-Party Parliamentary Group on Drugs, Alcohol and Justice. But there was now a political willingness to ‘spend big bucks – on some areas’, he said. ‘We’ve got the Treasury backing this with some major investment, for which a big hats off to Dame Carol.’ Once again, however, it was crime that had ‘animated the strategy and unlocked the funding.’
Collective Voice director Oliver Standing
Overall the strategy was ‘really good news’, he said, and it was important to separate the policy detail from the political framing that accompanied its publication. ‘Although the phrase “harm reduction” isn’t leaping off every page, one of the three key metrics that the strategy picks out is about reducing harm and deaths.’
The focus on workforce was ‘essential’, he said – and getting that right would be a necessary condition for everything else. ‘I’d also include commissioners in that – it’s become abundantly clear that the commissioning workforce that will enable these things to be funded and commissioned has been absolutely hammered. We need to be clear that investing in those back-office functions is not taking money from the frontline – we need the infrastructure to support the whole system.’ In political terms, the move from PHE to OHID was good news in that ‘it’s relocating our specialist policy function into a government unit that has an explicit mandate to reduce health inequalities’.
While the focus on crime was clearly politically driven, a huge number of people in the criminal justice system had challenges around drug use and ‘absolutely need our help’, he said. It was important to ‘not lose too much sleep’ over the launch’s punitive framing and instead ‘focus on the good stuff’. Talk of middle-class cocaine use might have accounted for much of the media coverage, but ‘if you look at the money there’s about £5m committed to that, and £700m on treatment and recovery’.
co-chair of LJWG, Dr Emily Finch
The acknowledgement that addiction was a chronic health condition was also ‘really helpful’, said Dr Emily Finch, vice chair of the NHS Addictions Provider Alliance and co-chair of LJWG. ‘That comes, of course, after years of being told that people have to get off methadone in the next three weeks and that drug misuse is a lifestyle problem.’ Although the strategy’s talk about preventing stigma was ‘perhaps not entirely supported by some of the language’ it was ‘good that it’s there,’ she added.
The commitment to improve treatment capacity and quality included metrics for numbers of places, but it was important to avoid ‘bean counting’, she stressed. There was still significant emphasis on performance and accounting, and ‘we need to be careful that doesn’t become more numbers and less actually doing things’ as the sector was already the most performance-managed in the whole of health. ‘It would have been very nice to have more emphasis on local creativity, and ability to develop your own targets.’
Allocation of the new money would involve a menu of interventions that local areas would be able to provide, she said. ‘That sounds good but again there’s a bit of me that says, “Is that going to mean we lose any ability to have individualised, patient-focused treatment, and perhaps a word that’s become completely alien – choice? You get what you’re given in drug and alcohol services, so it would be nice to offer a broader range of treatment.’
The field now had a real chance to come together, said Standing, and it was important that everyone played their role in damping down any potential conflict ‘along the old fault lines of harm reduction and recovery – we’ve clearly got to have both.’ In terms of funding, Dame Black had made recommendations for five years, and the spending review’s lifecycle meant ‘we’ve got the first three years of that – our job now is to deliver this really successfully for the people who need help.’ It was vital to demonstrate that the system was happy to be scrutinised and have accountability, he stressed. ‘If we can do that then we’re likely to get years four and five.’
Forward CEO Mike Trace
‘I think it’s very important to understand that the mood in which this money’s been allocated by ministers – and particularly the Treasury – is of support for the sector, but with patience running out for the delivery of outcomes,’ warned Forward CEO Mike Trace. The outcomes framework and accountability systems would need to be ‘really robust’, he stressed, with accountability focussing on issues like ‘have you reduced crime in your area, reduced deaths, eradicated hep C? That’s the sweet spot the Home Office and health are trying to find. But it’s crucially important that we deliver the outcomes the community and the government want. Because if not, it will end in three years.’
For service users with complex substance misuse and mental health needs, it’s common to use terms such as dual diagnosis and co-existing conditions.
While language is important, the reality for people who need help is that this debate can lead to a ‘chicken or egg’ scenario where they, their needs, and their hopes for recovery become lost in the cracks of who offers what within the limits of commissioned services.
Within North Yorkshire, York and Selby, as an attempt to come together across services, we’ve had in place for many years the Dual Diagnosis Network – with partner agencies from health, substance misuse, social care, police and wider services all collaborating to share learning, training and a hoped-for vision for a better way of joined-up working. However, we’ve also worked to build connections, offer system-wide supervision, and hear the valued work each other is doing to support a person-first approach. The hope is that by connecting the gaps between us and our services are reduced.
While each service has operational policies to support joined-up working we’ve acknowledged as a group that there remain times when the care for service users who experience complex dual diagnosis needs is not always as we would like it to be. As a result we decided to build a clear pledge to be better together, as individuals and services, so as to work in a way that truly and collaboratively joins up around the needs of service users.
While this is currently a work in progress, we’ve been spending time looking at building awareness of the challenges to system-linking, building a network of supportive ‘phone-a-friends’ and identifying how to share and spread our vision and enthusiasm to make every person’s experience of services truly joined up and connected. Many involved in this process highlighted that, while the infrastructure was important, it was the connections with people that made the difference in terms of managing barriers to care across services. For many of us, examples of high-quality patient care were those where clinicians were connected across the system, open to new possible approaches, leaning in at times of challenge, linking in with each other, having a face to a name, feeling safe to challenge the prevailing viewpoint, and asking for help.
By holding our three principles (see box) in all conversations and interactions, we all felt that the quality of care we provide can continue to be improved, and allowed for challenging yet healthy conversations to support the needs of those in our services – so they remain at the centre of what we do.
Working towards system togetherness is not without its challenges – funding, commissioning boundaries and attitudes can impact on what togetherness and system linking can realistically achieve. However, the common goal of supporting those with complex co-existing conditions should always be at our heart. So far, the pledge has been developed and is being signed up to by many of the key partners in our area. Watch this space to find out what we can achieve.
Dr Stephen Donaldson is a highly specialist applied clinical psychologist at Tees, Esk and Wear Valleys NHS Foundation Trust
Thousands of young people with substance issues are ‘falling through the cracks’ thanks to a perfect storm of the pandemic on top of years of cuts, according to the Royal College of Psychiatrists (RCPsych).
‘Intervening early will mean many kids won’t go on to have an addiction in their adulthood.’
Analysis of NDTMS data shows that the number of under-18s in treatment fell by almost 25 per cent between 2019-20 and 2020-21 to just over 11,000 – 55 per cent fewer than in 2008-09.
Most young people are in treatment for problems with cannabis (89 per cent), followed by alcohol (41 per cent), ecstasy (12 per cent) and powder cocaine (9 per cent). Further analysis of data from the Department for Levelling Up, Housing and Communities found that the amount spent on young people’s substance services had fallen in real terms by more than 40 per cent since 2013-14, from almost £74m to just over £43m. Every region in England had made real-terms cuts over the period, including of more than 60 per cent in the West Midlands.
Vice chair, Dr Emily Finch.
‘Children and their families up and down the country are having their lives blighted by drug and alcohol use due to drastic cuts, workforce shortages, and the impact of the pandemic,’ said vice chair of RCPsych’s addictions faculty, Dr Emily Finch. ‘Addiction is a treatable health condition. Intervening early will mean many kids won’t go on to have an addiction in their adulthood, keeping them out of the criminal justice system and helping them to live full lives. It’s now time for the government to act on their promise and deliver the multi-million-pound investment into drug services.’
Drug and alcohol charity WDP is delighted to announce that it has been successful in its bid to deliver a new integrated drug and alcohol service in West Berkshire.
The service will be delivered from a fixed hub in Newbury
The new service will commence from 1 April 2022 and will be operational for an initial five-year term.
Treatment and support will be available to all adults and young people who live in West Berkshire and require help with substance misuse of any kind. The service will be delivered from a fixed hub in Newbury as well as in a variety of satellite settings across the county.
The new service will have a strong focus on community, notably through WDP’s award-winning Capital Card scheme and will bring with it WDP’s recovery focus and commitment to working in partnership with the areas we serve.
WDP chair Yasmin Batliwala
Yasmin Batliwala, Chair of WDP said: ‘We are delighted to have been awarded the contract to partner with West Berkshire Council and to have the opportunity to provide high-quality substance misuse service provision to the residents of West Berkshire. As a lead agency in this field, we are looking forward to supporting the needs of the users of our services who are front and centre of all we do. We also look forward to welcoming our new staff team into the WDP fold.’
A new ‘national collaborative’ has been launched by the Scottish Government as part of its attempt to tackle the country’s ongoing drug-related death crisis. The collaborative will ‘ensure the views of people with lived and living experience are reflected in all aspects of the national mission on drug deaths’, the government says, and will be chaired by Professor Alan Miller, an expert in human rights law.
Chair of the collaborative, Prof Alan Miller
Regular forums allowing people with lived experience to make recommendations about improving treatment services will be chaired by Miller, with the rights of people affected by substance use ‘recognised in all relevant policy and practice in accordance with the new human rights framework for Scotland’. The country’s drug death rate is three times higher than it was a decade ago and remains the worst in Europe by a significant margin.
Angela Constance: Acknowledging the need to listen to the voice of lived experience
‘Successful delivery of the national mission requires a better way of listening to, and acting on, the voices of those with lived and living experience,’ said drug policy minister Angela Constance. ‘The people we need to be able to reach and support are some of our most marginalised and excluded citizens and ministers have been clear that it is for those people that the national mission aims to make rights a reality. Delivering on such an important strand of the national mission requires someone with a successful track record on delivering change on behalf of these groups of people and Professor Miller has been a leading voice in human rights through his work as independent co-chair of the National Taskforce for Human Rights Leadership and now on the Human Rights Bill Advisory Board.’
There were 280,000 alcohol-specific hospital admissions in 2019-20, according to figures from NHS Digital, a 2 per cent increase on 2018-19 and 8 per cent higher than 2016-17. The figures relate to the ‘narrow measure’ of admissions where the primary reason was an alcohol-related disease, injury or condition. According to the broad measure that includes a secondary diagnosis linked to alcohol, there were almost 980,000 admissions, a 4 per cent increase on the previous year and representing one in 20 of all hospital admissions.
The figures relate to cases where alcohol was the primary cause of admission to hospital.
Alcohol is now 14 per cent more affordable than it was a decade ago, says Statistics on alcohol, England, 2021, and more than 70 per cent more affordable than in 1987. The number of drugs prescribed to treat alcohol misuse in 2020-21, meanwhile, was 167,000 – a 1 per cent increase on 2019-20 but 15 per cent lower than 2014-15, with a net ingredient cost of £4.6m.
Northern Ireland registered more than 350 alcohol-specific deaths in 2020, an increase of 15 from the previous year and the highest yet recorded, according to the Northern Ireland Statistics and Research Agency (NISRA). Two thirds of the deaths were male, and most were in the 45-64 age range, with the highest death rate in the Belfast Health and Social Care (HSC) Trust area. ‘The relationship between the rate of alcohol-specific deaths per 100,000 population and the level of deprivation remains the same in 2020 – as deprivation increases, so too does the rate of alcohol-specific deaths,’ says NISRA.
WDP has launched its Individual Placement and Support (IPS) impact report for 2019-2021.
The report reflects the huge benefits that tailored employment support can have for people with experience of addiction as well as the wider community.
Since early 2019, WDP’s award-winning IPS Into Work service has focused on achieving sustainable employment to help reduce stigma, enrich lives, boost local economies, develop additional talents, and create workforces that reflect the diversity of their local communities.
Despite a challenging year due to the pandemic, our IPS into Work team has supported 218 service users into employment and provided over 3,700 hours of support to participants during 2019-2021.
Speaking about their experience of IPS Into Work, one service user said: “I have been in services for 15 years and truly believe this is an essential part of the jigsaw of which I call my recovery. [I’m] looking forward to my first step in that direction.”
One key success has been helping service users to engage with prospective employers and building up local networks so they have access to regular opportunities. Over the last year, the team has worked with more than 100 different employers and IPS Into Work service users have obtained jobs across 10 sectors.
Yasmin Batliwala, Chair of WDP, said: “At WDP, we are committed to supporting the development of resilient communities. Our experience tells us that helping service users to access employment opportunities, and subsequently supporting and sustaining such employment, is a vital part of what we do to achieve this commitment.”
Kim Archer, West London Alliance Commissioner, said: “We are delighted to have commissioned this innovative service from WDP. Employment is such an important part of sustaining recovery for people with addictions. WDP have been an excellent partner in delivering this personalised and effective service to our residents.”
SIG Medway outreach peer mentor coordinator, Donna Payne, has been looking at ways to engage peer mentors and clients and increase their mental and physical health wellbeing. Below, you can read an update from Donna of a successful initiative that did just that.
Since I became the recovery peer mentor coordinator for Medway, I have been working along with the peer mentors to engage with clients that are struggling with substance misuse.
A large number of clients have claimed that boredom and having no structure to their day is one of the main reasons for their substance misuse. A few have said they take drugs to sleep some of the day away, which is a sad thought, but one that all our peer mentors can relate to.
One of the peer mentors, Sam, and I came up with the idea of arranging badminton with a few of the peer mentor clients. We booked two courts at Medway Park, and this proved to be a great success and lots of fun was had by all. It was great to see the motivation and completeness of the clients coming out.
One of these clients who is also one of the ‘intense needs’ clients at Pathways came to me the next day and said he was on such a natural high that when he got home, he decided he didn’t actually need a drink or a ‘pick me up’ and just stayed in the house and watched TV.
Word has got out about our sporting trip and we recently had our second badminton session, and more people came along. As most of our clients are on benefits, they can get a £2.40 pass a year to get access to free or heavily subsidised activities at the leisure centre. It’s a win win all round, where clients can go to spend their time in a meaningful way, increase their mental and physical health wellbeing and is a great way for the peer mentors to engage with their clients.
People are using more cannabis since the COVID-19 pandemic, according to a major survey of almost 50,000 people by EMCDDA.
Cannabis and MDMA were the drugs most impacted by COVID-19 restrictions, it found, with use of ‘party drug’ MDMA unsurprisingly falling during the same period.
The European Web Survey on Drugs ran during March and April 2021 when many countries were under lockdown restrictions, with responses from across 21 EU member states and Switzerland. The survey targeted adults who had used drugs, with the aim of understanding patterns of use – more than 90 per cent of respondents reported using cannabis during the previous 12 months, with 32 per cent saying they were now using more (herbal) cannabis. More than 40 per cent, however, said that they were using less MDMA/ecstasy.
Last summer harm reduction organisation The Loop warned clubbers and festival-goers to ‘pace themselves’ as venues started to re-open after lockdown restrictions, particularly as their tolerance may have reduced after a period of abstinence. There have also been reports of an MDMA ‘drought’ in the UK since lockdowns ended, with production falling due to lower demand and suppliers focusing on trafficking more lucrative drugs for which the criminal penalties are the same. This has led to warnings about the availability of heavily adulterated drugs, or other substances being sold as MDMA.
While the European Web Survey data refer to a ‘self-selected sample who have used at least one illicit drug in the 12 months prior to the survey’ and are not representative of the general population, when ‘carefully conducted and combined with traditional data-collection methods, they can help paint a more detailed, realistic and timely picture of drug use and drug markets’, says EMCDDA. The most commonly used drugs after cannabis were MDMA and cocaine (35 per cent of respondents in each case), followed by amphetamines (28 per cent), LSD (20 per cent), NPS (16 per cent) and ketamine (13 per cent).
EMCDDA director Alexis Goosdeel
‘Web surveys are a key ingredient in our monitoring of Europe’s shifting drugs problem,’ said EMCDDA director Alexis Goosdeel. ‘They help us reach an important target population through innovative online methods. Today’s results reveal the wide variety of drugs available across Europe and provide valuable information on emerging trends and changing patterns of use during the COVID-19 pandemic. An impressive 100 organisations joined us this time in building, translating and disseminating the survey, ensuring that this is now an invaluable tool to help tailor our responses and shape future drug policies’.
People who were already at risk of alcohol harm bought ‘significantly’ more alcohol during COVID-19 lockdowns, according to a new study by Newcastle University and the National Institute for Health Research (NIHR). People in the top fifth of households for alcohol purchases bought 17 times more alcohol from retail outlets than the bottom fifth, says the study published in scientific journal PLOS ONE.
The research covers the March to June 2020 lockdown period and echoes previous studies which found that those already drinking the most increased their consumption during lockdowns. Households in the North were buying the most alcohol, the study found, with the North East of England consistently recording the highest alcohol-related death and hospital admission rates (https://www.drinkanddrugsnews.com/alcohol-specific-deaths-up-almost-20-per-cent/).
Researchers analysed shopping data from almost 80,000 households over a five-year period, which included around 5m purchases of alcohol. The average purchase per adult in the top fifth group was around 38 units per week – however, as this was averaged out per household it could mean that people in some households were ‘drinking much more than this amount’. Households in the North East and Yorkshire and the Humber regions increased their purchases more than in any other part of the UK, ‘with the suggestion that this is probably because the North has more socially disadvantaged, heavier-purchasing households’. Less pronounced purchasing increases in Scotland and Wales could be down to the implementation of MUP, say the researchers.
Prof Peter Anderson: Policies to reduce high levels of drinking ‘even more important’
‘Our analysis has highlighted that the heaviest drinkers and those living in some of the most deprived communities in the UK have increased their household alcohol purchases significantly during COVID-19 lockdown periods, with undoubted consequences for both physical and mental health – and in many thousands of cases sadly leading to death,’ said lead author Professor Peter Anderson of Newcastle University. ‘This suggests that a focus on policies to reduce high levels of drinking are even more important in extraordinary times, such as those we’ve seen since March 2020 – where a complex range of factors can lead to higher and potentially dangerous levels of longer-term drinking.’
Prof Sir Ian Gilmore: Another key opportunity for minimum unit pricing to make a difference
The findings have renewed calls for MUP to be implemented in England. ‘The alcohol harm crisis will continue to deepen if the government doesn’t take action now,’ said Alcohol Health Alliance chair Professor Sir Ian Gilmore. ‘This study suggests that minimum unit pricing can make a difference to purchases – with household alcohol purchases from shops and supermarkets in Scotland and Wales not increasing by the same level as England over the course of the 2020 lockdown. By failing to implement minimum unit pricing as part of its plans for public health, England is now falling further behind the rest of the UK in the race to tackle alcohol harm.’
Change Grow Live has been awarded the Investing in Volunteers Standard.
Investing in Volunteers is the quality standard for all UK organisations that rely on the hard work and dedication of volunteers.
Our volunteers help us make a real difference in people’s lives, and we couldn’t do the work we do without them. Achieving this standard shows the value we place on volunteering, but it is also a celebration of the volunteer experience at Change Grow Live
This is the first time that our approach to volunteering has been externally assessed. Towards the end of 2021, we carried out an assessment against the Investing in Volunteers standard, including volunteer recruitment, support, training and management.
Chris Benfield, head of volunteering and accredited learning for Change Grow Live, commented:
“We have a strong history of volunteers who make an enormous contribution to our services and the lives of those that use our service around the UK. Achieving Investing in Volunteers is a ringing endorsement of the efforts of staff across Change Grow Live in making it a safe and rewarding place to volunteer. The report has also identified several areas of outstanding practice, I couldn’t be happier!”
The assessment showed excellence in all areas of our work with volunteers. 52 volunteers and 16 staff (including our chief executive officer, Mark Moody), from across 20 services took part in the assessment. A further 145 volunteers participated in a related survey.
Some of the volunteers who took part in the assessment had the following insights to share:
“Volunteering has brought me on in my life and growth so much. I can’t thank everyone enough. The growth we’ve been given and the support to go for employment within Change Grow Live has been amazing.”
“Volunteering is inclusive. There are no restrictions. Equality and diversity is definitely there. You meet people from all walks of life and different types of volunteers.”
