Release’s Laura Garius discusses why universities must adopt harm reduction.
It’s time to adopt a harm-reduction approach to student drug use. Despite decades of universities taking the ‘just say no’ approach, and with some actively pursuing an idealistic ‘drug-free campus‘, research shows that the majority of students have, or will, use illicit drugs.
Now more than ever, as we see student drug use rise in the Covid-19 pandemic, universities must recognise the importance of adopting a harm reduction approach, and acknowledge the harm caused by their existing response(s) to drug use.
According to national surveys, students are the employment group with the highest prevalence of drug use. This trend is strongly linked to students’ age, given that 16 to 24-year-olds are the age group most likely to experiment with drugs. Furthermore, national surveys like the Crime Survey for England and Wales are likely to underestimate student drug use as they do not survey student halls of residence. Other surveys, including Release and NUS’ own 2018 student survey, confirm that drug use, whilst infrequent, is commonplace: with over half of the student population (56%) reporting having used drugs.
Despite this, there continues to be a concerning lack of harm reduction advice from higher education institutions. Equally concerning are the large number of institutions pursuing formal disciplinary measures, with some also introducing additional forms of surveillance, both of which are proven to cause harm to students.
Taking the hit: a review of drug policies across UK higher education
In our 2018 report, ‘Taking the Hit’, Release and NUS reviewed the drug policies of 151 UK higher education institutions. We found that for a student caught in possession of a drug, formal disciplinary measures could include temporary or permanent exclusion, eviction from accommodation, or referral to the police.
In fact, in more than a quarter of incidents (26%) involving students found in possession of drugs for personal use, students were referred to the police by their institution. Do institutions understand that there is no legal obligation to take this step? Or do they purposefully subject their students, for whom they have a duty of care, to potentially life-altering punishment?
One finding that does indicate a misunderstanding of current UK drug law is that over half of institutions have policies which allow for the punishment of drug-related behaviour not considered to be a criminal offence.
For example, despite the Psychoactive Substances Act 2016 not criminalising the possession of new/novel psychoactive substances (such as nitrous oxide), a number of policies are in place that equate this to possession of a controlled drug.
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A new updated toolkit to support those helping families with parental drug and alcohol issues has been issued by PHE.
Parents with alcohol and drug problems: support resources includes guidance for adult treatment and family services and an ‘investing in families’ workbook, as well as case studies to determine the cost benefit of different interventions.
As well as frontline drug and alcohol staff, the resources are aimed at commissioners, directors of public health and people working in children’s and family services. The toolkit also includes data from 2019-20 for each local authority on prevalence of parental alcohol and drug misuse and children in need, as well as an evidence slide pack to ‘encourage commissioners to invest in services working with families’.
Department for Education (DfE) statistics from 2019-20 found that parents using drugs was a factor in around 17 per cent of child in need cases, and parental alcohol use a factor in 16 per cent. Analysis of serious case reviews from 2011-14 also found that parental alcohol or drug use was recorded in 36 per cent of those carried out when a child had died or been seriously harmed.
‘Not all children of parents who use alcohol or drugs problematically will experience significant harm, but children growing up in these families are at a greater risk of adverse outcomes,’ says PHE. These can include their own substance misuse, offending behaviour, employment problems and domestic abuse. The new resources are also backed by support via the local government Knowledge Hub at khub.net.
“It is about uniting everybody,” says Dmitri Schusterman, a nearby resident who helped organize and build the center at the end of last year. Cob on Wood was brought to life with help from local advocacy arts and food groups who teamed up with Miguel “Migz” Elliott, an expert in the ancient technique of making cob structures. Together with teams of volunteers and residents, they built each component by hand.
Using drug checking services at festivals can permanently influence behaviour, according to a new study by the University of Liverpool.
The Loop provides drug safety testing, welfare and harm reduction services at nightclubs, festivals and other leisure events.
The study looked at almost 1,500 face-to-face brief interventions from three music festivals in England in 2017 before carrying out an anonymous follow-up survey three months later.
Of the 130 people who completed the follow-up questionnaire – the first of its kind – 92 per cent said that using the service had had an impact on their subsequent drug-taking behaviour, with the same proportion ‘strongly’ agreeing that they would use a similar service again and recommend their friends do the same. More than 40 per cent also said they’d continued to talk to friends about drug contents, with 38 per cent saying they’d sought out more information about drugs.
More than a quarter of respondents also reported that they’d now be less likely to buy drugs from strangers, while a third said they’d become more cautious about using multiple drugs. Around 20 per cent said they’d continued to take smaller doses since the intervention, with 15 per cent not taking any drugs at all in the three months after the festival.
Of the substances submitted for testing across the three festivals, almost 80 per cent were ‘identified as expected’ while just under 11 per cent were ‘substances other than those the subject thought they had been sold or given’. More than half of these were then either handed over for destruction or discarded.
‘Whilst relatively small, this follow-up study demonstrates the potential value of post-intervention surveys in examining outcomes that would not otherwise be identified on-site,’ said study lead Professor Fiona Measham. ‘Ongoing harm reduction practices that were attributed to engaging with the service included increased caution towards polydrug use, reduced dosage, and increased information-seeking and communication around drug use. This is particularly important given that just 3.6 per cent of those engaged said they had spoken previously with health professionals about their alcohol or other drug use.’
Meanwhile, a new YouGov poll has identified that the vast majority of people support the government’s plans to introduce nutritional labelling for alcohol products (DDN, September 2020, page 4). Three quarters wanted unit information included on labels, almost two thirds wanted to see calorie information and more than half wanted to see sugar content included. The survey coincides with an open letter to the health secretary from almost 100 health organisations calling for improved alcohol labelling ahead of the government’s planned consultation.
‘People both want and deserve to know what is in their drinks,’ said Alcohol Health Alliance chair Professor Sir Ian Gilmore. ‘We already empower consumers to make decisions about their health by displaying nutritional information on food and soft drink labels, so why should alcohol – a product linked to 80 deaths a day – continue to be exempt?’
Intentions, actions and outcomes: A follow-up survey on harm reduction practices after using an English festival drug checking service, published in the International Journal of Drug Policy here.
Adfam is a charity working on behalf of the families and loved ones affected by drug use.
It provides direct support to families through publications, training, prison visitors’ centres, outreach work and signposting to local support services. As the voice of families, it provides consultation on best practice in drug and alcohol-related family work and has published several guides for professionals and commissioners.
Date and Timings: The conference is on Thursday 13 July. The conference programme will run from 10am – 4pm with breaks for refreshments and lunch. Registration will be from 9am.
The Venue: The event will be held at The National Conference Centre (at the National Motorbike Museum) Birmingham, B92 0EJ. The venue is easy to reach by both car and public transport and offers free parking. Full details on location, accessibility and other information on the venue are here: www.nationalconferencecentre.co.uk/visitors/
Accommodation: The DDN Team are staying in the Arden Hotel which is close to the conference venue. Rooms are still available please call Jennifer Hancox on 01675 445605 to book. The DDN team will be having a small get together in the bar the night before the event, it would be great to see you there.
There are other hotels close by in the NEC or Birmingham city centre is only 20 minutes away.
Exhibitor Set Up: Exhibitors will have access to set up stands from 8am on the morning of the conference. There will be limited availability to drop stands and materials off at the venue between 2-4pm the afternoon before (12 July) but you will not be able to set your stand up until the morning of the event. Please let me know if you are dropping off material the day before.
Exhibition Space: You have an exhibition stand which will be a tabletop and chairs with space for pop up banners and stands. Please email if you have specific requests such as power or need extra space for stands etc.
As those of you who have attended before will know this is a vibrant area at the heart of the event and interactive stands and giveaways are incredibly popular.
Delegate bag inserts and information for couriers
The deadline sending inserts for delegate bags was 7 July. The bags are being packed by Volunteers at Changes UK
If you are sending your stand via courier a day or two before the event please send it to the details below.
If you are popping it in the day before please go to reception and ask for Dan Powell.
He will store your materials and it will be waiting for you in the exhibition area on the day of the event. Please note you will not be able to access the venue itself the day before as another event is taking place.
DDN can not take responsibility for delivery or pick up of stands from the venue.
Delegate Names:
Thank you to everyone who has submitted delegate names. Please do not worry if you have not been able to do so, we will be able to issue badges on the day.
Invoicing: You will be emailed an invoice for your booking to be paid in advance of the event by either BACs or credit card. If you have any questions regarding the invoicing please contact accounts@cjwellings.com
I hope this helps you prepare for what should be a fantastic, interactive, energetic and inspiring event. If you have any questions or would like to discuss the event or DDN magazine please contact ian@cjwellings.com 07711 950 300
Adfam Chief Executive Vivienne Evans discusses the latest alcohol dependency storyline on radio soap opera, The Archers.
One of my childhood’s most enduring memories is that of my father turning off the radio as soon as he heard the Archers signature tune, claiming that farmers were of no interest to him, and anyway, they were all ‘right-wing land grabbers’.
Perhaps because of this, I have been a dedicated Archers listener since I was able to make my own listening decisions. I often get frustrated with some of the story lines, exasperated and incredulous. However, there are story lines, matched by splendid acting, which are compelling, and remind me why I listen.
Such a story is the current one about Alice’s alcohol dependency. It is heart-breaking, and touches on key issues in our sector – and in society – about Foetal Alcohol Spectrum Disorder, about the torment of dependency and the scarcity of detox facilities.
Turning Point’s Nat Travis examines the impact of alcohol on mental health.
As we move out of lockdown and prepare for more freedom, it certainly feels like the appropriate time to highlight the link between the two. Often alcohol and mental health enter into an unhealthy cycle of exacerbating each other; you may drink when you feel bad but then feel bad because you’re drinking.
Alcohol is a depressant substance which means that it affects our central nervous system and slows everything down. Like most substances, the effect of alcohol on our mood is often dependent on the mood we are in when we begin drinking, the setting in which we use alcohol and also some of the physiology of who we are as a person e.g. height, weight, gender. What we do know is that alcohol affects the chemistry of the brain which can lead to anxiety, memory loss or depression.
Trying to maintain a healthy mental wellbeing is challenging in itself, adding in the additional hurdles alcohol throws at us is like adding extra weight to your backpack when running up hill. It may not be the root cause of the challenges you face, but it certainly doesn’t make things easier.
It’s important we all take the time to look after our mental health; regular exercise, eating healthy and enough sleep are often the foundations. Drinking excessively doesn’t lend itself to the foundations of good mental health, like high-calorie, high-sugar alcoholic drinks or being too hungover to exercise.
People often use alcohol as a ‘social lubrication’ or the old ‘Dutch courage’, helping them to ease into meeting and greeting new people, but over time regularly drinking too much and binge drinking can lead to becoming isolated and withdrawn for some individuals.
Anxiety can make social occasions difficult and at times drinking starts to affect relationships with those around us. It isn’t uncommon these days to hear a story about a family member or friend who had one drink too many and embarrassed themselves, but if this is happening all the time then you can begin to feel shame.
Deaths in England and Wales from alcohol-specific causes topped 7,400 last year, according to provisional data from ONS – almost 20 per cent higher than in 2019 and the highest since records began in 2001.
Alcohol Health Alliance chair Professor Sir Ian Gilmore called the increase ‘devastating’.
The final quarter of 2020 alone saw 1,963 alcohol-specific deaths, which at 13.6 per 100,000 people is the highest recorded in any single quarter. While the death rate for quarter one in 2020 was roughly the same as in previous years, the following three quarters saw rates that were ‘all statistically significantly higher than in any other year back to 2001’, says ONS. As in previous years, the death rate was far higher in areas of deprivation, with a male death rate more than four times as high in the most deprived local areas than the least deprived. The male death rate was also twice the rate for females.
Alcohol-specific deaths only refer to those the death can be wholly attributed to alcohol misuse – such as with alcoholic liver disease – which means the deaths are likely to be the result of a history of alcohol dependency or misuse.
DDN’s Alcohol and Health guide provides a clear and detailed overview of the risks from excess drinking and links to support.
Alcohol Health Alliance chair Professor Sir Ian Gilmore called the increase ‘devastating’. ‘Each of these numbers represents a life of an individual cut short by alcohol consumption and a family that has been left in mourning,’ he said. ‘The future impact of the COVID-19 pandemic on addiction and mental health makes action now all the more critical. If the UK government wants to demonstrate its commitment to turning this tragic trend around, it must urgently introduce an alcohol strategy which seeks to address health inequalities and stop the sale of cheap, strong alcohol that is so harmful to health. The government also needs to improve access to treatment for those who need it. We cannot afford to ignore the growing alcohol harm crisis – lives depend on action being taken now.’
Quarterly alcohol-specific deaths in England and Wales: 2001 to 2019 registrations and quarter 1 to quarter 4 2020 provisional registrations at www.ons.gov.uk
Diversionary schemes create better outcomes for young people and keep communities safer. Their time has come, says With You’s Jen Rushworth-Claeys.