The prevention of deaths in custody and after release needs to be ‘central to all work on substance misuse in the criminal justice system’, according to a report from the Independent Advisory Panel on Deaths in Custody (IAPDC) and the Royal College of General Practitioners (RCGP). A whole-system approach is needed to prevent drug and alcohol-related deaths among prisoners and those released back into the community, with all government and agency work putting prevention of avoidable deaths ‘at its core’.
Prisoners experience feelings of hopelessness, boredom and desperation.
Levels of drug and alcohol use in the prison system are high, says the document, with the pandemic exacerbating the situation – prisoners are spending up to 23 hours a day in their cells, worsening feelings of ‘hopelessness, boredom and desperation’. People are at particular risk of a drug-related death in transition between prison and the community, it states, with just over 60 per cent of prison leavers failing to attend treatment appointments despite the high risk of relapse and overdose.
Better collaboration between health, criminal justice and community staff is needed to encourage continuity of treatment, the document states, with community drug and alcohol services properly resourced to ensure full coverage, reduce waiting times and divert more people into community treatment. More work is also needed to improve data on substance misuse in prison, it adds, as the scale of the problem is still not adequately documented or understood
‘Every substance-misuse related death in prison can and should be avoided,’ said chair of the RCGP’s Secure Environments Group Dr Jake Hard. ‘Our report highlights how such deaths can be prevented by increasing the opportunities for collaboration between government departments, prison staff and treatment providers, to ensure treatment and recovery is effectively managed throughout the criminal justice pathway. It is not enough to simply focus on detection and disruption of drug supply – we must ensure every individual affected by drugs or alcohol within prison and on release has access to the same quality of treatment that would have been available to them in the community.’
There is a strong case for a peer-led needle and syringe exchange service in London, according to a new report from the London Joint Working Group on Substance Use and Hepatitis C (LJWG). The group has been working with Hackney Council to look into the feasibility of developing a peer-led and delivered NSP with added hep C awareness and testing facilities, using focus groups and interviews with specialists (DDN, December/January, page 5).
Peers are able to use their lived experience of injecting drug use to deliver education and advice, says LJWG, with a peer-led service able to fully ‘embed leadership’. More than 40 per cent of people who inject drugs still report sharing equipment, with hepatitis C infection levels remaining high.
The report, which was funded by Hackney Council as part of project ADDER, looks at the feasibility and acceptability of a peer-led NSP, as well as practical considerations. It found a high level of support among peers, people who inject drugs and commissioners, with an initial three-to-five-year funding commitment able to provide stability for the new service. The facility would be welcoming and non-judgemental, says the document, with people signposted to other essential services. Monitoring and evaluation mechanisms would need to be embedded, with peers delivering the service via clearly defined roles – both paid and unpaid – with training and supervision.
‘There is clear support from people who inject drugs, people who work with people who inject drugs, commissioners and from public health specialists for an innovative, peer-based needle exchange service in London,’ says the document. ‘This will support important public health goals including reducing health inequalities, reducing harms from drug use, and reducing hepatitis C and other BBV transmissions. There are complexities in developing and delivering such a service, which would need to be designed and led by a cross- stakeholder steering committee which will include peers. Robust evaluation mechanisms should be put in place so this service could become a blueprint for services across the UK and beyond.’
A sculpture, named ‘Hubert’ by one of the artists involved in its creation, was unveiled at the SIG Penrose Roots to Recovery Seasonal Gathering in December.
The sculpture was a culmination of weeks of work and was made totally from recycled and found items.
The body is an old trampoline decorated with CDs, the eyes are bike wheels carefully woven with pieces of old fabrics and the wings are made from chicken wire with the feathers cut from milk cartons – which was a very time consuming and incredibly effective idea.
Hubert’s eyebrows are plastic tennis rackets and his grown of glory part of a vegetable stand decorated in beads from a broken necklace.
The wooden framework that holds Hubert up are old bits of wood and the deep holes that secure him into the ground were dug by the hardcore gardening team.
Elizabeth Aldous, a core part of the creative team said: “It is a great example of how you take items that are seen as useless and turn them into something so stunning and imaginative.”
Everyone involved enjoyed the project so much that they are now thinking of ideas for the next installation. After all, they have the space and inspiration of nature around them at the garden.
Hubert’s unveiling was a great launch with fairy lights and tinsel added to bring the Wise Owl to life.
“We sang seasonal songs and even did a dance around him. The singing was so enjoyable that we are now hoping to begin our own Penrose Choir. This was a great end to the wonderful party that had been arranged by the Penrose Team who put on a great spread and decorated our polytunnel to look beautiful. Without sounding too corny it was a real hoot!” Elizabeth added.
Hubert can actually be seen over the hedge from the footpath leading to the garden and we hope he will continue to bring much happiness to those who see him.
The proposed ‘Right to addiction recovery (Scotland)’ bill would ‘further disempower’ people presenting to treatment services and create an oppositional rather than therapeutic relationship between providers and service users, says a joint statement from organisations in the Scottish drugs field.
Leader of the Scottish Conservatives, Douglas Ross MSP
Consultation has just closed on the bill, which has been proposed by leader of the Scottish Conservatives, Douglas Ross MSP and is intended to ‘enable people addicted to drugs and/or alcohol to access the necessary addiction treatment they require’.
However the signatories of the joint statement, which include the Scottish Drugs Forum, Release, The Scottish Recovery Consortium and HIV Scotland, assert that the bill’s proposals would result in ‘unintended consequences’ detrimental to the improvement of the country’s treatment system. Scotland’s drug-related death rate remains significantly higher than anywhere else in Europe, while the country’s alcohol-specific death rate was also up by a fifth last year (DDN, September 2021, page 4).
‘The evidence is that treatment is key to protecting people from drug-related deaths and supporting people with problem substance use more broadly,’ the statement reads, with the Scottish system overall lacking the ‘quality, diversity and capacity’ to fulfil its potential in protecting people from drug-related harm and death. While the draft bill’s proposals represent a welcome opportunity to raise awareness and promote discussion, they also threaten cross-party consensus, risk replacing a rights-based approach with a legislative approach, and ‘consolidate the idea that people with an addiction are not to be extended the rights afforded under the Equality Act to other people with significant health conditions’, it states.
SDF CEO David Liddell
The bill aims to ‘enshrine the right’ to treatment in Scottish law and ensure that people can access a preferred treatment option, including residential and community-based services, unless deemed harmful by a medical professional. However, its proposals are also ‘based in a false premise about the aims of treatment and a narrowly focussed recovery – about abstinence rather than quality of life’, said SDF CEO David Liddell. ‘That served as the premise of The road to recovery strategy that was so damaging to Scotland in the past – a strategy that the drugs field and the wider policy context has now moved well beyond. This wider view of recovery is vital if we are to deliver on reducing drug-related deaths.’
The proposals risked further disempowering people from seeking treatment by ‘giving others the power of veto over their treatment choice’, he said, something that also risked damaging the ‘establishment and development of a therapeutic relationship on which the success of all drug treatment ultimately depends. And lastly, the bill would be neither sufficiently radical nor bold enough to achieve its aims. People with a drug problem will have the rights they need and deserve, when they are fully recognised under the Equality Act – an act which currently enshrines in law their stigmatisation and marginalisation by explicitly excluding them.’
Forward’s employment service director Asi Panditharatna looks at what the organisation has achieved over the last year and goals for 2022.
Happy New Year to our commissioners, funders, partners, employers and the people we support.
In 2021 we had an amazing year providing more employability, vocational training, careers advice and enterprise support services to people across the country.
We started delivering new contracts including the Department for Work and Pensions Restart scheme in Thanet as well as the Kickstart programme for young people and an Adult Education Budget (AEB) programme in London and Kent. We are also proud to have launched new Information, Advice and Guidance services and expanded our enterprise and self-employment work.
We’ve extended our apprenticeships delivery through the provision of the Level 4 Employability Practitioner Standard and supporting more Employability Advisors to develop their practice by starting this apprenticeship. We have joined the Institute of Employability Practitioners and this affirms our commitment to supporting people to work, progress in and retain work.
In 2022, we look forward to further opportunities to expand our footprint and impact through the future commissioning of prison education and Information, Advice and Guidance services; probation education training and employment services; the new DWP Dynamic Purchasing System, more devolved AEB programmes and boot-camps through Combined Authorities, as well as growing our apprenticeships delivery.
Setting New Year’s Resolutions
Everyone should set goals at the start of the New Year. For 2022, we’re encouraging the people we work with and support to commit to the following behaviours that will help them achieve their goals:
Develop a strong sense of control over the parts of your lives or situations your can influence and spend your time and attention on these aspects. This also involves taking greater responsibility and discovering how to navigate a path to success. For example, this may mean attending networking sessions with our employer partners as part of our Restart or AEB programmes.
Become more motivated, work smarter and harder and take advantage of opportunities. For example in 2021 we offered work experience/taster opportunities with the Financial Times and Symphony to learn about the publishing and Fintech sectors.
React to your feelings of being overwhelmed and emotions with a clear head and put yourselves in control of the situation. For example if a job or interview feels overwhelming, ask your Forward Trust Employment Advisor to arrange some mock and practice interviews first.
Build and develop networks that will help you understand better an industry or sector, the career pathways and specific people who can help or advise you. Networks including those through LinkedIn or our exciting Forward Enterprise Club can also help you better understand how to behave and what to say in specific environments.
Ask for help when you need it. There is help out there and the Employment team at Forward are here to help.
A future regulated cannabis market in the UK needs to incorporate guiding principles to repair historical injustices, says a group of campaigning organisations and charities. With more than half of the British public supporting legalisation of cannabis for recreational use and widespread legislative change in countries from Germany to Canada, cannabis reform in the UK is now ‘inevitable’, states a new report published by Release.
‘The question is not when but how cannabis will be regulated in the UK,’ the charity states. While change may be ‘a few years away’ it should be guided by 14 social equity principles to be incorporated into any future legal market. These include investing tax revenue in communities that have previously been over-criminalised as well as in wider drug treatment, and the automatic expungement of past convictions for cannabis-related offences. Decriminalisation also needs to go ‘hand-in-hand with regulation’ by removing all criminal or civil sanctions for possession – whether the cannabis is of legal or illegal origin –and allowing people to cultivate cannabis domestically in the same way they are allowed to brew their own beer.
Thousands of people every year – predominantly those from ethnic minority communities or living in poverty – continue to be subject to life-changing criminal penalties for cannabis-related offences, says Release. So far 15 organisations including the Green Party, LEAP UK, International Drug Policy Consortium, Transform, the Beckley Foundation and Liberal Democrats for Drug Policy Reform have pledged support for the principles, which outline an ‘evidence-based roadmap to prioritise and protect those most vulnerable to the harms of prohibition’.
Laura Garius: Change is inevitable to overturn ‘tough on drugs’ rhetoric
“The UK government’s new drug strategy regurgitated a “tough on drugs” rhetoric, despite the Home Office’s own research concluding that the estimated £1.6bn spend per year on drug law enforcement is not impacting levels of drug use,’ said Release policy lead Dr Laura Garius. ‘Change is inevitable – cannabis is the most widely used illicit drug in the UK and the world, and it is simply too lucrative a market for politicians to ignore. However, we must make sure that cannabis will be regulated right. The legal renaissance of cannabis is a vital opportunity to address the harm that cannabis prohibition has caused to Black and Brown communities and to people with lived experience of cannabis policing.’
Steve Rolles: We need to hardwire a social justice agenda into legislation
‘The legal regulation of cannabis markets is no longer a theoretical discussion – it is being debated and implemented in jurisdictions on every continent,’ added senior policy analyst at Transform, Steve Rolles. ‘The inevitability of change creates a responsibility on policy makers to ensure that reforms serve the needs of the whole community, not just the profit-seeking priorities of big corporate actors. This means hardwiring a clear social justice agenda into legislation from the outset, in particular making sure that the marginalised communities who carried the greatest burden of the drug war’s failure are able to share in the peace dividends.’
Regulating right, repairing wrongs: exploring equity and social justice Initiatives within UK cannabis reform at www.release.org.uk
Turning Point’s director of quality and risk and registered mental health nurse, David Foord, talks about Blue Monday, winter blues, mental health tips, support available and impact of COVID.
Blue Monday is supposedly the saddest day of the year – is that true?
The concept was originally proposed by Psychologist Dr Cliff Arnall for a marketing campaign for a travel company. Dr Arnall developed a formula, which considered factors including Winter weather, people’s probable level of debt, time after Christmas and new year’s resolutions, generally lower motivation levels. Dr Arnall has since been remorseful about how his work has turned into such an annual phenomenon. In fact, he has more recently said:
“Whether embarking on a new career, meeting new friends, taking up a new hobby or booking a new adventure, January is actually a great time to make those big decisions for the year ahead”
Enough of the pseudoscience, feeling blue on any Monday or on any day is a serious matter and I am far from alone to feeling lower at this time of year than at others. There is evidence all of the factors Dr Arnall used in his formula have a significant impact on mood and mental health; however, there isn’t enough evidence that this can be pinned to a specific date. For some people the impact of these issues alone or in combination can be just a lowered mood and for others it can be a lot more serious such as a condition called Seasonal Affective Disorder (SAD). Personally, I love to be outside a lot so this time of year does get me down as the weather prevents me spending as much time in the open air as I would like to. There are many however who are much worse off than me in this season.
How has covid made this worse?
However severe an effect this time of year has on you, do take it seriously, especially with the added pressures on us all caused by Covid. The restrictions caused by our attempts to control the pandemic can lead to increased social isolation and loss of physical connection with people. This inevitably has an impact on our mood and mental health. As humans, we are social creatures and need physical contact with other people to thrive. There are many studies into the impact of social isolation on physical and mental ill-health, some of which are referenced at the end of this blog.
A very recent Systematic Review was published just this month, into studies of loneliness and social isolation during the current pandemic. This supports the view that there is a significant impact of Covid on social isolation, which in turn adversely effects physical and mental health. On top of this many people are suffering from Covid themselves at this time or from the longer-term effects of having had the disease. There is so much we don’t know about ‘Long Covid’, which again can cause further anxiety to those suffering from it and struggling to recover from infection.
What three things would I recommend to those with Winter Blues?
Be social! I appreciate that when you are at your lowest, being motivated to be social is difficult, but it really will help. Connecting with other people will recharge your batteries and reduce the feeling of isolation and helplessness. Try to reach out to neighbours and friends, they may be in the same boat as you and you could help each other. Join an online book club; these are often free to join and can connect you with people with a shared interest (just beware of online scams).
Be active! Motivating yourself to exercise can also be extremely hard when your mental health is affected in any way, but this time of year makes it even harder. Get social in your activities. This doesn’t have to be completing the Tour De France, join a local walking club, but most importantly, do something that is going to benefit you. Going for a run is great for some but isn’t for all. Group classes like Yoga and Pilates are excellent for overall physical wellbeing, which will help your mental health – they are also indoor activities, so ideal for this time of year! I really notice the difference in my mental health when I don’t exercise regularly. As I write this, I have a knee injury from rugby (I know, I should know better at my age!), and it is really affecting my mood that I can’t do any training at the moment.
Have a plan! If you don’t plan to do it, it’s less likely to happen. Schedule time to be social and schedule time to be active. Plan your meals in advance so that you don’t resort to too many takeaways or fast food. The food we eat has a massive impact on our mental health in so many ways. Personally, when I eat the wrong things, too late at night, I wake up feeling lethargic and unmotivated, which isn’t a great start to the day.
A trial of ketamine and therapy for people with severe alcohol disorder has shown ‘extremely encouraging’ results in preventing relapse, according to researchers at the University of Exeter.
The study’s lead author, Professor Celia Morgan.
Almost 100 people with alcohol problems who were abstinent at the time of the trial were given low doses of ketamine in the first trial of its kind, with the results published in the American Journal of Psychiatry.
Researchers found that people who had ketamine combined with therapy stayed sober for more than 160 days of the 180-day follow-up period, representing almost 90 per cent abstinence. People in this group were more than two and a half times more likely to remain completely abstinent than those on a placebo. The patients receiving ketamine also recorded lower depression scores after three months, along with better liver function.
The participants had been drinking every day before the trial, consuming an average of 125 units per week. Those given ketamine and therapy only drank more than the recommended guidelines on five days over the six-month trial period on average.
The Ketamine for Reduction of Alcohol Relapse (KARE) trial was funded by the Medical Research Council, with biotech company Awakn Life Sciences licensing the therapy to use in their clinics. The University of Exeter and Awakn have also signed an agreement with Devon Partnership NHS Trust to explore the potential of ketamine-assisted psychotherapy in the NHS. The use of drugs like ketamine in addiction and mental health treatment remains controversial, and would require approval from NICE to allow prescriptions by the NHS.
‘The number of alcohol-related deaths has doubled since the pandemic began, meaning new treatments are needed more urgently than ever,’ said the study’s lead author, Professor Celia Morgan. ‘We found that controlled, low doses of ketamine combined with psychological therapy can help people stay off alcohol for longer than placebo. This is extremely encouraging, as we normally see three out of every four people returning to heavy drinking within six months of quitting alcohol, so this result represents a great improvement.’
The researchers were ‘certainly not advocating taking ketamine outside of a clinical context’, she stated. ‘Street drugs come with obvious risks, and it’s the combination of a low dose of ketamine and the right psychological therapy that is key, as is the expertise and support of clinical staff. This combination showed benefits still seen six months later, in a group of people for whom many existing treatments just don’t work. Previously, there were some concerns about using ketamine in alcoholics due to liver problems, but this study has shown that ketamine is safe and well-tolerated in clinical conditions. In fact, we found liver function improved in the ketamine group due to them drinking much less alcohol.
‘This was a phase II clinical trial, meaning it’s conducted in people primarily to test how the safety and feasibility of the treatment,’ she continued. ‘We now have an early signal this treatment is effective. We now need a bigger trial to see if we can confirm these effects.’
Ketamine adjunctive to relapse prevention based psychological therapy as a treatment for alcohol use disorder available at https://ajp.psychiatryonline.org
DRINK AND DRUGS NEWS (DDN) is the monthly magazine for everyone working with substance use issues. Since 2004 it has become established as the authoritative voice of the sector, the place for in-depth news and features and the forum for debate.
Published independently by CJ Wellings, DDN is distributed through a printed circulation that has a readership of more than 25,000. The website, receives more than 20,000 visitors a month and the DDN Bitesize weekly email alerts go to 6,000 subscribers. It’s the place to find all the latest news, comment, information, resources and jobs. With its thriving comment and letters pages, the magazine is the must-read forum, linking to the DDN Facebook page and over 10,000 Twitter followers.
The DDN community links people working with drug and alcohol problems with the wider health and social care field. Through fair and balanced journalism the magazine has become valued as the regular read for a discerning and interactive community that includes treatment agencies, commissioners, medical professionals including GPs and nurses, those working in the criminal justice service, housing professionals, social workers, politicians and policy-makers, service users, advocates and people working in education, prevention and all areas of public health.
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Articles and feature contributions need to be emailed to claire@cjwellings.com by the 15th of the month before the press date. (News items can be sent up to the last minute!) The deadline for letters and comment is the Wednesday before publication. Please get in touch to discuss features so they can be scheduled in advance.
The advertising print deadline for each issue is 3pm on the Friday before publication. Please email ian@cjwellings.com for details
The mechanical information and sizes for print adverts is available here.
We publish ten issues a year, the issue dates for 2023 are:
February issue: Monday 6 February
March issue: Monday 6 March
April issue: Tuesday 3 April
May issue: Monday 1 May
June issue: Monday 5 June
July/August issue: Monday 3 July
September issue: Monday 4 Sept
October issue: Monday 2 October
November issue: Monday 6 November
December/January 2024 issue: Monday 4 December
Articles and feature contributions need to be emailed to claire@cjwellings.com by the 15th of the month before the press date. (News items can be sent up to the last minute!) The deadline for letters and comment is the Wednesday before publication. Please get in touch to discuss features so they can be scheduled in advance – and please see the scheduled themes for each month, below.