Diversion is a common sense approach that needs to be at the forefront of our thinking around young people in the criminal justice system for drug offences.
Between us we’ve worked in YP drug and alcohol services for nearly 15 years. We’ve seen first hand the ‘revolving door’ of low-level offending and short-term sentencing, and the disruption to treatment that it brings. We’ve seen the lost opportunities for engagement and support. We’ve seen how much the criminal justice system affects the futures of young people who otherwise need support.
Evidence has shown prosecuting young people for low-level, first time offences is not effective at reducing crime, and young people who find themselves in the justice system are often more likely to reoffend. It also creates long-term damaging consequences, from the impact and stigma of having a criminal record to having education and employment interrupted.
Our experience of delivering a diversion scheme for young people in Kent has shown us their importance, value and effectiveness. The Kent Youth Drug Intervention Scheme (KYDIS) provides an alternate means of dealing with young people under the age of 18 who are found in possession of class B or C drugs, and with no long-term history of drug use.
The programme reduces the likelihood of young people falling into a cycle of criminality by diverting them from entering the criminal justice system. This intervention entails the young person receiving a one-to-one intervention with With You. They are provided with direct support, education on drugs and alcohol, information regarding the law, prevention of drug use and harm reduction advice. Once police receive confirmation of attendance from With You, the associated crime report is finalised as a ‘Community Resolution with Restorative Justice’.
Substance Misuse Management in General Practice (SMMGP) is changing its name to Addiction Professionals, the organisation has announced. The grassroots GP network recently held its 25th annual Managing Drug and Alcohol Problems in Primary Care joint conference with RCGP (DDN April, page 10, and DDNMay, pages 10, 13 and 18) and in 2017 also took over the functions of the Federation of Drug and Alcohol Professionals (FDAP).
The decision to re-brand was taken to ‘reflect the growth and prominence’ of this joint organisation, it says, as the membership now encompasses GPs, counsellors, psychiatrists, psychologists, keyworkers, pharmacists, social workers, nurses and mentors.
‘As Addiction Professionals we offer a range of membership options to support practitioners throughout their careers, from voluntary registration and accreditation in our role as regulatory body, to regular continuing professional development through news, networking and education,’ the organisation states. ‘We have an extensive network of members from a wide range of professions and settings in the addictions field. We aim to raise and uphold high standards and quality in the addictions workforce.’
Change is always possible, say Lisa Ogilvie and Jerome Carson, as they share their own journeys to recovery.
Each person’s recovery journey is unique, and the process is nonlinear. So what makes our two stories different? Lisa used alcohol to make her mark on the world, or so she thought. Being able to consume extraordinary amounts of alcohol was a coveted talent when you were a young professional working on high-budget IT projects in the 2000s, and Lisa used this to justify chronic heavy drinking. Common sense tells us this is not sustainable, and that it puts one on a path toward alcoholism, something Lisa had to learn at great cost.
Jerome was a mental health professional, whose own father was an alcoholic. He could always falsely reassure himself that he was not as bad as his father. Following his move from the Institute of Psychiatry to the Maudsley Trust in 2006, Jerome spent the next five years working in mental health recovery. He co-developed a number of recovery initiatives, including co-authoring three books, the best known of which is probably, Mental Health Recovery Heroes Past and Present. This used patient narratives to share individual journeys and show that recovery is possible. In this vein, we humbly offer our own stories.
Lisa’s story
Lisa Ogilvie is studying for a PhD at the University of Bolton, having graduated with a distinction in her MSc in counselling and positive psychology.
I clearly recall when my relationship with alcohol began – a relationship that endured for nearly 30 years. I was 15 and working a Saturday job stacking shelves in a supermarket. I enjoyed being with people who I felt had ‘proper lives,’ by virtue of not being at school. They regularly went to the pub, and when an invite was extended to me, I discovered a social life encompassing alcohol. It gave me confidence, it made me funny, clever, popular. I was no longer just a teenager wanting to fit in. There were so many positive possibilities.
As life unfolded, the same underlying principle continued. Alcohol was an enabler of good times, friendship and success. I had excelled at university, been head hunted by the age of 25, and rewarded with an unreasonably large salary. Alcohol had proved to be a steadfast comrade – it let me show off, helped me stand out, and I believed it had even opened doors by oiling career-building conversations. A dependence had formed. I was aware of it, but actively welcomed it.
As time progressed, my dependence evolved. Alcohol increasingly became a crutch instead of an enabler, an excuse to socialise, a reason to relax, and sadly the source of what I believed happiness to be. In reality, it was an attempt to maintain the humorous, successful and caring employee, wife, daughter and mother I wanted to portray, all the while satisfying my growing need to consume alcohol at every possible opportunity. It worked for a while, so I thought – until it didn’t.
For many years, I had been sinking, using alcohol to manage the psychological and physical fallout of an addiction that I had unwittingly cultivated to the best of my ability. Time passed, the consequences grew, and not just for me. I was a damaging force to be around, especially to those I cared for. I was desperately trying to survive, and to survive I had to have alcohol.
There was no coming back. My fulltime vocation, 24/7, was as an alcoholic. It could not be hidden or denied anymore – it was too obvious, the consequences too embarrassingly typical. I faced a simple choice, one which was incredibly difficult to make – stop drinking or lose everything that mattered. In recovery, some would call this the gift of desperation, and for me making that choice did indeed turn out to be a gift.
I began my recovery. It was not easy, and involved lots of tears, guilt and shame. As my brain started to function without alcohol, further buoyed by support from people who understood addiction, my thoughts moved toward responsibility and acceptance. I started to feel hope, even optimism, when those I cared about recognised that I was growing, improving and learning new behaviours.
Since then, my world has grown in wonderful and unexpected ways – because of recovery, not in spite of giving up alcohol. I regained a sense of what it was like for people to value my contribution. This was something I didn’t even know I had lost, but which proved to be a striking discovery in what recovery looks like to me. That is to contribute valuable and respected research in the field of addiction recovery, work that will promote and enable others to engage in recovery, as a positive and life changing experience. I have now found my source of happiness, and it is unequivocally, embracing life in recovery.
Jerome’s story
Jerome Carson is professor of psychology at the University of Bolton.
Professionals are told not to let their personal lives intrude into their work lives. Here, Lisa and I are both allowing our personal lives to intrude into our storytelling. My father was an alcoholic. His father was teetotal. Why did I choose to follow my own father, rather than my grandfather? In truth, I rather envied my father when I was a teenager. He could be a charmer with the ladies, which I yearned to be, and had a wonderful singing voice, which generally only emerged when he was drinking.
My own formative years were spent in the North East. There were the usual adolescent drinking binges, which continued into university where I took up with a small group of young men for whom drinking became an occupation. In the first year on ‘beer race day’ we drank 16 pints, and over the years I became an episodic binge drinker, drinking until I could drink no more. As most of this drinking was conducted in small groups, where it was culturally normative, it was never considered excessive.
In my middle age, beer gave way to good wine. I would only go out occasionally, as by then I had a family of four children. One of my medical friends and myself would meet every couple of months for a meal in a posh restaurant, washed down with four bottles of wine. I think we both considered ourselves to be mentally stable and that our drinking was nothing to be concerned about. It was only in later years that I realised that by the criteria of the Diagnostic and Statistical Manual (DSM V), I met the criteria for an alcohol use disorder. My AUDIT score was also indicative of problematic drinking and I scored two of out four on the CAGE screening tool. After a very heavy drinking session with two university friends and our wives I became so unwell that I actually gave up drinking for three years. This was actually easy, as I was psychologically but not physically dependent.
On my 59th birthday I drank too much, had an argument with my partner and was given an ultimatum, the relationship or the alcohol. For once, I saw the effect that my drinking was having on someone close to me. This was the third such episode, and for her it was the last straw. I was in the proverbial last chance saloon and I decided to leave the bar.
At the time of writing, now four years, seven months and 20 days down the track, I have not had a single lapse. I will never go back. I have never been to a single AA meeting and never will, as I have managed on my own, though I have huge admiration for their work. I would never say, ‘I have done it, you can do it too.’ The fact that I had to wait until I was 59 to make this choice shows the degree of denial I was in. For some of us, there really is only one choice. That’s not red or white. It’s abstinence.
Two stories out of millions
Why might our stories be any more remarkable than anyone else’s? They probably aren’t. Yet as humans we have a need for stories to nurture, inspire or encourage us. Change is possible. It was the one life lesson that Jerome’s father failed to learn. In the end alcohol killed him while his own teetotal father had lived until his eighties. How many years does alcohol take from us? For Lisa and Jerome, giving up alcohol has opened up life’s possibilities in a way they never envisaged.
The Republic of Ireland will introduce minimum unit pricing (MUP) for alcohol from next January, according to health minister Frank Feighan.
‘MUP is a targeted public health measure which will ensure that cheap strong alcohol is not available to our most vulnerable people, children and young people at “pocket money” prices,’ he announced on Twitter. ‘The lead in time for this measure will be January 2022.’
Northern Ireland also plans to launch a ‘full consultation’ on minimum pricing this year (DDN, September 2020, page 4), in response to rising rates of alcohol-related deaths and hospital admissions. As was the case in Scotland, Ireland’s plans have met with resistance from the drinks industry, with some trade bodies criticising the government’s intention to press ahead without alignment with Northern Ireland and stating that it would simply result in a ‘surge’ in cross-border shopping. ‘We have seen in the past that consumers will travel long distances to save money,’ said director of Retail Ireland, Arnold Dillon. ‘While the retail sector understands and appreciates the public health rationale for MUP, it is vital that the measure is done in coordination with Northern Ireland.’
A minimum price of 50p per unit was introduced in Scotland in 2018 following almost a decade of legal wrangles with the drinks industry. However, Alcohol Focus Scotland is now calling on the Scottish Government to review and raise the price to ‘optimise its benefits’. While there have been ‘encouraging’ falls in alcohol-related deaths and hospital admissions, the impact of the 50p minimum price has been ‘significantly eroded’ by inflation since the amount was approved by the Scottish Parliament almost a decade ago, says the charity. The government’s plans to review the price last year were delayed as a result of COVID-19.
‘Minimum unit pricing is working,’ said Alcohol Focus Scotland chief executive Alison Douglas. ‘It has reduced alcohol consumption and there are early signs it is preventing illness and saving lives. But the policy has the potential to deliver even greater benefits. Now is the time to increase the minimum price to not only account for inflation since the Parliament approved MUP nine years ago, but also set it at a level that will save more lives and prevent a new generation from developing a problematic relationship with alcohol. We need the next Scottish Government to increase the minimum unit price to at least 65p per unit and to future-proof its positive effects by ensuring that the price is increased in line with inflation.’
The recent naloxone and overdose awareness campaign launched in the UK has stimulated an important conversation amongst many: what is naloxone? Though patented back in 1961, it is only now, in the midst of an opioid epidemic, that naloxone is beginning to assert itself within the general public. Anya Aggarwal debunks some common myths.
Naloxone is a life-saving antidote to an opioid overdose, whereby its pharmacological profile allows it to safely reverse the cardiovascular and respiratory depression associated with an opioid overdose. It is a prescribed medicine in the UK which comes in three FDA-approved forms: injectable, auto injectable, and most recently, as a pre-packaged nasal spray.
Pharmacologically, naloxone sounds perfect – easy, safe and incredibly effective in reversing an overdose; however, there are several public misconceptions and myths around naloxone that may hinder its positive effect.
This piece therefore covers a variety of common myths relating to naloxone and debunks them. We also speak with a volunteer working with Peter Krykant’s mobile safe consumption site in Glasgow, Scotland to assess how naloxone can be given empathically in order to reduce harms for the person overdosing.
1. Naloxone is not an opioid treatment, neither is it a long-lasting antidote.
Though naloxone can reverse the respiratory depression associated with an overdose (it’s an opioid antagonist), it is by no means a treatment option for opioid use. It is therefore a short-term fix, a plaster if you like, and it quite literally only reverses the overdose; but even then, it is only able to do this for a short period of time.
Although naloxone is distributed quickly around the body (one to two minutes for intravenous administration, three to seven minutes for subcutaneous or intramuscular administration), it does not stay in the body for long, meaning the duration of naloxone can be shorter than other opioids.
In such a scenario, the person can go back into respiratory depression (i.e., the overdose). This may require another naloxone dose to be given and it is important that someone stays with the person to monitor them and call an ambulance.
A stressful year is giving rise to a fresh approach to mental health at Phoenix Futures, as DDN reports.
‘People in treatment are keen to say they’re ok, but a significant amount of people have really struggled over the past year,’ says Phoenix Futures’ chief executive Karen Biggs of more than 12 months in lockdown.