The advertising print deadline for each issue is 3pm on the Friday before publication. Please email ian@cjwellings.com for details
The mechanical information and sizes for print adverts is available here.
DDN themes for 2023
February
Alcohol
Wellbeing
March
Housing & resettlement
Gambling
April
Training & careers
Early trauma
May
Criminal justice
Mental health (MH Awareness Week, 9-15 May)
June
Volunteering (Volunteers’ Week, 1-7 June)
Veterans
July/August
Hepatitis C (Hep C Awareness Day, 28 July)
Alcohol (Alcohol Awareness Week, 3-9 July)
DDN Conference coverage
September
Recovery Month
Enterprise
October
Criminal justice
Mental health (MH Awareness Day, 10 Oct)
November
Homelessness
Lung health (COPD Awareness Day, 21 Nov)
Dec/Jan 2024
Women’s services
Stigma
Throughout the year: ideas and innovations for the ‘best practice exchange’; career stories for the Careers Clinic and ‘I am a…’ series; interviews, Q&As, profiles and advice pages.
The pandemic has worsened health and wellbeing for many and widened inequalities further. Link workers can improve outcomes for people whom GPs may struggle to support and help achieve better results, writes Julie Bass.
Primary care is once again at the forefront of vaccination efforts, this time in the race to booster-jab the nation against Omicron.
GP resources were already stretched to the limit long before this latest crisis, and before the pandemic itself. What covid has done is to shine a spotlight on the need for better long-term solutions to lighten the ever-increasing load carried by practices.
Social prescribing is an approach that could make working life easier for a greater number of primary health care professionals. It could improve patients’ quality of life by tackling unmet non-medical need and delivering the right support.
A key part of NHS long-term plan goals, this form of community referral delivers help and advice through link workers or wellbeing coordinators. Although many schemes are relatively new, findings suggest they can improve wellbeing and encourage positive thinking. The NHS aim is to have 900,000 people referred to link workers by 2023-24.
So far, the focus has been on putting people with low-level health and wellbeing issues, such as anxiety and loneliness, in touch with befriending services, debt advice and bereavement groups. What these social prescribing schemes haven’t been able to do is take on (in a way that is effective) particularly vulnerable patients where there are high levels of risk.
However, Turning Point is well-placed to manage risk because of our established clinical governance structures overseen by a senior clinical team. The result has been a new approach that targets patients with complex needs who take up considerable GP time.
In the first service of its kind in the UK, we have joined forces with six primary care networks across 29 surgeries serving over 200,000 patients in and around Birmingham. This specialist social prescribing scheme is commissioned by Our Health Partnership which is one of the largest GP partnerships in England. Also involved are agencies including Age Concern, Shelter and local pharmacies.
Drug problems, domestic abuse, dementia. These are just some of the issues supported by our multidisciplinary team of staff who have the expertise and training to identify the right help in the community. To access a programme of support, the individual must be judged as having complex social needs: they could for example be homeless, a sex worker, abuse drugs and alcohol, engage in offending behaviour, or come from a traveller community.
The approach provides a space to tackle the social and economic inequalities that can impact on an individual’s health. The benefit of locating this type of service in primary care is that patients – whose social circumstances pose a major risk to their health – can be more accurately identified and supported, and GP time is freed up. Before, a significant part of a GP’s workload would have involved understanding a patient’s particular situation and liaising with other agencies to ensure they were getting the right support.
A social prescribing programme for non-complex needs is already delivered across Birmingham by The Active Wellbeing Society (TAWS). To create a smooth pathway, Turning Point and TAWS have created a joint referral form and single point of access for the forms to be submitted. This approach means GP practice staff do not have to triage in relation to the “complex” criteria – this is instead done after the referral has been put forward for consideration.
Since the specialist social prescribing service went live in August, there have been several success stories including that of Johnny (name has been changed) who was referred by his GP to a link worker. The former prisoner was known to drug and alcohol services but not engaging with them, and was also experiencing memory issues which put him in contravention of his probation terms (he hadn’t attended appointments).
What Turning Point’s link workers did was to liaise with probation who agreed to reconsider his breach while Johnny was being investigated for dementia. The (dementia) diagnosis was confirmed after our link workers supported him to access the GP for a capacity assessment.
This in turn meant he was eligible for social care support and additional help from his probation team in order for him to remain compliant with his probation order conditions.
Change Grow Live outlines its naloxone strategy for 2022, aiming to make the life-saving drug as available to as many people as possible.
Since 2015, naloxone has played a major role in supporting the people who use our services. By temporarily reversing the effects of an opioid overdose, naloxone has helped to reduce the risk of overdoses and save people’s lives.
Now we are launching our strategy for 2022 to make naloxone more available to people than ever before. We want to make sure that anyone who needs naloxone has it to hand and knows how to use it.
Bringing naloxone to communities
Until now, we have focused on making sure that naloxone is available to people who are already using our services. We have increased the amount of naloxone kits we hand out year on year. This has made it possible for more people than ever to help someone who is having an overdose. We want to carry on with this, but we also want to provide more naloxone to communities.
We want to bring naloxone to people, instead of waiting for them to come to us.
At the heart of our strategy is making sure people know how they can get naloxone, how to use it, and why they should carry a kit with them.
We also want to make naloxone more available through local partnerships and a peer-to-peer approach.
The key partners who can help local services provide more naloxone are: approved premises, pharmacies, police, hospitals, ambulances, hostels, homeless shelters, and prisons. People can also help to give out naloxone to their own peers.
By working together as organisations and as individuals, we can make sure that naloxone kits and training are available throughout communities. This approach will empower people to support each other and to save lives.
Leading drug and alcohol charity WDP has been successful in its bid to work in partnership with Surrey and Borders NHS Foundation Trust and Surrey County Council in delivering substance misuse services in Surrey.
WDP chair Yasmin Batliwala – ‘This partnership provides an exciting opportunity to deliver meaningful support.’
WDP will be providing services as part of the wider NHS service, i-access, which is jointly provided by Surrey and Borders Partnership NHS Foundation Trust and Public Health (Surrey County Council). The new service provision will commence from 1 April 2022 and will be operational for an initial three-year term.
WDP will be delivering one-to-one and group support for service users, as well as harm reduction. It has an award-winning Capital Card scheme, and a unique family safeguarding service which will be co-located with children and families’ social services teams.
Yasmin Batliwala, Chair of WDP, said: ‘We are looking forward to working together with the Surrey and Borders Partnership NHS Trust and Public Health (SCC) to provide high-quality support for all those living in the county who require help with their drug or alcohol use. This partnership provides an exciting opportunity to deliver meaningful support which will enable the users of our services to explore options to ensure a positive future. We also look forward to welcoming new staff into the WDP family.’
A trial scheme to decriminalise cannabis in London will involve just three of the capital’s 32 boroughs and has yet to be approved by City Hall, according to the office of the Mayor of London. The office was responding to media reports on the plan, including an article in the Telegraph stating that ‘Sadiq Khan is planning to end the prosecution of young people caught with cannabis in a move to decriminalise drugs in London’.
The trial will aim to keep young people caught with cannabis, ketamine or speed away from police custody
Police in the boroughs of Bexley, Greenwich and Lewisham would be ‘told not to arrest young people caught with cannabis, ketamine or speed’, the article states. ‘Offenders will instead be taken back to their family homes and kept away from police custody.’ However, the trial will only apply to 18 to 24-year-olds found in possession of a ‘small amount’ of cannabis and will not apply to any other substances, the mayor’s office states, with the results ‘robustly evaluated’ before any further roll-out is considered.
Funding for the scheme has yet to be approved by the Mayor’s Office for Policing and Crime (MOPAC), the mayor’s office continues, and ‘does not mean that the mayor is moving to decriminalise cannabis – something he does not have the power to do.’ Looking at ways to divert young people away from the criminal justice system is ‘not out of step with the government’s drug strategy’, it adds, with the pilot based on the Thames Valley Model, which won an award in 2021.
‘The idea of the scheme, which is already used by other police forces across the country, would be to divert young people who are found with a small amount of cannabis away from the criminal justice system and instead provide help and support,’ the mayor’s office spokesperson stated. ‘This has been shown to reduce reoffending. Reducing crime is the mayor’s top priority and he will continue to explore and implement the most effective solutions to help to divert young people away from drug use and crime for good.’
Public health minister Maggie Throup, with a new anti-smoking campaign
Meanwhile, a new promotional film from the government’s ‘Better health smoke free’ campaign warns that young people whose parents or caregivers smoke cigarettes are four times more likely to start smoking themselves. ‘We know that many people make a quit attempt in January, and while there are so many good reasons to stop smoking for yourself, we hope that this new campaign – by highlighting the inter-generational smoking link with parents influencing their children – will be the added motivation many need to ditch the cigarettes for good this year,’ said public health minister Maggie Throup.
Almost 625,000 more people aged over 65 are now gambling online than at the start of the pandemic, according to analysis of Gambling Commission figures by the Royal College of Psychiatrists (RCPsych). The data relates to people gambling ‘at least once a month’, it says, some of whom could be at risk of developing a gambling disorder.
Henrietta Bowden-Jones: Many more older people are now gambling online
The proportion of over-65s gambling online at least monthly has risen from just under 9 per cent in 2019 to almost 14 per cent, largely due to the closure of physical betting shops during lockdown periods, coupled with lack of access to other activities. The next biggest rise was among 45-54-year-olds, with an increase of more than 341,000, although the number of 16-34-year-olds gambling online fell by 307,000.
‘The pandemic has shaken our lives in so many ways and these data show that many more older people are gambling online than were before the start of the pandemic,’ said RCPsych’s Professor Henrietta Bowden Jones. ‘Not everyone who gambles will develop a gambling disorder, but some will. Gambling disorder is an illness and if left untreated can lead to significant depression, anxiety and suicidal thoughts. The new information published by the Royal College of Psychiatrists will help anyone who’s worried about their gambling or knows someone whose gambling is becoming a problem.’
RCPsych has produced a new online resource on problem gambling – including advice for anyone who feels they may be developing a gambling disorder – at www.rcpsych.ac.uk/mental-health/problems-disorders/gambling-disorder
The new drug strategy offered real opportunities for change, heard the All Party Parliamentary Group for Drug Policy Reform, but it would take commitment from professionals to make these a reality
It was initially hard for many in the field to work out exactly what the government’s new drug strategy was, Forward CEO Mike Trace told a special All Party Parliamentary Group for Drug Policy Reform session on the document, as ‘all of the press pieces and political messaging were about tackling middle-class drug users, zero tolerance and bashing down doors. But the vast majority of it is about other – and broadly more sensible – stuff.’
Mike Trace: Welcomed the ‘whole system’ approach
The most influential page of the entire document may well be page 60, he said, which contained a framework of the strategy’s objectives – ‘if you want to read just one page to see what’s likely to happen in the future, have a look at that matrix.’ The three headline objectives were reducing overall drug use, reducing drug-related crime and reducing drug-related deaths and health harms, with the government saying ‘very clearly that it wants a whole-system approach, with the money spent behind achieving those’.
Prof Dame Clare Gerada: Needs ‘joined-up effort’ on underlying causes
‘I broadly welcome the strategy – it’s about trying to bring people into treatment, providing them with evidence-based treatment, looking for the people who are hard to reach, and trying to prevent people from getting into substance misuse in the first place,’ said former council chair of the Royal College of General Practitioners, Professor Dame Clare Gerada. ‘I think it will go some way towards addressing the problems we face. But we do need to address the underlying causes, and the ACMD has told us this many times – the deprivation, the hopelessness, the lack of housing. Unless there’s a joined-up effort then I’m not sure just a drug strategy in isolation is going to touch those underlying social causes.’
Drug poisoning and overdose deaths were being overtaken in terms of mortality by long-term conditions among people who use substances, Harry Sumnall of Liverpool John Moores University pointed out. These couldn’t be separated from drug treatment services, said Gerada, with the aging population now dying from co-morbid conditions such as cancers and cardiovascular disease. ‘I started my career going into needle exchange schemes carrying my equipment in a tiny bag and treating intravenous drug users who had no access to healthcare – doing cervical smears, blood tests. That would be completely illegal now, because it wasn’t CQC registered.’
Prof David Nutt: What are they actually going to research?
‘I was disappointed by the one paragraph on research, because it doesn’t actually say what they’re going to research,’ former ACMD chair Professor David Nutt told the session. ‘We should be researching safe injecting rooms, and if we’re not going to do it in England we should do it in Scotland.’ We should also be establishing pilot sites for drug testing, he said, as there was a real threat that the American fentanyl epidemic could hit the UK, as well as evaluating current initiatives such as Project ADDER and Scotland’s ‘innovative decriminalisation approach’ to see which provided the best outcomes. Another disappointment was the lack of any mention of alcohol, he added – ‘it has a huge impact not just on deaths from other drugs, but the health harms from other drugs.’
In terms of supply reduction, the document was ‘broadly saying let’s follow the same strategy we’ve followed for 50 years and hope it works this time’, said Trace. ‘You need to be clear on the outcome you’re hoping to achieve.’ In terms of the reducing drug-related crime objective, the government needed to articulate what it meant by that, he said. ‘Let’s say we want less violence related to the market, less victimisation of vulnerable people – if those are clearly articulated then we should be looking at different PCC areas to see which initiatives they’re following and who’s getting the best results. That’s eminently possible, but you’ve got to set your objectives first because we’ve been measuring the wrong stuff for 50 years.’
‘I did get a sense that it was a “year zero” statement – there’s no literature review,’ said former chief constable of Durham, Mike Barton. When it came to talk about clampdowns on middle-class drug users, the reality was that they were ‘immune from policing’, he said, and always had been.
Mike Barton: Crackdowns can increase violence
‘And when we talk about crackdowns, if we take out organised crime groups then we’ll just increase the violence. As soon as there’s police intervention you’ll see a significant rise in violence, because the police destabilise the market. I’m not saying we shouldn’t enforce the law, but there’s a direct effect from that destabilisation.’
The document discussed ‘world-class intelligence’, but the one system used to track organised crime was the Police National Database (PND), he pointed out. ‘That’s the only mechanism, but the PND has been starved of any development by the government since 2017. If parliamentarians want this to work, then the Home Office has to be confronted with the withering on the vine of the only intelligence system we have in the UK to tackle it.’
County lines gangs operated by ‘cuckooing’ – finding vulnerable people and using their homes as a base for moving into local drugs markets – so it was vital to ‘capture those cuckoos’, he said. ‘When we’re talking about the criminal justice system getting tough, the people the police are capturing at the moment are principally victims themselves,’ with a significant decrease in the mean age of people involved in drug distribution.
On the subject of prisons, the worry was that ‘we can’t actually cope with the number of offenders coming out at the moment. The one thing you have to do is make sure it’s not the drug dealer who meets them coming out of the prison gates, and that’s what we tried to concentrate on. At the moment, we dislocate them from their family support network, then release them on a Friday with about 50 quid and if they’re lucky a travel warrant. So I worry about any expansion of prison places because we can’t make safe the people coming out as it is.’
‘Whatever happens with the rest of the strategy in the coming months, we do have an opportunity to invest more in treatment, which is the one area of consensus,’ stated Trace. ‘And I’d like to put out a call to the politicians to make sure that as we do that we don’t fall down the rabbit hole of “do we have a substitution treatment system or recovery/abstinence system” – we need a menu of treatments. Politically and professionally we’ve got to keep saying that, because there are people who still think it’s either/or. And in this political climate we do need to be very careful about bringing in punitive methods to push people off their prescriptions, because that will raise the death rate rather than bring it down. You achieve recovery by motivating and encouraging people to choose a different pathway, so everywhere we have this debate – from the House of Commons down to local drug projects – we’ve got to remember that we’re talking about having high ambitions for our clients.’
There were just over 1,000 suspected drug deaths in Scotland during the first nine months of this year, according to figures from the Scottish Government – a 4 per cent decrease on the same period last year.
‘We must do to get more people into the treatment which works for them as quickly as possible’ said drugs minister Angela Constance.
The figure for the July-September quarter, meanwhile, was down 13 per cent on the previous quarter and by 10 per cent on the corresponding quarter last year.
The Scottish Government has committed to releasing provisional figures every three months, following criticism that 2019’s figures were not published until the end of last year (DDN, October, page 4). However, the quarterly statistics refer to deaths that police suspect involved illicit drugs based on the reports of attending officers, rather than the official figures from death certificates and pathologists that are released annually by National Records of Scotland.
‘These quarterly reports were commissioned to provide more regular reporting of data on drug death trends in Scotland so everyone involved in our national mission remains focussed on the work we must do to get more people into the treatment which works for them as quickly as possible, regardless of where they live,’ said drugs minister Angela Constance. ‘The £250m we are investing in tackling this public health emergency will make a difference. I am working to ensure it reaches front-line services as quickly as possible and that every single penny will count as we continue to prioritise our efforts to turn this crisis around.’
Suspected drug deaths in Scotland: July to September 2021 at www.gov.scot
The Forward Trust’s Chief Executive Mike Trace welcomes the promise of investment in the addiction treatment sector but explains there is work to do to make sure this reverses the declines of the last 10 years.
On Monday 6th December, the government launched a new 10 year drug strategy. This follows a couple of years of raising expectations that we would see an overall addictions strategy – covering alcohol and prescribed drugs, as well as behavioural addictions such as gambling. The focus on illegal drugs inhibits a more comprehensive approach to tackling addiction in the UK. The treatment and recovery parts of the strategy do however provide for a treatment system that covers both alcohol and illegal drugs.
And this part of the strategy is positive – the government has accepted the recommendations in the review by Dame Carol Black, including an increase in funding for the addiction treatment sector, housing and employment of £780 million across the 3 years to 2024. The Dame Carol Black review found that the country’s treatment and recovery system had become overstretched and underfunded through lack of political support, and poor and unfocused strategy, over the last 10 years. Dame Carol recommended a significant new investment in our sector, and a much tighter focus on ensuring the money is spent on services that deliver real results in terms of reducing deaths and drug related crime, and increasing recovery.
The Forward Trust is particularly supportive of this focus on recovery outcomes – we have long said that, even within declining budgets, there has been far too little effort to ensure that every area of the country (and every prison) has a strong recovery community, a treatment system that inspires and supports people to overcome addiction, and a strong family support network. While it is welcome that the new strategy has warm words about this ambition, there is much work to do to make sure the new money achieves this transformation in practice and reverses the declines of the last 10 years. In October more than 60 Parliamentarians from all political parties joined The Forward Trust and Dan Carden MP to urge the Prime Minister to invest fully in Dame Carol Black’s recommendations. I am certain this support made a significant difference, but we should not lose momentum on the opportunity for recovery from this strategy. It is crucial that the investment announced increases access to residential treatment and recovery services for anyone who wants it.
On a more critical note, it is depressing to see the strategy launched with a flurry of headlines around the scourge of drug addicts swamping the country with crime and disorder. This is political spin at its worst – you don’t need to condemn and stigmatise millions of people to justify investment in the addiction services. Only two months ago, The Forward Trust joined partner charities to launch our ‘Taking Action on Addiction’ campaign with the Duchess of Cambridge for exactly this reason – a compassionate society should understand that most people struggling with addiction have come from childhoods characterised by abuse, neglect and poverty, or are facing mental health challenges such as depression, anxiety or loneliness. A compassionate response is to provide care, understanding, and the belief in people’s potential for recovery. It is good that the government are providing money for us to do this better, but we can do without the stigmatising language. Language that failed to match up to the ambition of the strategy and does little to inspire people that change is imaginable, that their life is worth investing in and recovery is possible.
In light of the release of the new drug strategy and as part of its Making Rehab Work report, Phoenix Futures is sharing the lived experiences of people who have accessed its residential services to reinforce the need for equality of access to residential treatment across the country.