Phoenix Futures’ chief executive Karen Biggs
‘Our residential services are where we’ve traditionally seen those with the most complex needs and where they will have an opportunity to engage with the appropriate medical help and psychological support,’ she says. So Phoenix made two key decisions, and the first was to stay open throughout, ‘because I knew the need was out there and if there was ever a time people needed access to rehabs it was during the pandemic.’
The second key decision was that ‘we were not going to take our foot off the pedal in our mental health work’. There were two important strands to this – a refresh of clinical interventions, and a specific look at what else they could be doing to make sure people could access the right interventions at the right time.
‘People with substance misuse and mental health conditions get passed from pillar to post, struggling to engage with substance misuse services and then mental health services at the same time,’ she says. With the expertise of the team’s psychologist and senior mental health nurse, the plan was to develop the team’s skills to ‘hold’ people and start to address their issues while they were in treatment – then to improve links with other services, ‘so there’s a really good pathway of support when they move out’.
Nothing has stalled over the past year – quite the opposite. Biggs is ‘terrified’ of what’s to come on drug-related death statistics as ‘there’s so much we don’t know about the experience of people in treatment over the last year’. Add to that the stigma, not just in the media but in the ‘everyday decisions made by professionals in the healthcare system’, and there is much to do. ‘Stigma is preventing people from accessing help,’ she says. ‘It prevents people from accessing substance misuse services and put together with a mental health condition it’s so hard. We need to speak out about it and support health professionals to understand the impact of their decisions.’
As the pandemic escalated, Biggs was acutely aware that her staff had support needs of their own, whether out on the frontline or adapting to the challenges of virtual support from home. Half of Phoenix’s staff continued to work face-to-face in the pandemic, in residential and housing services, and there was ‘a lot of fear’ to begin with, facing risk, adjusting to new protocols to keep everyone safe, and fighting for PPE, testing and access to the vaccine. (A particular challenge, says Biggs, as while residential rehabs are registered care homes, they were not viewed as priority.)
The decision to stay open was a ‘massive ask’ of team members and redoubled her commitment to staff welfare. She recognised that ‘there was a very real need for the staff to decompress’, particularly without the usual opportunities to get together, laugh, cry, hug, and share the load, so a much-valued wellbeing programme was introduced and has been extended indefinitely. ‘We have to continue to recognise that staff have been going into work and risking their lives every day,’ she says.
Phoenix has also taken the opportunity to learn from the pandemic by beginning a research partnership with Liverpool John Moores University. The aim is to study the impact of COVID on residential rehabs through surveying staff and service users, and results will be interpreted in June and fed into the organisation’s review of practice.
The other area for development – and something Biggs feels hopeful about – is the prospect of addiction services becoming part of the wider health and social care sector, post PHE restructure. ‘The pathways into and out of addiction services and how we are able to support alongside our health and social care partners should be made easier,’ she said. But she adds a strong note of caution: that we must not allow the specialism of addiction to get lost ‘within the broader health and social care tent’ – a real risk. ‘We’ve got to be braver and more confident as a sector in our communication on it,’ she says.
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As head of clinical interventions, Gabrielle Epstein is at the forefront of the revitalised mental health strategy and clinical review.
Gabrielle Epstein, head of clinical interventions.
People working in substance misuse manage people with mental health issues really well whether they realise it or not,’ she says, and we should be building on these strong skills.
An experienced psychologist, she talks of the ‘whole person’ arriving in treatment with various issues to address and is very keen to move away from the label ‘dual diagnosis’. Mental health needs were identified in 60 per cent of people admitted into Phoenix’s residential services – 66 per cent were found to have depression and/or anxiety, 7 per cent had PTSD and 12 per cent were diagnosed with a personality disorder/affective disorder.
People with mental health needs are ‘our bread and butter, this is who we’ve always treated’, says Epstein, but it’s not always straightforward. ‘Some substances are very good at masking the positive signs of mental illness… So heroin for example is quite good at dulling down the psychotic symptoms of schizophrenia, which is sometimes why people use it. If the substances are masking the symptoms, when you detox they will emerge.’
Many diagnoses were identified by GPs and mental health services before admission, but other people had mental health needs that had not been formally diagnosed. With a system of ‘dynamic assessment’ in place, their needs are reviewed regularly and the treatment plan adjusted to bring in the relevant expertise. Referrals are made swiftly and incorporated into risk assessment and care planning – an approach that’s working. Data on completion shows that those with a mental health issue are as successful as anyone else in completing the rehab programme.
The registered mental health nurse (RMN) is an important member of the team and a key to keeping the door open between substance misuse and mental health. Training for the entire team includes a full set of skills to recognise and manage mental health issues, and some of the nurses are dual qualified as CBT therapists. Everyone is switched on to helping people engage in treatment, explains Epstein, and that might mean clinical supervision, medical interventions or cognitive behavioural therapy (CBT) at different points in their journey. Anxiety, for example, ‘yields very well and relatively quickly to CBT interventions’ and a few sessions usually enable the person to engage in treatment.
The other major part of staff training is in trauma-informed care, because, says Epstein, ‘we know that nearly everyone who comes into residential treatment has an experience of trauma’. This has to include supporting staff to recognise their own triggers, as well as being fully aware of the risks of retraumatising people in their care.
Read more on mental health from DDN
The team is looking at some very promising (and cost-effective) interventions such as eye movement desensitisation and reprocessing (EMDR) – ‘evidence based and economical, because it’s a brief intervention with very good outcomes’, according to Epstein. While the intervention itself is brief, she adds, there’s a ‘long preparation period where people have to be stabilised enough to be able to engage in it’, which once again shows the need for close-knit working within the multi-disciplinary team and beyond.
The community mental health team form another essential link in the chain of care, and Epstein is hopeful that changes within the Department of Health and Social Care will give greater capacity for the multi-disciplinary team approach, including joint case conferences that support residents beyond discharge from rehab. It makes all-round (including financial) sense, she says. ‘People who come into residential treatment may have had frequent contact with the police and be frequent flyers with A&E. But we know that if you’re successful with your treatment and continue with your aftercare, those presentations to A&E will decrease and there’s an overall cost benefit to the health system.’ DDN
A powerful new national naloxone and overdose awareness campaign is using the faces of people with lived experience to get its message across.
Read about it in DDN Magazine
‘For me it’s about saving a life,’ says harm reduction activist Lee Collingham, one of the faces of the landmark, country-wide naloxone awareness campaign launched last month (see news, page 5). ‘Some areas still haven’t got access to naloxone, and until we have a national programme we need to get the basic messages across.’
What makes the campaign unique is that everyone featured in its posters carries naloxone themselves – having been personally affected by overdose – and has undergone the simple training needed to use it effectively. ‘I was approached about this campaign because of my interest in saving lives,’ says Collingham. ‘I come from a drug-using background and I know that simple things like giving chest compressions and calling an ambulance immediately are so important.’
His input extended well beyond simply posing for a picture, he stresses – healthcare communications group Havas Lynx discussed his experiences with him in detail and took ‘plenty of shots’, before he chose the one he was happy with from a smaller selection. ‘They mocked it all up with the message and explained how it would look in different spaces,’ he says. ‘I look like a normal guy on the poster, rather than a homeless person – the whole point of it for me is about getting people on board and making it more personable. You say “save the life of a heroin addict” and most people will walk by. There’s always been a hierarchy, and heroin is at rock bottom.’
The campaign also reinforces the importance of understanding overdose risks, and the fact that it’s been co-produced with people who may have been at risk of overdose themselves is key, the organisers state. ‘I’d heard of naloxone but I didn’t know what it was,’ says Andy (pictured left, with bulldog), who was also part of With You’s peer-to-peer naloxone programme in Redcar and Cleveland. ‘We were educated on signs of overdose, what to say, how it worked. Even if I only give out one pack I could have saved one life down the line – that makes me buzz. It gives me confidence.’
The idea behind a public-facing campaign was to deliver something ‘impactful, emotive and engaging’, says Stephen Malloy, strategy and public affairs lead at Ethypharm, who provided funding. ‘Accidental opioid-related overdose deaths are recognised as a public health matter and they are largely avoidable and preventable. That’s what the campaign is about – motivating people to find out more about overdose prevention and intervention with naloxone.’
The initiative has been welcomed by Release, whose executive director Niamh Eastwood states that widescale availability of naloxone and public education on how to use it should be at the ‘cornerstone of any response’ to the UK’s ‘shameful’ record on protecting the lives of people who use drugs. Previous research by the organisation had found that while all but three of the 152 local authorities who responded to an FoI request on naloxone provision now supplied it, the amount actually being given out remained ‘drastically insufficient’. In 2017-18, just 16 take-home kits were provided for every 100 people using opiates, with many areas failing to provide kits to the people most likely to need them (DDN, March 2019, page 4).
The hope is that with more money finally coming into the system, some of it specifically earmarked for naloxone provision (DDN, February, page 4), access can be improved. ‘Drug service staff can provide naloxone to anyone without a prescription, and the availability of nasal naloxone now makes it easier for more people to use naloxone,’ PHE’s alcohol and drug treatment and recovery lead Pete Burkinshaw tells DDN. ‘It’s vital that local areas have good naloxone supplies in place and government recently provided additional drug funding to local authorities, some of which will be used to increase the provision of naloxone. We know that getting more naloxone into the community will help save lives by preventing unnecessary opiate overdose deaths. This campaign will help to raise awareness of the life-saving potential of naloxone through powerful real-life stories.’
TalkingDrugs is encouraging people to share their pictures of the billboards. Take a picture and tag @TalkingDrugs and @Release_drugs and they will share it on their socials. Photo: www.talkingdrugs.org
The aim now is to allow the campaign to continue to develop and hopefully be rolled out again, says Malloy. ‘It may be that it inspires government public health agencies to see the importance of public-facing communication around accidental overdose, much in the same way as it does other public health matters.’
‘It’s about putting your passion behind a campaign that’s giving people the opportunity to save and improve lives,’ says Collingham. ‘But the journey isn’t finished. Beyond the “save a life” message is the ambition for a nationally funded naloxone programme. It should be as second nature as giving out methadone.’
This article has been produced with support from Ethypharm, which has not influenced the content in any way.
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Get it out there
The recent SMMGP conference heard how both the police and the ambulance service were helping to improve access to life-saving naloxone.
‘The unfortunate and startling reality is that the drug-related death rate in Scotland is three and a half times that of our neighbours in England and Wales, and the worst of any European country,’ Julie McCartney, clinical effectiveness lead for drug harm reduction in the Scottish Ambulance Service, told the conference.
Learn more about the Scottish Ambulance take home naloxone campaign on Youtube
More than 90 per cent of deaths involved someone having multiple substances in their system, she said. ‘Poly-drug use, unfortunately, is certainly the norm in Scotland, and more often than not it’s a toxic mix – a combination of central nervous system-suppressant drugs that contribute to the fatality.’ The use of naloxone to ‘remove opiates from the poly-drug use equation’ was enough to keep someone alive until the emergency services arrived, she said.
Each year the Scottish Ambulance Service received around 20,000 calls related to overdose and drug poisoning, and in 2019 responded to 5,000 calls where naloxone was administered by the ambulance crew. ‘Our naloxone administration has almost doubled since 2015 – following the trend of drug-related deaths, unfortunately,’ she said.
The Scottish Ambulance Service had a seat on the Scottish Government’s Drug Deaths Taskforce, and an ability to provide naloxone kits to people and communities that could be hard to reach by other services. It had also run a successful pilot project in Glasgow where paramedics distributed take-home kits to people at risk – and provided training in responding to overdose – which had now been re-launched on a national level.
The national training programme had a variety of options to allow the service’s 3,100-strong crew to complete their training in the most convenient way, including face-to-face and digital sessions, with Ethypharm providing extensive training materials. ‘The partnership approach and robust communication pathways that we’re putting in place are absolutely essential in our national fight to reduce drug-related deaths,’ she said. ‘We’ll continue to work alongside health boards and alcohol and drug partnerships across the country to make sure we’re able to share really relevant and meaningful data to support the allocation of resources where they’re needed most.’
As well as a take-home programme, Durham Constabulary had been using naloxone in its custody suites and officers were also carrying kits themselves, said temporary chief inspector Jason Meecham. ‘Problematic drug use is a significant issue in our area – according to ONS the North East has had the highest rate of drug misuse of any English region for the past seven years.’
There had been a spate of opiate overdoses in the force’s custody suites in 2018-19, he said. ‘In conjunction with the county council’s public health team we looked at bringing naloxone into the suites, as that’s what the ambulance crews were using.’ Working in partnership with the county council, local drug services and Ethypharm, all custody staff were trained to safely administer naloxone, including after-care.