Andrew’s Story
I was born and grew up in Stockport, it wasn’t a bad place to live and I was mostly a happy kid. I had a good upbringing from a loving family, my Mum was a dinner lady and my dad worked for the Post Office.
Around the age of 13 I had a few difficult experiences, I lost my Nanna and then someone else close to me died, I felt really down, I didn’t know how to process my emotions, so I never spoke to anyone about how I was feeling.
As the time went on my mental health was getting worse, it escalated when I was mugged, which really knocked my confidence and made me feel more anxious. I started smoking weed and drinking to manage my anxiety and disassociate. I was finding it hard to cope, especially at school.
Drugs were a part of the culture where I was growing up, it was what we did at the weekends to have fun, I was 15 when I first started taking amphetamines and times were good despite me having dropped out of school early as I was really struggling with my mental health. Years later drugs were still helping me to escape how I was feeling and the monotony of working night shifts.
Then, my relationship with my girlfriend ended and this sent me further down the spiral of struggling with my mental health, feeling depressed, anxious and using drugs to cope. I started taking out loans so that I could buy more drugs, then I started taking out loans to pay back the loans and buy more drugs. I was heavily in debt, addicted to using drugs and suicidal.
I was 23 when I first sought help, initially I went to my GP and he was really supportive, he referred me to Mosaic, a young person’s drug and alcohol service in Stockport, he also called me regularly to check that I was ok. I really appreciated him being so caring and not judging me, it’s not easy asking for help.
After a few months of going to groups I was still using and was desperately unhappy so when my key worker suggested rehab, I knew that this could be the opportunity that I needed to change my life and get better. I was awarded funding for 3 months and arrived at Phoenix in Summer 2019
After 3 months were up and I was making good progress, I applied for extended funding and was awarded another 6 weeks. I felt lucky to get extra time, there were people that I was in treatment with that really struggled to get funding at all, some had to wait years and were then only given 3 months. One man that I met said that he had to relocate to a different postcode area to access rehab as the town where he was from originally wouldn’t fund rehab placements. Whilst the access process was smooth for me and I felt fully supported and encouraged first by my GP and then by my keyworker at Mosaic, I understand that the process is not the same for everyone and that doesn’t seem fair.
Rehab worked for me, it was super difficult and challenging, but it helped me to learn to laugh again, my confidence grew, and it changed my life. It’s been nearly two years since I graduated, I am living in Phoenix supported housing here in the Wirral where there is a big recovery community, we all support each other. I am volunteering with a local youth club, I play guitar in the church band and am looking forward to getting back into work.
Christmas is coming up and I am excited to spend it with my family, I have a brother and two sisters and love watching their faces as they open their Christmas gifts. I am playing guitar in a candle lit carol concert at the church this year. I feel so lucky that I have been able to get my life on track and for all the support that I have received especially because I know that not everyone gets that opportunity.
Change Grow Live has strongly backed the new approach to treatment in the Government’s new 10-year Drug Strategy and has called for a renewed focus on the needs of people who use drugs when the strategy is implemented.
With drug-related deaths at an all-time high and frontline services facing rising demand, Change Grow Live said that the needs of people who use drugs must be prioritised if the strategy is to achieve its aims.
The Government-wide strategy implements the key recommendations laid out in the second part of Dame Carol Black’s landmark review of drugs in July, which argued for wholesale change to the approach to drug treatment.
Mark Moody, Chief Executive of Change Grow Live, welcomed the new approach to treatment in the 10-year Drug Strategy:
‘We welcome the major step forward that this strategy signals for the long-term future of drug treatment and harm reduction. We back the strategy’s acknowledgment that addiction must be treated as a chronic health condition. This is a significant breakthrough for drug treatment and a critical first step in removing the stigma that prevents people from walking through the door of treatment services.
And we welcome the new investment to rebuild drug treatment and increase capacity by 54,500 high-quality treatment places. We also back the ambition to see the full range of evidence-based harm reduction and treatment services available for all those that need them in every community, starting with the most deprived areas, which are disproportionately affected by drug use.
But to be successful, the needs of people who use drugs must be prioritised when it is put into practice, and we must ensure that some of the proposed compliance and enforcement measures don’t put people off seeking help.
The success of this strategy depends in large part on the people who deliver treatment and recovery services, from psychiatrists to caseworkers and volunteers, so we welcome new funding to attract people to jobs in the sector, to support better training for them, and to keep caseloads manageable.
Today is just the start. As Dame Carol Black noted, people who use drugs have been ignored and marginalised for too long by policymakers. We look forward now to working closely with the Government and all our partners to put the needs of people who use drugs at the heart of this new approach over the next decade.
If we do this, we can bring about genuine change to drug treatment and harm reduction that will benefit us all, in communities up and down the country.’
A statement from 70 organisations calling for the establishment of pilot overdose prevention centres in the UK has been coordinated by the Faculty of Public Health (FPH). Signatories include nine royal colleges, a number of drug treatment agencies, the Association of Directors of Public Health, the Hepatitis C Trust, National Aids Trust and the BMA’s science board, alongside individual signatories.
The statement calls for overdose prevention centres and says we can ‘no longer accept the UK’s record number of drug-related deaths’.
‘As public health and healthcare professionals, we the signatories can no longer accept the UK’s record number of drug-related deaths without implementing all available evidence-based interventions to save lives and protect health,’ it says. ‘Urgent action is needed to tackle the spiralling rates of drug deaths across the UK.’ The government’s new drug strategy does not go far enough in implementing a public health approach, as it does not include plans for setting up overdose prevention centres, the document continues. ‘In addition to the substantial body of evidence demonstrating that OPCs reduce drug deaths and related harms, we also see no evidence linking OPCs to increased drug use, criminal activity, or associated policing problems,’ it adds.
Meanwhile, a new study published in Lancet Public Health states that the number of deaths for which an opiate is mentioned on the death certificate increased by 54 per cent between 2010 and 2020, to 2,138 deaths per year. The study collected data for almost 107,00 people with a history of illicit opioid use, with a median follow-up of just under nine years.
While opioid-related deaths are also increasing in other countries, the ‘causes of this crisis’ differ, with far greater problems with fentanyls in the US and Canada. Although ‘the long-term trend of ageing and increasing frailty in this population’ is one explanation for the UK’s increasing death rates, the study points out that significant cuts mean that treatment services have been ‘struggling’ to meet their clients’ basic needs – and are also often the only point of contact with wider health services for their client group, it says. ‘The increasing rate of fatal drug poisoning between 2010-12 and 2016-18 in our cohort was not explained by ageing of participants,’ it concludes.
A call to pilot overdose prevention centres (supervised injecting facilities) in the UK at www.fph.org.uk – read it here
One in five people are worried about drinking more over the Christmas period, according to a poll of more than 1,000 people commissioned by With You.
A quarter of people polled said they were expected to drink to have a good time with friends and family
One in four said they felt pressure to drink more, while one in six had concerns about spending too much money on drink. One in seven also said that they felt they needed to drink to have a good time with family and friends, with a quarter feeling they were ‘expected’ to.
Almost a quarter also said they regularly drank for five days in a row, or more, at this time of year. Around 12 per cent of people said they drank to cope with loneliness over the festive period, with 11 and 10 per cent respectively drinking to cope with bereavement and past trauma. A recent report from the Alcohol Health Alliance also found that the ‘constant bombardment’ of alcohol adverts over the Christmas period could act as a trigger for relapse for people in recovery (DDN, December/January, page 5).
With You’s executive director of services for England, Jon Murray
‘Throughout December and the New Year, social calendars will be filling up, with some eager to make up for missing out on last year’s celebrations,’ said With You’s executive director of services for England, Jon Murray. ‘It’s an exciting time for many, but our research shows that it can be a difficult time for those who would like to drink less or struggle with alcohol. Our research shows that as many as one in five are worried about alcohol at this time of year, backing up what we hear from the people who come to our services for support. We often hear of how not just family gatherings and other social events, but also financial pressures and feelings of loneliness and bereavement all come together to make it harder than ever to avoid alcohol.’
With You has also partnered with Snapchat and Frank for an in-app drug education portal called Heads up. The app – which was launched in the US earlier this year – includes information on using drugs like cannabis and MDMA, as well as advice on issues like being pressured to take drugs. Snapchat is also taking measures to prevent drug sales on its app, it says.
‘We’re pleased to be partnering with Snapchat on Heads Up, an initiative that will help raise awareness of drugs and how to stay safe across a platform used by millions of young people each day in the UK,’ said With You’s head of young persons service delivery, Jennifer Rushworth-Claeys.‘It comes at a crucial time with levels of drug use remaining high among young people who increasingly turn to social media to access information and connect with friends.’
The New Zealand government has announced some of the toughest anti-smoking measures in the world as part of its plan to make the country smoke-free by 2025 – including banning the sale of cigarettes to future generations.
Alongside policies in the action plan that will become law, practical support measures for smokers are also being prioritised.
People aged 14 or under when the new laws come into force will ‘never be able to legally purchase tobacco’, the government states. Eighty per cent of New Zealanders who smoke start by the age of 18, with 97 per cent having started by 25.
The government would also be taking steps to reduce the ‘appeal, addictiveness and availability of smoked tobacco products’, it said, with laws permitting only products containing very low-levels of nicotine to be sold alongside ‘a significant reduction’ in the number of shops allowed to sell them. The measures will be accompanied by more support for people trying to quit.
‘This is a historic day for the health of our people,’ said health minister Dr Ayesha Verrall. ‘Smoking is still the leading cause of preventable death in New Zealand and causes one in four cancers. Smoking related harm is particularly prevalent in our Māori, Pacific and low-income communities. While smoking rates are heading in the right direction, we need to do more, faster to reach our goal. We want to make sure young people never start smoking so we will make it an offence to sell or supply smoked tobacco products to new cohorts of youth. Alongside policies in the action plan that will become law, practical support measures for smokers are also being prioritised. Preventing people from starting to smoke and helping those who smoke to quit means we are covering both ends of the spectrum.’
UK charity ASH recently predicted that without ‘radical changes to smoking rates’ the next 20 years would see 2m people in Britain die as a result of smoking, on top of the 8m who have died since the early 1970s. The government’s plan to make England ‘smoke-free’ by 2030 is unlikely to be met, it added (https://www.drinkanddrugsnews.com/people-with-substance-issues-may-be-at-higher-risk-of-covid/)
Regulatory impact statement: Smokefree Aotearoa 2025 action plan at www.health.govt.nz
Release outlines its position on the UK Government’s 10-year Drug Strategy.
On Monday 6th December, the UK Government released their 10-year Drug Strategy entitled: “Harm to Hope: a 10-year drugs plan to cut crime and save lives”. The strategy outlines three main priorities for the next decade:
Break drug supply chains
Deliver a world-class treatment and recovery system
Achieve a shift in demand for recreational drugs
The strategy rightly recognises that half of people dependent on opiates and crack cocaine are not in treatment, and that drug addiction co-occurs with a range of health inequalities, especially mental health issues, homelessness, and deprivation. An additional investment of nearly £900 million is promised over the next three years to “deliver 54,500 more treatment places, prevent nearly 1,000 deaths, and close over 2,000 more county lines”, with £780 million of this total amount being spent on drug treatment and recovery support over the next three years.
Investment in improving the quality and capacity of treatment, as recommended in Dame Carol Black’s independent review, is long overdue following the decade of spending cuts to treatment services. The renewed focus on recovery is both welcome yet ironic given that cuts to funding were originally championed by the incumbent Conservative government, as the Advisory Council on the Misuse of Drugs (ACMD) noted in 2017. Its impact is also diluted by the strategy’s focus on punishment; a contradiction in terms given that the threat of punishment, and stigmatisation, undermine treatment efforts and prevent people seeking treatment for their drug use, should they want it, in the first place. The strategy proposes to increase punishment for people who supply drugs, and for “lifestyle users” – people who use drugs recreationally – and leaves us in little doubt that we are still in a failed war on drugs.
We are pleased to see naloxone recognised in the strategy as a life-saving and harm-reducing intervention to be offered across the country. Unfortunately, this is only one of many types of tried and tested harm reduction measures that have been implemented by nations more progressive than ours – including heroin assisted treatment, drug consumption rooms (overdose prevention sites/supervised injecting facilities) or medical safe-supply of drugs, including prescribed diamorphine – which are not even mentioned in the new strategy. The government is aware of the evidence that these initiatives not only save lives, but can promote entry into treatment and employment, facilitate other health interventions and social integration, and can reduce offending. We know that the government is aware of these options as they were recommended by the ACMD in 2016 (the government’s expert advisory council), and are included in the Department of Health and Social Care’s 2017 Clinical Guidelines.
These notable omissions from the strategy threaten the government’s ambitious aim to establish a “world-leading evidence base” around the drivers of drug use. There is little to indicate that the government will listen to the evidence gathered, given that evidence has been ignored from: (1) the ACMD on the reclassification of drugs and measures to reduce opioid-related deaths; (2) the Home Office, whose research found no relationship between the toughness of drug sanctions and levels of drug use; and (3) the United Nations (UN) and World Health Organization (WHO), who both advocate for drug decriminalisation.
Prisons will have a ‘zero-tolerance approach to drugs’
All prisoners will be assessed on arrival for drug and alcohol issues, says the Prisons strategy white paper, with a ‘comprehensive plan to support them to properly recover from day one’ – including abstinence-based treatment. New-build prisons will also have airport-style security, including ‘cutting-edge’ body scanners, to prevent people from ‘continuing criminal activity’ while in prison. ‘It is crucial that we close off every avenue for the entry of drugs into our prisons to uphold stability, order and rehabilitation efforts,’ the document states, adding that the government will also ‘carefully consider the merits of piloting the introduction of drugs testing of staff’.
Dominic Raab: ‘Re-orienting the regime’
New key performance measures and public league tables will ‘incentivise’ the spread of best practice in areas including drug and alcohol issues, employment and training, and the white paper also includes a commitment to recruit 5,000 more officers for the under-staffed prison estate, with 2,400 to be employed in the next two years. There will also be new programmes to match people with job vacancies in the community on their release, as well as dedicated employment advisors in prisons and ‘resettlement passports’ bringing together CVs, ID, bank accounts and community support information in one place to help people ‘start looking for work straight away’.
‘We’re building the prisons to incarcerate dangerous and prolific offenders,’ said deputy prime minister Dominic Raab. ‘We’re deploying the tech to stop the flow of drugs, weapons and phones into prisons. And we’re re-orienting the regime to get offenders off drugs for good, and into work – to cut crime, and keep the pubic safe.’
WDP has welcomed the publication of HM Government’s 10-year drugs plan and, in particular, its adoption of the recommendations of Dame Carol Black’s Review of Drugs.
As a third sector provider of recovery treatment and support services, we welcome the additional investment in these systems. We are positive about the difference this can make to the health and wellbeing of those suffering from addiction issues and society as a whole.
The new funding will help providers such as ourselves to invest in more specialist roles to support our most complex clients. Increasing client-facing staff numbers overall will also help to increase the quality of personalised care.
The continuation of current increased funding is appreciated, as is the introduction of further investment, staggered over the next three years according to geographic areas of need. However, it should be borne in mind that every local authority has a proportion of people with the highest levels of need, and they must benefit from this investment equally.
A holistic approach to recovery, including accommodation and employment status is encouraging, particularly the commitment to have IPS employability programmes in every local authority by the end of 2024/2025. We have seen first-hand the effectiveness of this approach in our award-winning IPS Into Work service in West London.
The strategy recognises that addiction is a long-term health condition. This is vital, as is the focus on equality in treatment opportunities. WDP treats all those who access our services with the utmost dignity and will ensure that their voices are continually heard as the recommendations of this report are implemented.
We look forward also to the further development of the 10-year plan beyond the detail for the first three years outlined today. It is critical that the ambitions of this strategy are realised for the social, physical, and mental wellbeing of the nation.
WDP chair Yasmin Batliwala
Yasmin Batliwala, Chair of WDP said ‘We are encouraged by the financial investment being put into drug treatment; Dame Carol Black’s Review rightly states that the ‘payoff is handsome’ with each £1 spent on treatment saving £4 from reduced demand on other services. It is imperative that services are evidence-based and robust, providing a comprehensive range of treatment and care to meet the differing and complex needs of those we support. Dynamic partnerships will be essential if the drugs strategy is to work, and this will require coordinated action within and between government departments and the drug sector.’
I’ve seen first hand the challenges women face navigating a system that is often not designed for them, says Siobhan Peters, Director of Services North West, With You.
Looking back Tina feels like her drug issues were inevitable. Growing up in a domestically abusive environment she found this experience moulded her. “As I entered adulthood domestic violence was part of every relationship I had because I had no idea how to have a healthy open relationship,” Tina said. Eventually she started using heroin and crack cocaine.
Decades later, now in recovery and working as a volunteer in her drug treatment service, Tina identifies being around other women as important to her journey. The women’s groups she participated in helped her with her confidence and self esteem. Tina said: “having those role models, strong women who believed in me and helped me grow, was so important.”
Women and men’s experience of using drugs and alcohol, accessing support, and engaging with drug treatment is very different. Men make up the vast majority of people who attend drug services and services are often based on their needs. Time and time again, we hear that for many women who come to us seeking support, that services are daunting and intimidating places.
Having worked in this sector for over a decade, I’ve seen first hand the difficulties and challenges women can face navigating a system that is often not designed for them. I know how seemingly simple things like location and times of appointments have more of an impact on accessibility of services for women than men, especially when women have child or family care responsibilities.
Women face additional stigma as primary caregivers, they are disproportionately disadvantaged in the criminal justice system and face barriers entering services which all too often trigger memories of abuse and trauma. I’ve also witnessed the amazing difference it can make to women when services have designed elements with them in mind, have considered their specific needs and have been co-designed by the women who use our services.
Though With You has many services that do an amazing job of accessing and engaging women in their communities, we know there is more we can do.
Earlier this year, we set out to improve our understanding of this issue and have now published our research report ‘A system designed for women?’ with the findings.
We spoke to women from across the UK, from Cornwall to Ayrshire, to better understand their experiences of seeking support for their drug use. We heard how women who have already faced traumatic experiences and set-backs throughout their lives — such as abuse, domestic violence, cultural stigma and family breakdown — are held back from getting support by services and a system that often lacks the capacity and flexibility to cater for their needs.
We found that women face a postcode lottery as to what services will be available to them. Some areas had a whole range of services designed for women, from groups, to women on services, to family sensitive services, other areas of the country had almost nothing but generic services.
And we heard how accessing services is more challenging for women from different and diverse communities. The barriers they face are amplified by services that lack cultural sensitivity and often employ a universal approach to women.
Too many of our communities’ most vulnerable women fall through the gaps, disengaging from services that aren’t designed for them, and not getting the support they need. This has a major impact on women with children and consequently adds to intergenerational cycles of drug use.
The number of deaths from alcohol-specific causes rose to 8,974 in 2020, according to the latest figures from the Office for National Statistics (ONS) – 18.6 per cent up on the previous year, and the highest year-on-year increase in two decades.
Alcohol Health Alliance chair Professor Sir Ian Gilmore said the figures hide many more deaths where alcohol is a major contributory factor.
The statistics only include deaths where the cause was a ‘direct consequence’ of alcohol misuse – almost 78 per cent were the result of alcoholic liver disease, with the remainder including alcohol poisoning and ‘mental and behavioural disorders due to the use of alcohol’. Rates of alcohol-specific deaths in the UK had remained stable between 2012 and 2019, says ONS, before the latest ‘statistically significant’ increase. As in previous years the death rate for men was almost double that for women, with the biggest overall increases seen in England and Scotland. The North East of England had the highest death rate for the seventh year in a row.
‘The annual number of alcohol-specific deaths released today, twice as many as drug-related deaths, hide many more where alcohol is a major contributory factor, such as deaths from cancers and strokes,’ said Alcohol Health Alliance chair Professor Sir Ian Gilmore. ‘We applaud government action on illicit drugs but fail to understand their complacency on this other drug of dependence, alcohol.
‘The ONS figures highlight that our poorest communities suffer most from alcohol harm, and so if our prime minister is serious about “levelling up” he must back the robust plans for drugs with an alcohol strategy that seeks to turn this tragic trend around. The strategy must include policies to stop the sale of cheap, strong alcohol that is so harmful to health, reduce the availability of alcohol and restrict its marketing. Importantly, we also need to make sure that support is available to those who need it now.’
A ‘record’ £780m over three years to ‘rebuild the drug treatment system’ has been announced by the government as part of its much-anticipated new drug strategy. While every local authority in England will receive extra money ‘to combat drug and alcohol misuse’ over the next three years, those with the greatest need will receive the funding first, the government says.
The 50 local authority areas with the highest needs will be prioritised in order to ensure access to treatment for ‘the poorest and most vulnerable’
The ten-year strategy is intended to ‘tackle the scourge of drugs and prevent crime’ – addressing both supply and demand and creating a ‘world-leading’ treatment system within a decade by improving access and increasing capacity. The 50 local authority areas with the highest needs will be prioritised in order to ensure access to treatment for ‘the poorest and most vulnerable’ – there will also be increased housing support and access to treatment for people sleeping rough, along with more employment support, including a peer mentoring programme. The role of health and justice partnership coordinators – who liaise between prisons, probation and treatment providers – will also be expanded to cover every region in England and Wales, with the aim of boosting joined up working and ensuring consistency in treatment plans.
The success of the strategy will be measured against national and local outcomes frameworks to achieve a series of targets by the end of 2024-25, it says, including ‘a phased expansion to deliver at least 54,500 new high-quality drug and alcohol treatment places – a 19 per cent increase on current numbers’. This would include 21,000 new treatment places for opiate and crack users, and 30,000 new treatment places for non-opiate users, including 5,000 for young people.
As has been predicted, there is a significant focus on drug-related crime in the strategy, with plans to improve treatment for people in the criminal justice system, more testing regimes in prison, more use of Drug Rehabilitation Requirements for people on community sentences, and better support for prisoners to engage with community treatment ahead of their release. However, proposals to take away people’s passports and driving licences for possession offences – widely reported in the press ahead of the document’s launch – are not included in the document itself.
Crime minister Kit Malthouse
Instead there will be a planned £9m future investment in the ‘Tough Consequences out of court disposals scheme’, the government says, intended to deter people from drug use through a range of potential civil penalties that could include ‘fines, curfews, or in the most exceptional cases, the temporary removal of driving licences or passports’. A white paper to be published next year ‘will consider a series of escalating sanctions’, with crime minister Kit Malthouse telling Sky News that it ‘might involve, we hope, interfering in their lives in a way that brings about behavioural change’. In the meantime, a £300m investment will target supply chains and aim to disrupt gang activities, including the target of dismantling 2,000 county lines operations. With the £780m treatment investment, the total spending on both treatment and drug-related law enforcement will top £3bn over the next three years, the government states.
The government intends to bring about a ‘generational shift’ in terms of demand, it says, with other planned future action including £15m over three years towards rolling out drug testing on arrest through police forces across England and Wales, as well as £5m for an ‘innovation fund to develop a world-leading evidence base to better understand what works in driving changes in attitudes towards drug use’.
‘This is a huge moment which will not only save lives but help level up the country,’ said health and social care secretary Sajid Javid. ‘We’re investing a record amount into treatment services with money to break the cycle of drug use and to support communities by cutting the drug use which drives crime. Treatment services are just one part of the comprehensive strategy which includes helping people back to work, into permanent housing, and cracking down on supply.
Dame Carol Black
The document has been shaped in response to Dame Carol Black’s Independent review on drugs, the government said, with her continuing to monitor and advise on the strategy’s progress. ‘I am delighted that the government is making this very significant investment in drug treatment and recovery services, alongside the funding allocated to tackle drug supply,’ she stated – money that would ‘transform substance misuse services, providing people with high quality treatment and support for recovery. The investment to improve housing support and employment opportunities is just as critical because people need hope, purpose and practical steps to help them achieve a better future. This strategy comes with high expectations and I look forward to advising the central unit and relevant government departments to ensure there is a step change in treatment, recovery and prevention.’
From harm to hope: A 10-year drugs plan to cut crime and save lives at www.gov.uk
RESPONSES FROM THE FIELD…
Chair of the Local Government Association’s Community Wellbeing Board, David Fothergill
‘People with drug and alcohol problems should be able to get the right supportand treatment when they need it, which this comprehensive strategy sets out to achieve. Councils, which are responsible for public health, share this ambition and want to see vulnerable people being given another chance to find work, rebuild relationships and find safe and secure accommodation. Boosting direct funding for drug treatment and recovery is helpful to meet rising demand, but we also need to see significant investment in the services which help prevent problems before they occur, such as in housing, youth services, mental health and children’s services.
‘As this strategy outlines, investing in drug prevention and treatment now will reap benefits for everyone longer-term, including for the NHS, criminal justice and other public services. This needs to be supported by extra opportunities for users to gain employment, housing, mental health care and help from other agencies.’
Turning Point chief executive, Julie Bass
‘We very much welcome the government’s plans for the largest ever single increase in investmentin treatment and recovery. Drug-related deaths are the highest they’ve been since records began and a decade of austerity has taken its toll on the sector. Properly funded treatment services will be able to reach more people and reduce the harm caused by drugs to individuals, families and communities.’
Chief executive of Change Grow Live, Mark Moody
‘We welcome the major step forward that this strategy signals for the long-term future of drug treatment and harm reduction. We back the strategy’s acknowledgment that addiction must be treated as a chronic health condition. This is a significant breakthrough for drug treatment and a critical first step in removing the stigma that prevents people from walking through the door of treatment services. And we welcome the new investment to rebuild drug treatment and increase capacity by 54,500 high-quality treatment places. But to be successful, the needs of people who use drugs must be prioritised when it is put into practice, and we must ensure that some of the proposed compliance and enforcement measures don’t put people off seeking help. The success of this strategy depends in large part on the people who deliver treatment and recovery services, from psychiatrists to caseworkers and volunteers, so we welcome new funding to attract people to jobs in the sector, to support better training for them, and to keep caseloads manageable.
‘Today is just the start. As Dame Carol Black noted, people who use drugs have been ignored and marginalised for too long by policymakers. We look forward now to working closely with the government and all our partners to put the needs of people who use drugs at the heart of this new approach over the next decade. If we do this, we can bring about genuine change to drug treatment and harm reduction that will benefit us all, in communities up and down the country.’
WDP chair, Yasmin Batliwala
‘We are encouraged by the financial investment being put into drug treatment; Dame Carol Black’s review rightly states that the ‘payoff is handsome’ with each £1 spent on treatment saving £4 from reduced demand on other services. It is imperative that services are evidence-based and robust, providing a comprehensive range of treatment and care to meet the differing and complex needs of those we support.
‘Dynamic partnerships will be essential if the drugs strategy is to work, and this will require coordinated action within and between government departments and the drug sector.’
Humankind CEO, Paul Townsley
‘The government noted in their announcement that the £780m in funding that they have committed will rebuild the sector and that is what we need to do – rebuild. A decade of disinvestment and sporadic funding has decimated drug and alcohol services at a time when demand has increased and the number of people dying has risen by almost 80 per cent. This new strategy will help us get back on our feet but there is a lot of catching up to be done, especially in light of the pandemic which was not factored into the Dame Carol Black review and has caused disproportionate harm to people who use drugs. Despite the much-heralded crime and enforcement elements of yesterday’s announcement, this strategy indicates that the government has begun to recognise that drug use is also a health issue.
‘While this strategy contains few bold new ideas, it does provide the funding, support and commissioning standards that the sector has been requesting for many years. And, most importantly of all, this strategy will save lives, help people to build resilient futures and ensure the most marginalised members of society get the support they need. It is now up to all those working in the sector to use the extra investment to shape and develop service delivery so that we have more impact on more people by expanding the evidence base and the range of services we offer.’
Phoenix Futures chief executive, Karen Biggs
‘Beyond the damaging rhetoric that accompanied the launch the considerable investment in treatment and the acceptance of the Dame Carol Black recommendations in totality are very welcome. The largest ever investment in improving treatment is extremely welcome. This strategy will not reverse the harms of those cuts on the lives of families across the country over the last decade. Nor will it repair the stresses on the working lives of frontline staff across the treatment sector who are the unsung heroes. But looking to the future we should be hopeful that we can now improve the lives of hundreds of thousands of people in need of support and support our workforce to grow, develop their skills and maintain their incredible dedication. We believe the strategy offers the promise we have been campaigning for over the last decade.
‘Strategies are only as strong as their implementation and the culture in which they exist. We have a culture which stigmatises people affected by dependency and addiction leading to daily prejudice and discrimination that limits life opportunities. This strategy references stigma briefly only twice – we know that for the record levels of investment to achieve the desired treatment outcomes we need to address the outdated views of addiction as a moral failing and a purely criminal issue. On this point the tone of the strategy is a missed opportunity.’
London Friend CEO, Monty Moncrieff
‘It’s no coincidence that the government’s own wording is a promise to “rebuild” treatment services and the workforce delivering them. It’s perhaps the closest to an acknowledgment we’ll get that those years of cuts have done immeasurable damage to the drug treatment system. Coping with the daily demand has left services with little time or resource to develop different approaches with diverse communities, although we know from 20 years’ experience that not doing so will perpetuate barriers and inequalities for LGBT people, as well as for other minority groups.
‘It’s vital that investment in treatment services reaches organisations experienced in supporting chemsex users including those with offending histories. Much of this expertise exists outside of traditional treatment providers in small and specialist charities like our own and our LGBT sector partners. We understand the factors that lead to problematic use of chems and are trusted by the communities we work within. As demand for this specialist support grows treatment provision can’t be left to chance, backed by a commissioner or two here and there, or – more likely – left to grant giving trusts to pick up the slack. It must form a core strategic element of a joined-up approach.’
Forward Trust CEO, Mike Trace
‘The government has accepted the recommendations in the review by Dame Carol Black, including an increase in funding for the addiction treatment sector, housing and employment of £780m across the three years to 2024. Dame Carol recommended a significant new investment in our sector, and a much tighter focus on ensuring the money is spent on services that deliver real results in terms of reducing deaths and drug-related crime, and increasing recovery. The Forward Trust is particularly supportive of this focus on recovery outcomes – we have long said that, even within declining budgets, there has been far too little effort to ensure that every area of the country (and every prison) has a strong recovery community, a treatment system that inspires and supports people to overcome addiction, and a strong family support network. While it is welcome that the new strategy has warm words about this ambition, there is much work to do to make sure the new money achieves this transformation in practice and reverses the declines of the last ten years.
‘On a more critical note, it is depressing to see the strategy launched with a flurry of headlines around the scourge of drug addicts swamping the country with crime and disorder. This is political spin at its worst – you don’t need to condemn and stigmatise millions of people to justify investment in the addiction services. It is good that the government are providing money for us to do this better, but we can do without the stigmatising language. Language that failed to match up to the ambition of the strategy and does little to inspire people that change is imaginable, that their life is worth investing in and recovery is possible.’
Statement from André Gomes, Laura Garius, Kirstie Douse and Claire Robbins, Release
‘The strategy rightly recognises that half of people dependent on opiates and crack cocaine are not in treatment, and that drug addiction co-occurs with a range of health inequalities, especially mental health issues, homelessness, and deprivation. Investment in improving the quality and capacity of treatment, as recommended in Dame Carol Black’s independent review, is long overdue following the decade of spending cuts to treatment services. The renewed focus on recovery is both welcome yet ironic given that cuts to funding were originally championed by the incumbent Conservative government, as the Advisory Council on Misuse of Drugs (ACMD) noted in 2017.
‘We are pleased to see naloxone recognised in the strategy as a life-saving and harm-reducing intervention to be offered across the country. Unfortunately, this is only one of many types of tried and tested harm reduction measures that have been implemented by nations more progressive than ours – including heroin assisted treatment, drug consumption rooms (overdose prevention sites/supervised injecting facilities) or medical safe-supply of drugs, including prescribed diamorphine – which are not even mentioned in the new strategy.
‘What is more difficult to spot among the ‘tough on drugs’ fanfare is that there are some positive steps included in the strategy which move us away from the criminalisation of low-level drug possession. Diversion schemes currently operate in a small handful of police forces, and their inception has been police-led, in the absence of government leadership. Diversion schemes are considered de-facto decriminalisation – but they are not described this way in the new drug strategy – which includes plans to double “out-of-court disposal schemes” by the end of 2024/25. It is telling that the expansion of drug diversion was downplayed in the strategy: instead of being celebrated as a step towards avoiding creating criminal records for people, the government’s “tough” rhetoric was reinforced by including the underdeveloped threats to remove people’s passports and driving licenses as possible civil sanctions under diversion schemes (which is to be further elaborated in a white paper in 2022). It is an imbalanced proposition considering that current diversion schemes inform people of the harms of drugs via short drug awareness courses, as opposed to restricting their liberties. The government has made their point: they are still tough on drugs.’
A new national campaign to address the stigma around substance use has been launched by the Scottish Government.
The campaign, which coincides with the publication of the UK government’s new drug strategy, is designed to highlight the ‘damage caused by the stigma of problem drug and alcohol use’.
The campaign will emphasise that substance use is ‘a health condition’ and include TV and newspaper adverts as well as billboards, supported by a webpage on NHS Inform. The aim is to make it easier for people to ask for help, says the Scottish Government, and emphasise that judging people can have a ‘devastating effect’ on their ability to seek and access support,
Scottish drugs policy minister Angela Constance
‘This is a hard-hitting national campaign which encourages people to see the personal story behind the stereotype,’ said drugs policy minister Angela Constance. ‘Stigma is damaging not only to the individual in terms of their mental health and sense of self-worth, but it also discourages them from coming forward to get the help they need. It also impacts on friends and family members. We must remember that people with a substance use problem are family members, neighbours, friends and colleagues. By addressing stigma, and the silence and alienation it causes, we make it easier for people to seek help and that is to the benefit of each and every one of us.’
‘We are acutely aware that stigma and shame are major reasons for people not or delaying seeking help,’ added executive director of We Are With You Scotland, Andrew Horne. ‘This hard-hitting national campaign challenges our view that people with drug and alcohol problems are different. This is not true. In Scotland, drug and alcohol issues are sadly very common and can affect anyone. People experiencing problems shouldn’t be made to feel ashamed as we know that stands in the way of people getting the help they need.’
This series of three articles series examining the past, present and future of buprenorphine in the treatment of opioid dependence ran in DDN Magazine. They are all available below.
Skip to part one ‘Filling the prescription’ The surge of buprenorphine prescribing during the COVID-19 pandemic triggered a reflection of its journey, and with the recent introduction of long-acting injectable buprenorphine Dr Georges Petitjean and Deanne Burch question what its future is within drug treatment services.
Skip to part two ‘Weighing up the benefits’ where Dr Georges Petitjean and Deanne Burch explore different buprenorphine preparations, its use during the COVID-19 pandemic and its safety and cost in comparison to methadone.
Skip to part three ‘The long game’ in which Dr Georges Petitjean and Deanne Burch look at the opportunities, and challenges, presented by long-acting Buvidal injections and Dr Jan Melichar discusses the Welsh roll-out of Buvidal.
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Filling the prescription
This article is the first in a series examining the past, present and future of buprenorphine in the treatment of opioid dependence. Buprenorphine is a medication used in opioid substitution treatment (OST), and it has also been used extensively for the management of pain. The surge of buprenorphine prescribing during the COVID-19 pandemic triggered a reflection of its journey, and with the recent introduction of long-acting injectable buprenorphine we question what its future is within drug treatment services.
Development
In the USA, the Committee on Drug Addiction was created in the 1920s where it studied the morphine molecule, searching for medicines which would not cause addiction. It was hoped that they would find a medicine which could be used in the place of opium based medicines.
The search to find a non-addictive analgesic began in the 1920s following increasing concerns that opioid addiction was resulting from iatrogenic prescribing. The opioid agonist methadone was initially developed during World War II and it was prescribed minimally in the 1950s. Due to the lack of agreement on its safety and its inability to produce the desired effect without addiction, the search for opioid antagonists commenced.
The concept of ‘substitution treatment’ was first developed in response to the opium and morphine addiction epidemic in the USA. It was fully recognised by then that even if a safe and side-effect free alternative was discovered, the addiction problems countries faced would not be resolved in totality due to the complex factors that influence addiction. Therefore, it was suggested that antagonists may assist in managing the problems associated with addiction, rather than completely resolving them. During the 1960s there was a shift from attempting to cure addiction to finding a medicine that alleviated some of the risk. Naltrexone, an opioid antagonist, was produced in the 1960s but only used as a supplementary treatment from the 1980s.
Discovery
In the mid-1960s buprenorphine was discovered. Longer acting relapse prevention methods such as antagonist depot injections were studied in the 1970s, while researchers also explored whether naloxone could be added to opioid medicines, and it was around this time that the search for a medicine with both antagonist and agonist properties began to really accelerate. Methadone maintenance was largely looked upon as a solution to treating opioid-dependent veterans and crime in the USA. Despite its support, its limitations were recognised fully.
By the late 1970s it was assumed that buprenorphine could effectively replace methadone as a treatment in opioid dependence because of its low misuse potential – essentially it was thought to have the benefits of both methadone and naltrexone but fewer drawbacks.
Treatment
Although sublingual buprenorphine was launched from 1982 for analgesia, it wasn’t until 1998 that it was licensed for the treatment of opioid dependence in the UK as an alternative to methadone.
Despite the support buprenorphine gained as having the potential to be the next major medicine for treating opioid dependence, it took three decades to be fully approved and utilised in drug treatment services. The development of buprenorphine met with political and social challenges and as an additional option for opioid substitution treatment it has had mixed responses from patients. The dismantling of the barriers that can exist for opioid substitution treatment, as seen with the widespread use of buprenorphine in France, have led to innovative ways of tackling overdose, treatment and retention rates.
In the next article we will look at the introduction of different buprenorphine preparations, its use during the COVID-19 pandemic, and its safety and cost in comparison to methadone.
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What do patients think about buprenorphine?
We asked some patients what their experience was of being prescribed buprenorphine and received both positive and negative feedback
Positive experience of buprenorphine
‘Buprenorphine is far better than methadone – when I came off it [methadone] I had to go through six weeks of hell. I felt like an old man, with aches and pains, hallucinating. I did a 14-day detox. When I came off buprenorphine it was much easier, just a few days of restless legs and that was it If I’d have known what it was like coming off of methadone I’d rather have just stopped off the heroin. Methadone is worse than heroin itself. I went down to 2mg on methadone – three weeks after coming off methadone I felt so bad I took a total of 100mg diazepam, and they didn’t even touch the sides.’
‘You feel like an old man, the pain is unbelievable – 18 years ago this happened, they kept me on maintenance.’
‘I came off buprenorphine a few times, no issues like I said, just restless legs the first night, then the second night a full night’s sleep. I was a lot younger back then, the helpful thing is to exercise.’
Negative experience of buprenorphine
‘I didn’t get on with buprenorphine at all, although most people I know have got on with it. The first time they didn’t bring me down to 30 mg of methadone before I switched onto it, I was on 70mg. I left it two to three days to be in withdrawal, took one and then I was ill, I was actually going to a job interview that day – 20 minutes before I went for the job interview it felt like a super cluck. I had to go out and get something.’
‘I tried to get onto buprenorphine three times. This was seven or eight years ago.’
‘I prefer the methadone. It’s something mental I suppose, I’ve been on it for so long.’
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Buprenorphine Chemistry
Buprenorphine is a partial agonist at the mu opioid receptor and an antagonist at the kappa receptor:
μ-opioid receptor
Buprenorphine has a very high affinity, a low intrinsic activity, and a slow dissociation at the mu receptor.