More than 200 police officers and civilian staff had now been trained, he said, with naloxone ‘used across all our sites really successfully’. After the pandemic led to concerns around increased numbers of methadone prescriptions potentially leading to more overdoses, the decision was made to provide personal issue naloxone kits to officers in a position to respond quickly. ‘We now have a wide spread of police officers around County Durham and Darlington who carry naloxone, and it’s been used on quite a few occasions, either in police stations, out on the street, or where we’ve responded to reports of overdoses before the ambulance crew. It’s important to say we’re not replacing the ambulance crews here – it’s just if we happen to be there first.’
A third strand of the work was take-home naloxone, he said. ‘We’d identified quite a lot of people we see in custody who quite clearly don’t have frequent contact with their GP or drug treatment services, but who do have problematic drug issues.’ The programme had been rolled out following extensive legal discussions, he explained. ‘I believe we’re the first force in the country where trained and authorised police officers are giving it away – there are others where custody staff are doing it – and it really is a partnership approach with the county council’s public health team. Between us we agreed on the identification criteria for possible recipients, and the training and guidance requirements.’
While people could view a training video and receive appropriate referral material for drug treatment services there were ‘absolutely no strings attached’, he stressed. ‘If they want a kit and they’re eligible – and it’s quite wide eligibility – they will get given a kit, and there’ll be no further contact from us or treatment services. It’s all about trying to get it into the hands of people who need it the most.’
‘The healthcare system doesn’t care. It sees me as an unnecessary expense.’ Hearing feedback from people who are perceived as ‘hard to reach’ (p10) gives direction on offering more effective treatment. But more than that, it gives clues on why people often don’t connect with the most appropriate service to help them move forward.
Seeing the ‘whole person’ is at the root of everything, as we hear in this issue – from teams working in substance misuse and mental health, GPs, and people sharing their experiences of treatment (including what really helped them). We’ve moved on from passing the parcel in ‘dual diagnosis’ and learned that many complex issues manifest in many different types of behaviour, so it makes absolute sense to integrate our approach. One of the big challenges ahead will be to safeguard addiction specialisms as we grasp the opportunity to coordinate care pathways (page 6).
Looking back over 25 years of events (p10) SMMGP have realised how far they have come in listening to lived experience. We aspire to do likewise, and have personal stories on trauma, recovery, and peer-led action. For some unflinching first- hand views on drug treatment, turn to p22. We asked for feedback and we got it!
On his retirement from Change Grow Live, Chris Bruce reflects on the impact of trauma and the power of sport as a recovery tool.
At 66 it was time to go. After emerging from detox in 1980 I would never have imagined in my wildest dreams what an incredible journey it has been, but in this article I wish to concentrate on two themes – trauma and how it affected me, and sport as a recovery tool.
In 1969 my father, a consultant physician, committed suicide. At the time I was at a boarding school in Sussex. This did not immediately lead me to start misusing drugs and alcohol, but it did have a severe impact on my outlook on life and on my fellow human beings. No one spoke to me about the ‘event’ –even the family remained silent. Friends stayed away and psychologically my view of people and life changed.
A serious injury at school kept me out of sports for a year and my elevation to the 1st XI football team was halted. Going up to London in 1972 on the outside I presented as ‘cool’ and ‘laidback’ but on the inside I was rudderless and angry. Searching for a father figure with my trust blown away, getting stoned and having fun. That’s where I wanted to be. In the end of this particular downward journey I ended up with six years of addiction to diazepam after being prescribed them by a GP when complaining that I was unable to sleep coming up to college exams. The irony of it now seems incredible – a drug that slowed me down and eventually emptied me out, leaving me a paranoid wreck. Working through this ‘residue’ has taken time. AA plus NA and counselling and ten years of abstinence after my detox allowed my brain to start a healing process. It has been challenging at times. And on it goes.
Match Highlight
best job For not only my introduction to working with probation clients but also helping me to achieve so many things in my own life: The WYSCA 1993-96 Team. From left to right: John Wheeler (Manager), Paul Kendall (sports leader), Marion Oldham (secretary), (the late) Mark Milner, Adrian Tolan and Chris Bruce (sports leaders)
Sport growing up was at the centre of my life. I was fortunate to be good at most that were on offer. My eye for a moving object was excellent. Football and tennis were my top two games, especially football. One of my great humiliations was being sacked from my college team in 1974 for turning up to a match still high from the night before. In 1980 prior to going into detox, when I lay in a snow drift in Yorkshire simply wishing for it all to end – most certainly my final rock bottom – I was mentally and physically gone. Then as I remember clearly to this day into my head came a powerful light with a question attached to it: What happened to the person who won his school colours? Where was the fighting spirit? On the first day in hospital I signed up for the gym and vowed I would play football again.
In 1991 I completed a three-year BA in sports and American studies, played football again for the college team and captained the tennis team, even winning an international tournament. On a personal level I was back, but the mental recovery was still ongoing.
At college I attended many sessions with the college counsellor, and my first job was a sports-focused one with West Yorkshire Sports Counselling Association. I was one of four sports leaders, supporting clients on probation to engage in sport as a way out of their offending behaviour. One of my clients fancied getting some proper coaching at badminton and every week we met at the sports centre – he became a good player, improving week by week, and his motivation and self-worth improved. Time and again I saw for myself the positive outcomes for those who were signed up to our service.
Match Highlight
Proudest moment The then ex prime minister John Major presenting me with my Winston Churchill Fellowship medallion at the Guildhall, Westminster in 1999. He said the ‘normal’ congratulations text to me, then I asked him if he thought Michael Owen would start for England.
In 1997 I won a Winston Churchill Travelling Fellowship to the US, and the research I carried out was ‘can positive strategies help divert drug abuse and offending behaviour?’. This too focused on sports as a way of re-engaging individuals in society through positive activities. When I returned, highly motivated, I took up the post of day care co-ordinator at Harrogate Alcohol and Drugs Agency, where I arranged outdoor activities, including hiking and football, for our service users. So a circle had been completed – I was now giving back because of something I had experienced for myself. Seeing it work for others was what inspired me to continue to deliver sports activities to my service users throughout my working life.
And as part of the other healing circle, three years ago I met an amazing individual Dr Sharon McDonnell giving a presentation around the issue of bereavement. She now runs Suicide Bereavement UK based at Manchester University, and asked me to take part in their study on the effect of suicide on children, which is due for publication soon. Attending the Suicide Bereavement UK conference in 2019 was an incredible and moving experience for me – there are so many wonderful projects out there. One basic message from the day was ‘just let someone know you care’. This resounded massively with me.