It has unique and clinically desirable pharmacological properties: lower misuse potential, milder withdrawal symptoms on dose reduction than methadone and a ceiling effect at higher doses (meaning that an overdose of buprenorphine is less likely to cause fatal respiratory depression than an overdose of a full mu opioid agonist like methadone).
Buprenorphine produces a dose-related blocking of drug ‘high’ from ‘on-top’ use of heroin, making it particularly appealing to well-motivated patients.
However, if taken too soon in opioid-dependent patients, buprenorphine can displace heroin and other opioids from the receptors, yet not provide the equivalent degree of receptor activation, thereby leading to a rapid drop in opioid effect and the onset of opioid withdrawal symptoms (‘precipitated withdrawal’).
κ-opioid receptor
The high-affinity kappa receptor antagonism of buprenorphine is involved in reducing stress-induced drug-seeking behaviour. Also, kappa antagonism has demonstrated antidepressant properties.
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The French model
In France in the 1980s, the widespread off-label use of buprenorphine was being used to treat addiction. In 1995, it was the first country to approve the use of buprenorphine for the treatment of opioid dependence.
There was an acknowledgement at the time of increasing levels of overdoses and it was suggested that the majority of people who were opioid dependent were not receiving treatment. GPs were enabled to prescribe buprenorphine and they adopted a low threshold, far-reaching approach.
This approach incorporating GPs had the benefit of normalising addiction treatment into mainstream care. Financial barriers were reduced for GPs and patients. The outcomes were:
• The number of people treated for opioid dependence with buprenorphine vastly overtook the numbers prescribed methadone.
• The majority of buprenorphine treated patients in Europe were in France.
• Overdoses reduced enormously.
• Pharmacists saw an increase in retention into treatment rates.
• HIV infections in people who injected drugs fell dramatically.
• However, France saw a higher number of patients injecting their buprenorphine, particularly when lower dosing was used.
The French model is an example of where reducing the financial, procedural and stigmatising barriers associated with treatment has resulted in positive outcomes for patients.
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What did clinicians think about buprenorphine?
We asked Dr Emily Finch, vice chair of NHS APA, vice chair of the Addictions Faculty at the Royal College of Psychiatrists and clinical director at South London and Maudsley NHS Foundation’s Southwark Central Acute and Addictions Directorate.
When buprenorphine first came to the market as an addiction treatment option in the UK, what were the fears and expectations in drug and alcohol services?
Discussions were dominated by cost when it first came in. It was initially much more expensive. So there were many thoughts about who was most suitable for it – essentially we were rationing it. The first person I gave it to [in 2004] went into precipitated withdrawal. It probably made me very cautious. Over time prescribers and service users gradually understood the need to be in withdrawal when given the first dose.
There were concerns about the difficulties supervising it. It took longer. It was a time when methadone maintenance was not very old in England and most methadone was supervised. At that time we also had lofexidine which we were using for detox. Service users did not like it at all initially.
We were sceptical about the evidence from France, where methadone was not an option, and the US literature where it was introduced because they couldn’t use methadone in ‘office based’ settings – effectively primary care. We knew about its reduced overdose potential but we weren’t that convinced.
In your opinion, has buprenorphine reached its initial expectations of being a safer and preferred alternative to methadone?
I don’t think that was the initial expectation – perhaps by the drug companies, but not by most UK prescribers. It has revolutionised opioid detox and has been successful where drug use may be less chaotic. That is its biggest impact – it is safer but only if the service user will take it. All of my prescribing and the policies I have written have emphasised offering buprenorphine as an option equal to methadone – maximal patient information and influenced by the NICE technology appraisal. Often this means prescribing buprenorphine first, then if that is not successful they’re prescribed methadone.
How do you explain that buprenorphine prescribing has not become the ‘gold standard’ in opioid substitution therapy, as it was originally predicted to be?
I don’t think it was predicted to be the ‘gold standard’. Perhaps it is because it doesn’t make service users intoxicated. So, they stop taking it. The fact that they need to be in withdrawal for induction is a barrier. Other barriers can be the perception that you cannot ‘use on top’ and the fear of not being able to use.
Additionally there has been diversion of buprenorphine in prisons because of the inability to supervise it and the difficulty in induction for many. This can reduce retention rates. The reality is that many people who use drugs in the UK carry on ‘using on top’ of their opioid medication. Does that say something about the adequacy of the rest of the treatment system?
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Dr Georges Petitjean is the substance misuse medical lead for Inclusion, part of Midlands Partnership NHS Foundation Trust.
Deanne Burch is the hepatitis C elimination coordinator for the NHS Addictions Providers Alliance (NHS APA).
The authors have not received any financial or other support from pharmaceutical companies and the articles are their own opinion. See the February 2022 issue for part two.
In the second of a three-part series, Dr Georges Petitjean and Deanne Burch explore different buprenorphine preparations, its use during the COVID-19 pandemic and its safety and cost in comparison to methadone.
Different forms of buprenorphine have been developed since its introduction into the drug and alcohol field as an alternative to methadone. Transdermal patches were launched in Germany and Switzerland in 2001 for analgesia, and buprenorphine/naloxone sublingual tablets (also known under the brand Suboxone) were authorised for marketing in 2017 in Europe. The buprenorphine contained within buprenorphine/naloxone is absorbed sublingually but the naloxone component has a 5-10 per cent absorption, essentially leading to a low clinical effect. However, if the buprenorphine/naloxone is injected this would enable a dose of naloxone to induce opioid withdrawal, providing a reduced potential for misuse.
Advantage
In 2017 buprenorphine lyophilisate (also known under the brand Espranor) was introduced to the UK market. Buprenorphine lyophilisate had the advantage of dissolving on the tongue, enabling quicker supervision by pharmacists and making diversion less likely. Many drug treatment services switched to prescribing buprenorphine lyophilisate amid the increasing cost of sublingual buprenorphine in an effort to manage budgets. The increased bioavailability of buprenorphine lyophilisate presented an initial challenge for drug treatment services who wished to switch patients from sublingual buprenorphine, as the products were not believed to be dose interchangeable.
Methadone domination
Despite there being good evidence that buprenorphine is as effective as methadone as a form of opiate substitution treatment (OST) for maintenance and detoxification, and its perceived safety, rates of methadone prescribing continue to dominate those of buprenorphine within UK drug treatment services. In regards to its safety, buprenorphine – like methadone – can cause respiratory depression leading to death, but this is more common when buprenorphine is used in conjunction with other sedatives such as alcohol or benzodiazepines.
During the early months of the COVID-19 pandemic drug services closed to minimise the risk of infection within a vulnerable population. Many utilised alternate forms of assessment via telemedicine, and were unable to use drug screens to provide objective evidence of opioid dependence. The result was the rapid increase of sublingual/lyophilisate buprenorphine prescribing due to the perception of increased safety upon initiation. The ability to prescribe buprenorphine in this context enabled service users to continue to receive opioid substitution treatment.
Transformation
Rapid changes in practice came with the initial stages of the pandemic, such as the limitations on face-to-face assessments and relaxed daily supervised consumption arrangements at pharmacies. This period brought mixed reports from clinicians and patients, with many patients self-reporting reduced heroin use and more stability on prescribed opioid substitution treatment, whilst many clinicians spoke of concerns around risks.
The transformation of buprenorphine into different preparations has given an opportunity for drug treatment services to respond effectively to changing and emerging risks to patients, but also to organisations. During the COVID-19 pandemic buprenorphine’s safety profile was utilised to ensure the continuity of opiate substitution treatment for patients in what was an anxiety-provoking time for clinicians and organisations alike, and lessening the risks associated with not being on treatment.
2019 saw the introduction of the long-acting buprenorphine injection, Buvidal, which has not yet been fully embraced within all drug treatment services nationally. We examine its place in the future of opiate substitution treatment in our third instalment.
Key questions
We asked several experts about their views on the differences in cost, the uptake of buprenorphine lyophilisate within treatment services, and the role of the commissioner in supporting the cost-effectiveness of treatment.
What were the differences in cost that presented challenges for drug and alcohol services?
Around 2019 there was a significant increase in the drug tariff costs for buprenorphine of up to 800 per cent, while methadone costs remained relatively stable. During the same period a number of services saw a reduction in funding received from commissioners.
Affected services needed to review their service model in order to continue to serve the population effectively and give service users a choice on the pharmacological treatment offered. The alternative would have been to employ strict rules on buprenorphine prescribing pathways such as time-limited treatment, having the drug as a second choice on formularies – restricting service user choice – and having stricter rules on testing for illicit substance use.
One solution adopted by a number of services was to implement a buprenorphine pharmaceutical rebate scheme, the application of which did not influence prescribing as the therapeutic intervention already had a place in clinical practice. This provided stability in the cost of the drug, allowing services to manage drug budgets as well as providing significant efficiency savings that could be re-invested into the service. Whilst it is acknowledged that these rebate schemes could undermine the competition required to drive down the costs of medicines, a number of service providers felt compelled to sign up to these schemes in order to remain viable.
Primary care rebate schemes are now a common feature within the UK health system, with a significant number of schemes in operation. PrescQipp (a not-for-profit community interest company set up to help NHS organisations to improve medicines-related care to patients) have created the Pharmaceutical Industry Scheme Governance Review Body (PISGRB) with the sole aim of giving an unbiased view on the available rebate schemes and making a recommendation to commissioners as to whether these schemes can be supported.
Are you able to give us an indication of the estimated savings achieved by drug and alcohol providers following the switch from generic buprenorphine/Subutex to Espranor?
Paul Concannon, senior vice president of commercial operations at Ethypharm.
We estimate that since the start of 2019 we have saved the NHS approximately £14,760,000 across all the UK services that have offered Espranor when compared to the generic drug tariff over that period.
Have all drug and alcohol providers switched to Espranor yet? What are the obstacles for some providers who have not switched yet? In your opinion, what would enable them to switch to Espranor?
At this stage, based upon prescription data, we believe that approximately 45 per cent of all oral buprenorphine is prescribed as Espranor in the community in England. In the UK prison estate the percentage is 82 per cent.
The reasons given by the organisations that have not made the move to Espranor include not wanting to use a branded product, not wanting to enter into a rebate agreement and not wanting to engage with a pharmaceutical company. We also had a number of organisations that were planning to move to Espranor in 2020 but were unable to due to COVID. We’re hoping to capture further real-world evidence of services that have moved to Espranor to show how easy a change it is, and in particular the patient’s positive experience of the product, which we hope will benefit those services not currently using Espranor.
What is the role of the commissioner in finding the most cost-effective drug and alcohol treatments? For example, the switch from buprenorphine or Subutex to Espranor?
Kevin Malone, public health programme manager, Thurrock.
Generally I believe the role of the commissioner is to review the available treatments, evaluate the evidence base and design these into a service specification that has structure but leaves space for change/innovation during the life of the contract.
The increased costs for buprenorphine were astronomical and in our case, left the provider carrying the risk due to the terms of our block contract. So we worked together – the provider sought a safe and more cost-effective solution to reduce the financial risk and that had robust medicines management applied, while I sourced additional funding to meet the reduced uplift in costs. This prevented decommissioning elements of the service to afford the increased medicines costs – fundamentally we all want the same outcomes and it was a case of working together during a turbulent period to stabilise service provision and meet the needs of our clients.
What was your experience of working with Inclusion during the COVID-19 pandemic in regards to the increased prescribing of buprenorphine?
During the pandemic we were constantly updated by and reassured that the provider was managing the ever-changing situation. All prescribed clients were assessed for home treatment and storage, and some were retained for daily pick up. Policies and standard operating procedures were routinely revised and proactively provided to myself, reinforcing the sense of safety and transparency at a time when site visits were not possible.
The Long Game
In the last of their three-part series on the past, present and future of buprenorphine, Dr Georges Petitjean and Deanne Burch look at the opportunities, and challenges, presented by long-acting Buvidal injections.
The long-acting buprenorphine injection Buvidal was introduced in 2019, providing an opportunity to treat patients who would benefit from longer-term and stable dosing. Since its introduction, Buvidal has not yet been fully utilised as a treatment option in many drug treatment services.
Despite Buvidal being a welcome additional option within OST prescribing there are perceived difficulties and important considerations with regards to cost, implementation and ensuring equitable access for patients across national drug treatment services.
Long-acting injectable buprenorphine clearly has a place but can present financial challenges and complexities in implementation, as well as pose concerns about continuity of prescribing for patients who move to different areas because of inconsistency in prescribing rates. If long acting injectable buprenorphine is going to become a more common treatment option, then the issues which have been outlined need to be addressed. However, the ongoing exploration of how it may work within drug treatment services in the form of pilots is a positive sign towards its uptake in the future.
Dr Georges Petitjean is the substance misuse medical lead for Inclusion, part of Midlands Partnership NHS Foundation Trust. Deanne Burch is the hepatitis C elimination coordinator for the NHS Addictions Providers Alliance (NHS APA).
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Dr Jan Melichar
A conversation with Dr Jan Melichar
Jan K Melichar, MD FRCPsych, is an NHS consultant addiction psychiatrist, visiting senior lecturer at Bath University and visiting professor at the University of South Wales. In 2020, he put in a successful bid to the Welsh Government to fund nationwide use of Buvidal. Working together with colleagues, he has rolled it out to more than 1,000 patients and has personally given more than 400 injections to over 100 patients.
What were your fears and expectations when you first began prescribing Buvidal?
To be honest, I was excited to start it as I saw it as a big step forward for many patients. Having worked at getting the most out of buprenorphine for the past two decades, I knew it would be great for settling the peaks and troughs you see with daily dosing. That understanding had led to me to using daily buprenorphine for outpatient detoxification (‘detox-in-a-box’) and seeing it as valuable in the opioid analgesia dependency (OAD) field. Some OAD patients were on so many short and medium and long-action opioids they were in a constant up and down of opioid effects. So I was very excited about seeing it in action, in terms of smoothing things for people on daily opioids and becoming an amazing detoxification option.
What has been your experience as a clinician?
Much more amazing and unexpected – life-changing for nearly everyone who is on it. Being on Buvidal did more than just settle the expected daily peaks and troughs – it utterly flattened most people’s cravings and settled their anxieties so they simply moved on with their lives. It was as if the daily grind of heroin/methadone/buprenorphine kept them trapped – it was a daily reminder that they were ‘an addict’ and all their emotional energy each day went to dealing with that. Being on Buvidal freed them from that and released their recovery capital to simply move on. And this was regardless of which opioid they were on at the start. We recently looked at the Kaplan-Meier survival curves for them and found, regardless of sex/age/addiction severity or present drug use – were they on methadone/buprenorphine/heroin/codeine/tramadol before Buvidal? – that four in five benefited. This answers the question, ‘Who is Buvidal for?’ – it’s for everyone.
What changes have you seen in your service users?
It was, and continues to be, life-changing for most who try it. It suits at least four in five of those who try it – they stay on it, turn up and have used it as the missing link to their recovery.
They’ve moved on with their lives. One week after their first injection, they turn up, some having already re-engaged with their families, got back to work, got on with their lives. That persists over the months they are on it. Our fear of bringing out their past traumas – given trauma is the gateway drug, with them self-medicating with heroin and then developing maladaptive coping strategies – have proven unfounded.
About half just move on, able to just live their lives again. Of the remainder, about two thirds need to have here-and-now psychological support as past traumas/current issues surface – ably provided by the drug service workers in the coming year as Wales rolls out trauma-focused training for all workers. About 10 per cent need more psychological support. Crucially, though, they have reduced craving, reduced anxiety and therefore have the energy and capacity to engage with that support in a timely way.
What has been your experience of implementing Buvidal in your service?
We initially thought it would be fantastic for the pandemic – we asked both English and Welsh governments to fund it during that period and the Welsh Government stepped up to the plate – the roll-out across Wales has been fantastic. It’s easiest to summarise in the feedback we get week in and week out – 19 out of 19 nurses we surveyed who had seen it in use wanted to continue using it, the receptionists love it as patients turn up happy, on time and even phone if they’re running late for whatever reason.
There was, because of the pandemic, a flexibility in the bureaucracies to support service development at pace. So we implemented fast and developed how we gave Buvidal faster than similar developments in the past – it took years to move out of the shadow of slow-motion starts for oral buprenorphine 20 years ago and we’ve done similar in less than a year. Although there will always be resistance to new things and practices in services, once staff saw the dramatic changes in people they’d long given up on they were equally enthused.
What learning would you share with others who are considering prescribing long-acting injectable buprenorphine?
Just do it. Get commissioners to fund ten – it can be in the homeless services, primary care, prison releases. Make sure you measure how well they are before starting – quality of life, attendance records, A&E records, engagement with work or family and so on. Measure those again on Buvidal. You should see four in five make improvements, with the majority being significant. Commissioners like engagement figures so note that they attend every injection.
Figure out how to run their appointments alongside their injections as there is a risk they will not turn up for appointments outside of that time. Not for the reasons we automatically assume with oral opioids – assuming the worst. instead they miss those appointments as they’re well, getting on with their lives, working, engaging with their families, and don’t need to see anyone.
It’s easy to use – a small injection of 0.5ml given subcutaneously. If an old consultant psychiatrist like myself can do it, anyone can. We’ve developed and evolved the practicalities so now we start people on either a weekly dose of 24mg – equivalent to around 16mg of oral – 20-30 minutes after a trial dose of 4mg of oral buprenorphine, so they’ve come in on the usual withdrawal for that, or have a two-day oral buprenorphine dosing of 8mg daily. Then straight to monthly 96mg, also equivalent to around 16mg oral. For the ones that start at weekly 24mg, we then offer a monthly dose the week after of 96mg or 128mg.
What are your views on the cost of long-acting injectable buprenorphine?
It is roughly £200 more annually than oral buprenorphine so this isn’t actually an issue, especially as Dame Carol Black’s report notes how much, when untreated, opioid users can cost the government per year. Confusion arises as commissioners sometimes forget to include the dispensing and other fees commercial pharmacies get for giving methadone and buprenorphine. Unfortunately, those dispensing fees are sometimes hidden in other budgets or given to commercial pharmacies as a difficult-to-disentangle block grant. So commissioners forget this extra £1,000 that is added to the cost of oral buprenorphine annually and fear the cost of Buvidal as it’s ‘much more expensive’. I don’t think £200 per year more is that much more expensive, do you?
How do you see the future of long-acting injectable buprenorphine in services?
Massively expanding – we didn’t expect it to be this good, this life changing and this effective. A true game changer which will see services pivot from ‘script and chaos management’ to finally having the capacity to help these people move on from having made the mistake of self-medicating to deal with their childhood traumas and being stuck with that mistake for decades. It’s wonderful to see them suddenly getting back to swimming in the sea of life after so much time simply spent in a daily drowning as they worried about how long they had before they needed their next dose of daily opioid.
I suspect we, in the UK, are at the forefront of seeing the changes as we’ve given Buvidal to patients due to the pandemic rather than the select few already stable on oral buprenorphine. I think its remarkable action – the reduction in craving and anxiety and the return of normality – is, in part, due to novel allostatic pharmacology, with us finally seeing kappa antagonism, but that’s another story!
Inclusion is running an innovative pilot in partnership with HMP Chelmsford to facilitate a smooth prescribing transition for people being discharged from prison to local drug and alcohol services. We asked Kevin Malone, public health programme manager in Thurrock and commissioner of the local Inclusion drug and alcohol service, for his thoughts on the pilot.
What are your hopes for the Buvidal pilot happening across Inclusion Thurrock and HMP Chelmsford?
My hopes for the Buvidal pilot are positive. For the right client, can we provide a solution that better meets their needs, mitigates the risk of relapse and breaks the cycle of recidivism? It may not be the solution for everyone, but the broader the range of support available, the more choice we can offer our diverse treatment population. The main legwork with this intervention is ensuring that preparation takes place prior to release, not just for the client but for the range of multi-agency staff that need to play their part in the community, however large or small that role is in supporting the client. I shall have a keen eye on future evaluation data for what is an interesting and exciting opportunity.
Dr Georges Petitjean is the substance misuse medical lead for Inclusion, part of Midlands Partnership NHS Foundation Trust: www.inclusion.org
Deanne Burch is the hepatitis C elimination coordinator for the NHS Addictions Providers Alliance (NHS APA): www.nhsapa.org
The authors have not received any financial or other support from pharmaceutical companies and the articles are their own opinion.
It’s been a while since we got together for ‘live’ debate, so what a treat to be given DDN sessions at HRI’s online Constellations event. We chose to focus on naloxone action, peer-led initiatives on hepatitis C, and two issues that have fired up our pages for many years – ensuring people are on the dose that suits them, and the all-important dialogue that moves way beyond the ‘harm reduction v recovery’ days and focuses on our collective assets and interests.
Our reports on pages 10, 12, 16 and 21 give a flavour of the will – and urgent need – to unite on these vital issues. The timing and the need to challenge spending cuts could not be more important, so please send us your thoughts and let’s keep up momentum.
Getting – and giving – the right dose means staying informed enough to make these decisions, so we’re excited to offer the first in an authoritative and independent three-parter on buprenorphine (page 6). It’s part of our role to present the facts while giving you the forum to debate, question and offer vital lived experience to complete the picture. And as we take stock of the year that was (p23), let’s be thankful for the will to communicate, which helps our sector rise to the challenges ahead. Have a happy and safe festive season and here’s to strong bonds between all of us in 2022.
The need for quality supported housing is now greater than ever, says Gill Arukpe. Read it in DDN Magazine
I have worked in supported housing for a long time, over forty years to be precise. I was a frontline worker in Women’s Aid, housing women and children fleeing from violent and controlling relationships – sometimes three or four families sharing a three-bed house in a residential street. Just pause and think how desperate all those women and their children were, and still are today, to uproot courageously and move into overcrowded shared accommodation, often staying for over a year before their housing situation is resolved.
In the ’90s, I managed one of the largest hostels in London, Arlington House. It accommodated 400 men who had been homeless and had mental health and substance misuse issues. I share this with you to show how the needs of people in the UK have not changed over decades. Supported housing was and still is needed for the most vulnerable of our society, and we need to continue providing it – and doing so even better.
Changing times
Over the past ten to 20 years, the supported housing field has changed hugely. Most supported housing schemes for adults with social care and health issues run in much smaller buildings now, which is positive. In the Social Interest Group (SIG) we provide housing and accommodation services for adults who have had a long-term enduring mental illness and often have comorbidity with addiction or personality disorder. We also work to support people who have been in the criminal justice system and have mental health issues, personality disorders and substance or alcohol misuse.
It is essential to our residents and us that we provide trauma-informed accommodation. It is vital that our residents feel valued, and that the look of the housing and the upkeep of that accommodation is of high specification – this is essential in aiding residents’ recovery and rehabilitation or resettlement. In my experience, if you offer poor quality accommodation, no matter how good the support is residents will find it difficult to trust you and engage. Their mood is affected, and the level of aggression in the house can rise quickly.
Essential space
Providing spacious rooms with ensuite facilities so residents do not have to share is essential. Many of our residents have had to share facilities for years. They have often experienced trauma and had poor experiences using support in the past. The need to value them as people by the quality of the accommodation is essential. The SIG has a property strategy which we hope to realise over the next three years – to replace all our accommodation that does not provide ensuite as a minimum.
Very recently National Housing Group approached me and told me about their vision to provide supported housing that was fit for purpose. Refreshingly, they asked for our input while they got the building ready before completion. I have visited a property they are working on now and they have thought carefully about residents’ privacy, mental wellness, and the light in communal areas, while also recognising the need to keep everyone safe and involved. They are not insisting that all rooms are for rental income – they have listened to our need to have space for us to provide education and learning on-site. They have even thought about the environmental impact and the cost of running a supported house.
New Partnerships
Gill Arukpe is CEO of the Social Interest Group.
I am looking forward to entering a partnership with the National Housing Group soon – their staff are not only property experts but have employed people who have previously worked in the sector and understand our needs as providers and residents as recipients of support. Look out for our announcement of the opening of our first partnership house.
A version of this article also appeared in Inside Housing magazine.
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Firm foundations
National Housing Group share the story of one of their residents
James was helped by our Pathways to Independence service in Kent. He entered our low/medium support Newlyn Court project in July 2018 – he had been referred while homeless and has spent time in custody and on community orders. His most recent offence was for shoplifting in July 2019 – he was given a 12-month suspended sentence.
James has struggled with an addiction to heroin for 14 years. He moved away from his family home at 15 and has been without a settled home since then. He had surrounded himself with associates who held pro-criminal attitudes and who also struggled with addiction. Rough sleeping exacerbated this lifestyle, and he became reliant on services like the local day centre for support, food and social interaction.
James had additional support needs – he had no budgeting skills as all his adult life was spent homeless, with poor money management leading to debts and an acknowledged struggle to take responsibility for himself and his actions.
James’ health was compromised. After years of drug use, he has contracted hep C and had never prioritised treatment for this because of homelessness and recovery from addition. James has struggled with his mental health and emotional wellbeing during his time with us, and he was diagnosed and medicated for anxiety and depression. During his time, he has experienced suicidal thoughts and overdose attempts. James accepted the support from staff and engaged well with primary healthcare services during times of crisis.
For now, James is doing very well. He has drawn strength from the peer support he finds in Cocaine Anonymous meetings, having a sponsor, studying the ‘big book’ and talking with others who share his experiences and can offer him support. He has recently completed 90 meetings in 90 days, has spoken publicly and applied to volunteer back at the day centre which once was a trigger point for him. James is on a reduction programme and plans to spend a short time in detox to wean himself off completely.
James is now self-sufficient in most areas of his life. He manages his accommodation well and is now in one of our self-contained units in Tumim House, as a stepping stone to complete independence. He can now budget effectively and has no debt. James has better relationships with family which he cherishes, and he is looking forward to a family wedding this year. He has worked hard and even though he sometimes still has ‘drug thoughts’ he has learnt from experience not to let his guard down and to renew his commitment to support networks and communicate openly with his support coach, probation and drug workers.
The latest Drugs, Alcohol and Justice Parliamentary Group invited discussion on more positive initiatives than punishment.
Read it in DDN Magazine
It was time to balance necessary enforcement with the support and engagement of people who were being exploited, said police and crime commissioner for Lancashire, Andrew Snowden. Together with colleagues at Blackpool’s Project ADDER – the government’s programme for Addiction Diversion Disruption Enforcement and Recovery – he was seeing encouraging results from exploring more positive pathways than the criminal justice system.
With ‘some of the worst outcomes in the country’ in Blackpool and ‘top of the leaderboard for ten years’ for drug-related deaths, harm reduction lead for public health, Emily Davis, explained how the region was one of the original pilot sites for Project ADDER and had been given the brief last year, in the middle of the pandemic. Partners from criminal justice, public health, lived experience and commissioning had been asked to consider what they would like to see as a model, and had decided with ‘a resounding positive’ that the outreach model was the way to go, with the individual at the centre.
The Homeless Health Division was seeing many people with health issues relating to their heart, liver and lungs – ‘all contributory factors to an untimely death’. The health of the drug using population was getting worse, she said, with conditions such as COPD ‘the norm’. People in their 40s were needing end-of-life care.
Read DDN coverage from meetings of the Drugs, Alcohol and Justice Parliamentary Group
Project ADDER had given the opportunity to prioritise health-focused interventions, such as treatment with long-acting injectable buprenorphine, and there were ‘lots of positive things going on’ alongside significant challenges.
Detective chief superintendent Susannah Clarke, head of the Violence Reduction Network, said ADDER was ‘the most hopeful project’ she’d worked on in her 30 years in the police – a ‘holistic offer’ that contributed to the goal of trauma-informed practice being a part of treatment. Steven Brown demonstrated how the Lived Experience Team were a vital part of this process, as they knew most of the clients and were talking to them on a daily basis. He and his colleagues were involved in all levels of the project, including job panels and recruitment.
Suzie Hodgson, working at the Young ADDER Project, added that for young people it was an opportunity to build relationships and trust, helping them to get into their own accommodation and teaching them about earning respect and learning how to flourish.
Another perspective on such alternative approaches to drug policy was offered by Michael Collins, strategic policy and planning director for Baltimore City State’s Attorney. Baltimore had become known as ‘Ground Zero for the drug war’ he explained, but building good relationships – such as between the police department and the mayor – had led to stopping arrests for possession. He had worked with researchers to analyse public safety factors, which highlighted that people arrested for drug-related crimes were unlikely to commit more serious offences. The time saved on not prosecuting low level offences could mean dedicating resources to more serious crime.
Taking individuals away from involvement with the criminal justice system meant more work on relationships, including with services – many of which did not have the comparatively ‘huge budget’ of the police. There was also a need to educate police on the street and members of the public, to counter misinformation about not prosecuting people – and it was ‘also about educating drug users themselves, from a situation where they were afraid to ask for help’.
We needed to move from the ‘othering’ of people who use drugs, where ‘people want these people out of sight and out of mind’ to a health-based approach, said Collins.
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No time to lose
The facilities will be in two sites in East Harlem and Washington Heights
Two safe injection sites have just begun operating in New York City – the first publicly recognised facilities in the country. The ‘overdose prevention centers’, co-located with established NSPs, will be an extension of the city’s harm reduction services as it records its worst year for overdose deaths. The Centers for Disease Control and Prevention projects that US overdose deaths for 2020 will top 90,000, with more than 2,000 people estimated to have died in New York alone.
The city’s health department estimates that the sites would save around 130 lives a year, with increased focus from health agencies around the facilities.
‘After exhaustive study, we know the right path forward to protect the most vulnerable people in our city,’ said New York mayor, Bill de Blasio. ‘And we will not hesitate to take it. Overdose prevention centers are a safe and effective way to address the opioid crisis. I’m proud to show cities in this country that after decades of failure, a smarter approach is possible.’
Recovery is the process of becoming well. In terms of general health, it is often considered a return to healthy function following an illness or accident.
In mental health this does not accurately reflect recovery for people who see it as an ongoing endeavour instead of an end destination. Here recovery is more ideological and involves taking positive action to implement lifestyle changes that improve wellbeing.
The concept of recovery as a lived experience was first popularised in Alcoholics Anonymous (AA), through the 12-step programme it advocates. Its success resulted in the proliferation of 12 step programmes to other areas of addiction, for example, Narcotics Anonymous (NA) and Gambling Anonymous (GA). Moreover, the positive testimonies of people in addiction recovery describing experiencing a meaningful life encouraged health professionals to start looking at where people with mental health problems could also embark on a process of personal change. One that could build resilience for living a happy and satisfying life, irrespective of the limitations presented through illness.
Broad view
Recovery as an approach in mental health takes a broader view of the person than is seen in traditional psychiatry, one that does not aim to treat symptoms or adjust for deficits, instead promoting self-management and the re-assertion of control. A substantial body of knowledge now exists on the use of recovery-based approaches within mental health services. This importantly has the backing of empirical evidence to demonstrate its efficacy. A review of the material resulted in a valued and respected framework for understanding personal recovery known as CHIME: Connectedness, Hope and optimism about the future, Identity, Meaning in life, and Empowerment.
This framework lists five significant and supporting components of recovery and has become an important tool for gauging recovery in addition to offering a model for developing interventions and evaluating clinical endpoints. The CHIME model has proved to be adaptable, for example, C-CHIME considers using creativity to promote recovery, CHIME-A is an adaptation specifically for adolescents and children, and CHIME-D considers recovery in terms of the difficulties overcome.
Growth
This presented the opportunity to consider what can be appropriated from this model and returned to where the idea of recovery started – addiction. One such study used CHIME-D to look at recovery in terms of the difficulties overcome, however this found that difficulties did not generally fall into their own classification, instead being more relevant to the other components of CHIME. Here we discuss an adaptation to the model that includes a sixth dimension important to addiction recovery, Growth, resulting in G-CHIME.
If the five components of CHIME fit so succinctly with addiction recovery, then why adapt the model to incorporate a dimension for growth? Perhaps this is best explained by the stages of change model commonly referenced in the field of addiction, where personal growth is recognised through a series of changes that demonstrate an individual’s disposition to learn, improve and continue to develop, rather than remain in the same mental and emotional state.
This willingness to adapt and learn, to personally grow, is a fundamental principle in 12-step programmes, where recovering addicts are encouraged to keep an ongoing inventory of their conduct and when appropriate accept responsibility for wrong doings and make positive changes to support a morally strong and motivated way of living. In psychological terms, this is an example of practising reflective thinking, where an individual can compassionately look at their strengths and weaknesses and use this evaluation to constructively inform their future choices. Furthermore, research has shown this is an essential ingredient for personal growth and development. For recovering addicts, following a path of continuing self-improvement, along with having the ability to enact constructive change, safeguards recovery. Negative behaviours and ways of thinking are reflected on, unhelpful ways are left behind, to be replaced with more positive equivalents that strengthen recovery.
For practitioners working with people in recovery, such as those engaged with addiction services, the G-CHIME model is multi-faceted. It can be used for targeted interventions when it is felt that an individual has a deficit with one or more of the components, for example, promoting mutual aid meetings and recovery activities for clients feeling lonely or disconnected or running workshops to help clients who are prone to negative bias foster a more hopeful and optimistic outlook in decision making and goal setting. Similarly, it could be extended as a treatment approach, in a similar way to that seen with the Five Ways to Wellbeing, where the components are grouped together to offer a more holistic package of support, in this case encouraging a broader perspective on resilience in addiction recovery.
Raising awareness
G-CHIME can provide an itinerary for raising client awareness and educating them on the key aspects of recovery, as well as helping them understand where personal responsibility lies. As a framework, it offers a structure for assessing client development, as well as tracking progress over time to support addiction recovery as long-term endeavour. Matching appropriate scales to the six components of G-CHIME, such as, the Perceived Hope Scale, the Office for National Statistics personal wellbeing questions, or the meaning in life questionnaire, will enable practitioners to evaluate the personal resources held by their clients for each of the components.
The G-CHIME model is currently being used to study addiction recovery through a series of first-hand accounts of addicts living in recovery. Each story is unique to the experience and circumstances of the individual author. For each, a structured interview is conducted based on the six components of the G-CHIME model. This provides a basis to standardise the different accounts in relation to the common and necessary components of successful addiction recovery. In addition to this, G-CHIME is being used to promote the use of positive psychology in addiction treatment services, to disseminate positive addiction recovery to clients as an achievable lifestyle choice.
Meaningful lives
Recovery as a recognised approach to improving wellbeing started in addiction services and offered an alternative way to live. An approach that when transferred to mental health helped shape how people with mental illness were viewed and treated. This has seen a move from an assumed dependence on traditional psychiatric treatment to one that supports and encourages people with mental health problems to live a meaningful and satisfying life that is not defined by the challenges presented through illness.
From this, important knowledge has been acquired about the components necessary to support recovery, resulting in the advent of the CHIME model. G-CHIME takes the existing recovery components of Connectedness, Hope and optimism in the future, Identity, Meaning in life, and Empowerment, and adds Growth. This adaptation enhances it for addiction recovery where personal growth and development are a necessary part of sustaining recovery as a prolonged lifestyle choice. We commend it to colleagues.
Lisa Ogilvie is a PhD student and Jerome Carson is professor of psychology at the University of Bolton
CHIME components
The CHIME model represents five necessary components for mental health recovery – these are equally important, with an enduring body of research that is testament to this.
Connectedness, a key component in recovery communities that offers a supportive alliance to recovering addicts. This is evident in the local, national, and international membership of organisations such as AA and NA.
Hope and optimism about the future, summarised by the well-known AA recovery adage ‘living a life beyond your wildest dreams,’ which conveys a message of what recovery means to those living it. Describing an addict’s transition to a happy and free life beyond the constraints of addiction, where everyday possibilities are seen as attainable.
Identity, in 12-step programmes, the starting point is admitting you are powerless in addiction. Identifying as an addict is part of the recovery process, along with the transformation that happens in identifying as someone who lives in recovery, as opposed to someone defined by addiction.
Meaning in life, lost to those in active addiction, when purpose is driven by obsession with a substance or substances. Finding meaning is important to experiencing a renewed enthusiasm for life, and is necessary in having the aspiration to maintain recovery. Research has shown that meaning in life correlates with the longevity of recovery.
Empowerment, is minimised in addiction where choice is narrowed, having been limited by unhealthy behaviours and thought patterns relied on. The freedom of having a choice no longer restricted by active addiction is empowering. This is apparent in the many accounts recounted by recovering addicts telling of mended relationships, a return to education, finding employment, and forming
new friendships.
Mohammed Fessal is chief pharmacist at Change Grow Live
The continued increase in the rate of drug-related deaths in England, Wales and Scotland is a tragedy, not only for those individuals and families directly affected, but for the UK as a whole. Proactive responses are vital, and naloxone supply must be a crucial priority in efforts to reduce the death rate. At Change Grow Live, a key focus in our harm reduction work over the last five years has been increasing the availability of naloxone to those within structured treatment, as well as their family, friends, and wider network.
Naloxone penetration has accelerated since the onset of the pandemic – between 19 March and 21 July 2020, we reached an additional 7,418 service users, meaning 70 per cent of our opioid caseload was in possession of a naloxone kit and efforts to expand our reach are ongoing. Our priorities for national naloxone supply are set out in our new Naloxone strategy for 2021, and a key focus is reaching people who are not in structured treatment and are therefore at most risk.
The strategy identifies the need to prioritise naloxone supply and awareness in hospitals, prisons, homeless hostels/shelters, as well as within ambulance services and across regional police forces. Homeless hostels and pharmacies remain key allies in ensuring naloxone penetration within communities, and pharmacies also play a central role. Since 2015, 19 per cent of the 3,768 kits that Change Grow Live has supplied to pharmacies have been used in an overdose situation, compared with 4 per cent of kits supplied to services and wider settings.
As part of efforts to reach high-risk groups, Change Grow Live has been running the first ever naloxone project within approved premises (APs). Formerly known as bail or probation premises, APs house high-risk individuals who have left prison. There are 101 APs in the UK, providing over 2,000 bed spaces, and more than half of deaths in APs are drug-related.
This project has resulted in the successful distribution of naloxone across over 40 per cent of the national network of APs and gives us confidence that, with the support of the relevant stakeholders, current gaps in provision can be rectified rapidly. Change Grow Live has worked closely with the National Probation Service to develop a comprehensive online training module, and this has now been rolled out across the 42 APs where we provide substance misuse services.
This training module provides clear, evidence-based guidance, empowering staff to know when to use naloxone and to have the confidence to act fast. Feedback from staff shows beyond doubt that effective training, not just supply, is an essential component of successful implementation – staff want to help keep people safe, but the idea of administering a drug in a crisis situation raises multiple questions and concerns.
Since the project started naloxone has already been administered to reverse two potentially fatal overdose cases and the National Probation Service is now planning the roll-out of training and naloxone supply to the remainder of the AP estate. We are supporting this roll-out wherever possible, through the sharing of training resources and best practice, and the training module and approach to distribution is also informing ongoing projects with regional police forces in the West Midlands and Cambridgeshire and a planned national roll-out in settings managed by the Salvation Army.
My hope is that our new naloxone strategy provides a useful guide to where the gaps currently are, but also demonstrates to wider stakeholders working in high-risk settings that naloxone supply is not just possible, but essential. Navigating multiple systems and achieving buy-in from the gatekeepers of those systems is essential, but ultimately our strategy is calling for a joined-up approach founded upon a shared commitment to save lives wherever possible. The more that our sector can demonstrate the immediate benefits of naloxone provision in new settings, the quicker we will be able to fill the current gaps in provision.
In 2008, in a boring-looking room, a psychiatrist gave me a diagnosis I could have done without. She made an assessment, asking me many questions, and after 88 minutes concluded I had ‘a lesser form of bipolar affective disorder’ (bipolar type 2).
Somewhat shocked, but definitely terrified, I looked at my 15-month-old daughter, and began to fret. Then the processes of grief kicked in as I thought I was being told I would not be able to think well.
In one phone call with this doctor, I said, ‘Hey, you should research open “addiction” self-help groups. We’re all like “that” in there,’ meaning that mental health was an issue for almost half of us – hardly surprising as those rooms are full of people in early addiction-healing, not to mention hepatitis C, HIV and other BBVs. She proceeded to suggest I keep taking vitamin D, as it is helpful for people with depression.
I didn’t mind the upswing of my newly-diagnosed condition, but the lows often left me suicidal. Try as she might, this poor clinician couldn’t get me to take drugs for the bipolar 2 –it didn’t help that the psychiatric profession are not sure whether it requires medicine anyway. According to a fellow living with BP1, the main difference between BP1 and BP2 is that when, for example, I think I’m super-woman on a well-day, my ‘sane brain’ will let me know that is clearly not true. I was ‘lucky’ – my diagnoses left me with enough connection to reality (as we know it) to protect me from the excessive sex, retail therapy, and other behaviours that often bedevil people living with BP1, getting us into terrible debt, not to mention STDs.
I was already taking low doses of opioids for chronic pain and SSRIs for the suicidal phases of my illness. The idea of taking another medicine was hardly attractive, and let me say there were people in ‘the rooms’ who were dubious about my decision not to take drugs for the BP2, but it took me nine years to finally ‘research’ whether lamotrigine actually stabilised my moods.
To this day, I’m unsure whether it did but I, as ever with unpleasant psychoactive drugs, took the lowest possible ‘clinical dose.’ I was in 12-step and we didn’t do those kinds of drugs, right? Wrong. How many of us have utterly ignored the one page in ‘the big book’ about how when a professional advises us to take a medicine, we should seriously consider it. After all, they are trained to know better than many ‘recovering addicts’ when a drug is necessary or not. Lots of people ‘in-recovery’ or not take psychoactive medicines for mental health care, chronic pain and so on. So what’s the problem? Several.
When you live within a community whose narrative is anti-psychoactive drugs, and you’re enduring countless illnesses, lack of paid employment and sleep, your own thought process will struggle to remain grounded in fact and reality, as most people know it. Then there are the infrequent ‘amateur psychologists’ who will tell you that you should not take tramadol, SSRIs or anti-psychotic medication as that is a relapse. To be fair, anyone in those rooms who knew me knew I was the last person to advise not to take psychoactives therapeutically as a passionate proponent of harm reduction, but most didn’t know me at all.
The only groups I regularly go to now are full of people navigating similar dilemmas. Some opt to take the prescribed medicines, some opt not to and use other tools (yoga, vitamins, meditation) to cope, and a few like myself do both. One thing’s for certain. As we age, some of us will hurt, creek and often be challenged by illness, drug prohibition and socio-economic deprivation. Therefore it is our job as responsible citizens to ensure we do whatever it takes to ensure the highest possible levels of self-care.
Andria Efthimiou-Mordaunt is an activist at ACT.UP London, actuplondon.wordpress.com. This article is in memory of Mary P.
The risk of ‘SARS-CoV-2 breakthrough infection’ (COVID-19) among fully vaccinated people may be higher for ‘people who misuse substances such as alcohol, tobacco, marijuana and opioids’, according to recent research.
The risk of COVID-19 may be higher for ‘people who misuse substances such as alcohol, tobacco, marijuana and opioids’,
The findings are based on analysis of the electronic health records of almost 580,000 fully vaccinated people by researchers at the New Case Western Reserve University and the National Institute on Drug Abuse (NIDA) in the US.
Co-occurring health conditions and ‘adverse socio-economic factors’ are likely to be largely responsible for the increased risk of infection, says the study, which is published in the journal World Psychiatry. Although infection rates for people with substance use disorders were still low overall they did have ‘elevated rates of severe outcomes, including hospitalisation and death’. With waning vaccine immunity and a ‘high comorbidity burden in the US population – six in ten adults have a chronic disease – it is important to continuously evaluate the effectiveness of COVID-19 vaccines and the long-term effects of COVID-19’, said the study’s lead author, Rong Xu.
Meanwhile, Almost 8m people have died in the UK as a result of smoking since 1971, according to new analysis commissioned by ASH to mark its 50th anniversary. The next two decades will likely see 2m more people die ‘without radical changes to smoking rates’, the charity states, with the government’s pledge to make England ‘smoke-free’ by 2030 unlikely to be met.
‘Government knew about the terrible harms from smoking in the 1950s but it took the tireless efforts of campaigners to bring about change,’ said chief executive Deborah Arnott. ‘Today, we have a government with a vision to make smoking obsolete, but vision alone is not enough. Two years ago the government committed to “bold action” to “finish the job”, including the option of a “polluter pays” levy on the tobacco industry. When will it deliver on this promise?’.
Two safe injection sites have begun operating in New York City, the city’s mayor and health department have announced – the first publicly recognised facilities in the country.
The facilities will be in two sites in East Harlem and Washington Heights
The ‘overdose prevention centers’ are an extension of the city’s existing harm reduction services and will be co-located with established NSPs.
The US has been in the midst of an opiate overdose crisis since the turn of the millennium, with almost 850,000 people dying of a drug overdose between 1999 and 2019, according to the Centers for Disease Control and Prevention – in 2019, more than 70 per cent of the deaths involved an opioid. The agency’s projected figure for overdose deaths for 2020 tops 90,000, making it the worst year on record, with more than 2,000 people estimated to have died in New York alone.
A feasibility study by the city’s health department estimates that the supervised consumption sites would save around 130 lives a year, and a range of health agencies will also be increasing their focus on the areas around the facilities.
New York Mayor, Bill de Blasio
‘New York City has led the nation’s battle against COVID-19, and the fight to keep our community safe doesn’t stop there,’ said the city’s mayor, Bill de Blasio.‘After exhaustive study, we know the right path forward to protect the most vulnerable people in our city. And we will not hesitate to take it. Overdose prevention centers are a safe and effective way to address the opioid crisis. I’m proud to show cities in this country that after decades of failure, a smarter approach is possible.’
Meanwhile, New Zealand is set to introduce legislation to legally allow drug testing at venues and festivals, after politicians passed the Drug and substance checking legislation bill – making it the first country to vote to protect the practice in law. ‘This will help ensure this vital service is accessible to more communities, and ultimately prevent more drug-related harm,’ said managing director of harm reduction organisation KnowYourStuffNZ, Wendy Allison.
Natalie Travis, National Head of Service Public Health & Substance Misuse at Turning Point, looks at how the Comprehensive Spending Review will impact substance misuse services.
In the government’s recently announced Comprehensive Spending Review, Rishi Sunak has committed to increased public service funding, with support for the Department of Health and Social Care set to be 57% higher in cash terms in 2024-25 than it was back in 2019-20. These announcements are warmly received, yet the apparent lack of pledges made to increase spending for substance misuse services and the absence of detail in response to Dame Carol Black’s recommendations is concerning.
Nationally, funding for substance misuse treatment has been in steady decline, reducing by 24% between 2014 and 2019.1 During the same period, seven in 10 councils in England have made cuts to the amount they planned to spend on drug and alcohol services.
Third sector organisations such as Turning Point have risen to the challenge posed by over a decade of austerity, taking on large integrated drug and alcohol services which provide substantial savings to local commissioners, whilst maintaining standards and preventing the need to introduce waiting lists. However, increasing caseload sizes as a consequence of funding reductions (with recovery workers in some services have caseloads as a high as 80-90), inevitably compromises the number of interventions and amount of support that can be provided.
Dame Carol Black’s review of drug treatment services, published earlier this year, clearly charted the necessity and urgency of investing in these services as part wider attempts at addressing spiralling substance misuse related deaths. The review also outlined the relationship between health inequalities and substance misuse, with entrenched substance misuse and premature deaths occurring to a greater extent in deprived areas.
The benefits of properly funding substance misuse services will be far-reaching. Estimates show that the social and economic costs of alcohol related harm amount to £21.5 billion, while that of illicit drug use costs £10.7bn. These include costs associated with deaths, the NHS, crime and, in the case of alcohol, lost productivity.
Alcohol treatment provides a return on investment of £3 for every pound invested, whilst drug treatment reflects a return on investment of £4 for every pound invested. One report shows that if only a 7-10% reduction in young people continuing their dependency into adulthood is achieved, the lifetime social benefit of treatment could be as high as £49 million -£159 million. This equates to a potential £5-£8 for every £1 invested. Consequently, drug and alcohol treatment benefits people and communities, as well as the wider economy and our national healthcare system.
Substance misuse, poverty and social exclusion are closely intertwined, with drug and alcohol used by many as a coping mechanism. Individuals are more likely to struggle with addiction, and neighbourhoods be affected by drug related crime and anti-social behaviour, in communities which have been underinvested or ‘left behind’. Investment within substance misuse can therefore aid the government realise its ambitions to level up communities.
More than 90 per cent of people who complete gambling treatment show an improvement in their condition, according to the 2020-21 statistics from the National Gambling Treatment Service (NGTS).
70 per cent of clients in treatment were male.
Ninety-two per cent of people completing their scheduled treatment recorded a reduction in their Problem Gambling Severity Index score, while 70 per cent were no longer defined as ‘problem gamblers’ by the end of the treatment. While there were 518 fewer people in treatment than in the previous year – largely as a result of COVID – almost three quarters completed the treatment, compared to less than 60 per cent in 2016.
The percentage of people seeking treatment for online gambling also increased, from less than 60 per cent in 2015-16 to almost 80 per cent. Half of people were able to start treatment within three days of contacting the service, and three quarters within eight days. Less than one per cent of referrals came from GPs, however, with 93 per cent of people self-referring, and 70 per cent of clients were male. The figures relate to structured treatment, and don’t include people using the National Gambling Helpline.
GambleAware CEO Zoë Osmond.
‘It is encouraging to see that during an unprecedented year, when many of the services had to move online, the National Gambling Treatment Service has been able to continue to deliver good results for those receiving treatment,’ said GambleAware CEO Zoë Osmond.
‘The worryingly low uptake of services however underlines the very real need to continue to raise awareness of and improve pathways to the service, so that more people know that help is available. To assist here, we are continuing to deliver impactful campaigns to help elevate awareness of the service across the country. We also encourage healthcare professionals and other community support figures to refer people in need to the service, yet we recognise that the NGTS cannot tackle this problem alone and we therefore call on other statutory sectors to track results of gambling treatments to help to deliver a clearer picture of treatment in Great Britain.’
Alcohol marketing can act as a ‘trigger’ for relapse. Pic by Marco Verch
The ‘constant bombardment’ of alcohol adverts, particularly over Christmas and during major sporting events, makes it difficult for people in recovery ‘to fully participate in everyday life’, says a new report from the Alcohol Health Alliance (AHA). The umbrella group of more than 60 organisations is calling on the government to take urgent action to protect ‘both those in recovery and children from overexposure to alcohol marketing’.
Marketing can act as a ‘trigger’ for relapse among vulnerable groups, says No escape: how alcohol marketing preys on children and vulnerable people. Children also demonstrate high levels of brand awareness through their regular exposure to alcohol marketing, it states, with more than 80 per cent reporting seeing it within the last month and more than 40 per cent also seeing it on social media platforms. ‘Research has consistently shown that alcohol marketing is causally linked to alcohol use among young people, including starting to drink at an earlier age or engaging in riskier consumption,’ AHA states.
Prof Sir Ian Gilmore: ‘We are in desperate need of a new approach.’
Alcohol marketing was a ‘significant contributor’ to alcohol harm in the UK, said AHA chair Professor Sir Ian Gilmore. ‘The glamourisation of a harmful product creates a culture where alcohol is seen as an essential part of everyday life. With deaths linked to alcohol at record highs, we are in desperate need of a new approach. The Health and Care Bill plans to introduce advertising restrictions such as a 9pm watershed for ‘less healthy food or drink’ advertising on TV and a prohibition of paid-for ‘less healthy food or drink’ advertising online, at the end of 2022. Alarmingly, alcohol is not currently included in these plans and is bizarrely not considered a less healthy drink. This needs to change. The government must now introduce comprehensive marketing restrictions in both real world and digital spaces to ensure that vulnerable adults and children are protected from alcohol advertising and its harm.’
‘The current self-regulatory alcohol marketing system is failing to protect our children and vulnerable adults from exposure to alcohol advertising,’ added chair of the APPG on Alcohol Harm, Christian Wakeford. ‘Restrictions for tobacco advertising have been in place for many years, and stricter requirements have been proposed for junk food advertising. We need to ensure alcohol marketing regulations are entirely independent of the industry and are effective to protect the most vulnerable in our society.’
As part of the NHS’s goal to eliminate hepatitis C as a major health concern in England, Change Grow Live is leading a ground-breaking new approach to treatment in North Yorkshire and Humber.
For the first time, we are bringing together drug treatment providers across the region to share their expertise and deliver support directly to the people who need it.
People will now receive their hepatitis treatment as a part of their overall support, in a setting they are comfortable with and from people they know and trust. This new approach will remove barriers to treatment, build greater trust with the people we support, and encourage more people than ever to engage with treatment and be cured of hepatitis C.
An innovative approach to hepatitis C treatment
Traditionally, drug treatment services have tested and identified people with hepatitis C, before referring them to their relevant NHS Operational Delivery Network (ODN) for treatment. Now, services will be working together to share expertise and resources, and deliver treatment directly to the people they support. By linking up care across different providers, we can make sure that everyone is getting the highest quality support in the way that is most accessible for them.
This partnership approach has been developed by the North Yorkshire and Humber ODN with input from Change Grow Live. As the lead provider, we will be sharing our expertise in this area, including our blood-borne virus toolkit, treatment pathways, and specialist teams and workers.
Our Hull Renew service will act as the central hub for this new model, which also brings together Changing Lives, Humankind, East Riding Trust, We Are With You, and Spectrum Community Health CIC. Each provider will cover their own area, but we will be working closely with each other and our specialist colleagues from the NHS. Our colleagues at the Hepatitis C Trust will continue to offer care and support to people
Carrie Richardson, Northern Regional Manager for the Hepatitis C Trust, said: “We are really excited to see the launch of this new service and the impact it will have on easing patient access to treatment. We hope this approach could act as a blueprint for future models of hepatitis C care and lead to a greater number of patients in substance misuse services achieving a cure.”
Almost 3,800 people died while in contact with drug and alcohol treatment services in 2020-21, according to statistics from the Office for Health Improvement and Disparities (OHID), a 27 per cent increase on last year.
The period covered by the figures represented a ‘uniquely challenging period in our field’s history’, said Collective Voice.
While all substance groups saw a decrease in deaths in treatment last year, this year there were increases of 20 per cent in the opiate group and 36 per cent in the non-opiate only group. The alcohol-only group also saw an increase of 44 per cent, while the non-opiate and alcohol group recorded an increase of 37 per cent.
Much of this will have been the result of the pandemic, says OHID, with fewer people able to access inpatient detox and reductions in treatment for BBVs and liver disease. ‘It’s likely that a number of factors will have contributed to the increase in the number of service users who died while in treatment during 2020 to 2021,’ says Adult substance misuse treatment statistics 2020 to 2021. ‘These include changes to alcohol and drug treatment, reduced access to other healthcare services, changes to lifestyle and social circumstances during lockdowns, and COVID-19 itself.’
There were 275,896 adults in treatment services in 2020-21, a slight increase on the previous year. More than half were in treatment for problems with opiates, and almost 30 per cent for alcohol. Unlike previous years there was a fall in the number of people entering treatment for crack cocaine, used either with or without opiates, with the number at its lowest level since 2016-17. There was a 5 per cent increase in people entering treatment for cannabis, however, and a 6 per cent increase for benzodiazepines. Almost two thirds of people entering treatment had a mental health need, with over half requiring mental health treatment, and almost 20 per cent had a housing problem.
The period covered by the figures represented a ‘uniquely challenging period in our field’s history’, said Collective Voice. ‘People facing drug or alcohol addiction, already a vulnerable and oftentimes isolated group, had to endure a global pandemic that radically altered how they could receive support.’ The death statistics were ‘deeply shocking’, and OHID was right to note that a number of factors were likely to have contributed to the increase, it said. ‘In the early phase of the pandemic the treatment system had to adapt almost overnight to new agile ways to deliver core interventions. And despite the heroic efforts of workers, managers, commissioners and peers, many services were forced to temporarily close their doors. The pandemic also prevented those with drug and alcohol problems from accessing the wider array of ‘safety-net’ services including primary, secondary and acute care.’
However, the reasons behind the long-term erosion of the field’s capacity to support people in need were ‘plain to see in Dame Carol Black’s recent review’, it stated. ‘This recent rise in deaths makes only more important the announcement of the cross-government drug strategy in the coming weeks.’
We are proud to work in partnership with many of the leading charities and treatment providers in the sector.
At the core of this research was a series of focus groups with people who inject drugs and peer workers, in order to build it around their experiences with current services as well as what they would want to see. Jason, a peer volunteer who has used services, said, ‘There were lots of ideas at our workshop, everyone had something to say and it was great to hear ideas. Why not have availability at night, or why can’t we have access at the needle exchange to other support – health, legal or housing?’
Elliot Bidgood is a policy adviser with the London Joint Working Group on Substance Use and Hepatitis C (LJWG).
Some of these harm reduction heroes, such as Professor Pat O’Hare, Alan Parry and Alan Mathews, led the way in the late ’80s, and much of my own learning came from great tutors and influencers such as Alan McGee, Jon Dericott, Andrew Bennet, and many more. The Maryland Centre opened up a whole new world of learning for me. It taught me about working with the most marginalised and vulnerable groups of people, the many benefits of needle and syringe programmes, street outreach work, low-threshold prescribing and HIV prevention. This experience has stayed with me throughout my career.
For service users with complex substance misuse and mental health needs, it’s common to use terms such as dual diagnosis and co-existing conditions. 
While this is currently a work in progress, we’ve been spending time looking at building awareness of the challenges to system-linking, building a network of supportive ‘phone-a-friends’ and identifying how to share and spread our vision and enthusiasm to make every person’s experience of services truly joined up and connected. Many involved in this process highlighted that, while the infrastructure was important, it was the connections with people that made the difference in terms of managing barriers to care across services. For many of us, examples of high-quality patient care were those where clinicians were connected across the system, open to new possible approaches, leaning in at times of challenge, linking in with each other, having a face to a name, feeling safe to challenge the prevailing viewpoint, and asking for help.
Cannabis and MDMA were the drugs most impacted by COVID-19 restrictions, it found, with use of ‘party drug’ MDMA unsurprisingly falling during the same period.
People who were already at risk of alcohol harm bought ‘significantly’ more alcohol during COVID-19 lockdowns, according to a new study by Newcastle University and the National Institute for Health Research (NIHR). People in the top fifth of households for alcohol purchases bought 17 times more alcohol from retail outlets than the bottom fifth, says the study published in scientific journal PLOS ONE.
A future regulated cannabis market in the UK needs to incorporate guiding principles to repair historical injustices, says a group of campaigning organisations and charities. With more than half of the British public supporting legalisation of cannabis for recreational use and widespread legislative change in countries from Germany to Canada, cannabis reform in the UK is now ‘inevitable’, states a new report published by Release.
We are proud to work in partnership with many of the leading charities and treatment providers in the sector.
The campaign, which coincides with the publication of the UK government’s new drug strategy, is designed to highlight the ‘damage caused by the stigma of problem drug and alcohol use’. 
This training module provides clear, evidence-based guidance, empowering staff to know when to use naloxone and to have the confidence to act fast. Feedback from staff shows beyond doubt that effective training, not just supply, is an essential component of successful implementation – staff want to help keep people safe, but the idea of administering a drug in a crisis situation raises multiple questions and concerns.