Match Highlight
Most Bizarre moment Wimbledon 2015 – My brush with fame! Daily Mirror picture of me sat with a certain David Beckham and son (he sat down with me by the way!). Seeing all the cameras focused on him as he sat down was something I shall always remember. Now I know what fame feels like! I was asking whether his son played tennis.
For the last two years I have been running a community sports session at the Lytham YMCA, which has attracted ages from 35 to 83. Everyone attending has loved the variety of activities on offer, and I’ve witnessed people taking up something new and developing their skills. Now that we are (hopefully) coming out of the worst of COVID, there is going to be an even greater call for activity community groups, and improving mental health is also going to fall within this remit.
I was so pleased in my latter days with Change Grow Live that I saw them recognise the importance of offering all kinds of outside interventions including sport with the Community Sports Initiative (CSI), and the massive move forward in seeing trauma as a major cause of ‘meltdown’ in many people’s lives leading to alcohol or drug misuse.
In ‘retirement’ I’m going to continue with my sports groups and have other project ideas on the go. And finally, quoting from one of my favourite bands, the mighty Black Sabbath: ‘Is this the end of the beginning or the beginning of the end? We will see.
If anyone out there would like to contact me please email: Bruce.C2@sky.com
We may be experiencing fatigue after more than a year of Zoom sessions but we still need to brush up those online skills, says Angela Calcan.
DrinkCoach has offered online interventions since 2014 so we were well equipped when COVID arrived. Prior to the pandemic there was often scepticism from other professionals – you can’t engage people properly online, digital doesn’t work and it will never take off. Out of necessity, both the sector and service users have embraced the use of technology throughout the pandemic, and while the initial enthusiasm all round was high it’s interesting to hear about the drop-off in online attendance as time has gone on. We know that online working is much more nuanced than it may first appear.
There is much potential for technology to enhance the treatment offer, but when done poorly it can be equally damaging. There is also the real issue of digital exclusion for some service users, which often dominates discussions. Online interventions will not be appropriate for everyone, but digital aspects may enhance services or bridge an existing gap. There are many service users who will still require face-to-face contact.
Despite the increased use of Zoom groups, Teams meetings and video calls, it’s been interesting to observe people’s behaviour online. It’s important when using this technology to put some thought into how to get the best experience from it – there’s so much to pay attention to, and we’re using different skills to make up for the loss of cues that we rely on in face-to-face settings. All this while paying attention to how we are perceived by others. No wonder we’re exhausted.
Whilst most mistakes are unintentional they are usually avoidable and relate to poor set up – lighting, sound, camera angles, proximity to the screen, distracting backgrounds and difficulty using platforms. And let’s not forget the unexpected Zoom bombs from pets and children (I’ve certainly had this happen a few times in my home). Then there’s the poor etiquette observed – which has included people lying in bed during training, vaping mid meeting, or forgetting to mute microphones while holding unrelated conversations off camera.
We also fail to recognise how off-putting it can be for a trainer/presenter to be talking to a screen of small blank boxes rather than seeing people’s faces. Some of these could pass as rookie errors early on but it’s disappointing to see them continue as time passes. I get it – online work is fatiguing and sometimes we can’t face putting our videos on. Sometimes it’s the equipment failing to support the work – poor Wi-Fi connection, microphone issues, camera not working. These aspects are so important to sort out before you can really commit to online working. I regularly encourage people to ask themselves – would I do this if I was in a face-to-face setting? If the answer is no, then the same should apply to our online etiquette too. You would wait for the break to grab a drink or have a smoke, and you make eye contact and introduce yourself to a guest that is attending your team meeting. We do need to make the same effort in the online world.
Switching to online working is not merely substituting the meeting room for a virtual one. There has to be consideration for the nuances of this work and the challenges it ultimately brings. Expect adjustments to the way we work and the workload – organisations should embed a support structure for the workforce to ensure that online work is conducted in the safest and most supportive way possible. It almost seems that we have more meeting demands as geographical boundaries are removed, and there’s now the expectation that you will squeeze every minute of your day into some online interaction.
We know that there are many challenges to remote working including online fatigue, so it’s important to schedule those ‘watercooler’ moments or small breaks into our day just as we would in the office environment. Block out your diary to protect your time – after a morning of running online groups book in ample debrief and note-writing time, and if you know your concentration levels may be lower in the afternoon protect that time in your diary so it’s not hijacked for another meeting.
It’s important that careful consideration is made each and every time we are on camera. It does involve being organised and putting yourself in the shoes of the person on the receiving end. We do need to think about the context. Whilst I am more relaxed with my colleagues I have different standards for any external meetings, training or online interventions I attend or deliver. With the rush to get online it seems that the considerations for set up may have suffered.
Angela Calcan is operations manager for DrinkCoach at Humankind Charity
It’s essential that we ensure data protection for our service users and that starts with the policies and procedures that support online working. It also means that when remote working we must take confidentiality as seriously as we would in person. We should ensure a confidential space where the conversation will not be overheard or interrupted, and if you can’t guarantee this, then some adjustments need to be made. I have two young children and I appreciate the challenges that this year has brought to privacy and disruption in the home. Although many service users are forgiving of interruptions we do need to protect that virtual therapeutic space. Over time these blips can add up, and if not properly addressed cause the service user to lose confidence in the system.
Finally, although online fatigue is a real issue at the moment I would encourage those interested in working effectively online to continue this work. We know that there are digital exclusion concerns for many service users, but we also know that many hard-to-reach service users may be more inclined to engage via this method. At DrinkCoach we have been able to engage women and a younger cohort as well as working professionals through our online work. I hope the sector can continue to offer online as an option and maximise the benefits of online interventions, not just out of necessity but because it has value to our [potential] service users.
Who exactly is drug treatment designed to benefit, asks Nick Goldstein.
The genesis of this article was Priti Vacant’s (Patel’s) recent bung of £148m to cut drug crime and introduce project ADDER (DDN, February, page 4). ADDER is yet another treatment service acronym standing for ‘addiction, diversion, disruption, enforcement and recovery’, although if history is anything to go by shouldn’t it really translate to just another dumb drug exercise? It doesn’t really matter what it stands for, because the odds are it will end up in the government policy wastebasket with all the other failed new agendas.
ADDER doesn’t inspire confidence. Little of the money is ‘new money’ and on a close reading it can only really be described as grossly depressing. In fact its only saving grace is we’ve heard it all before, which makes the depression seem like an old acquaintance – like meeting a cop who’s arrested in you in the past.
Although the actual document is meaningless pap there were several interesting comments from the rogue’s gallery of ministers who were rounded up for its release. Our esteemed minister for health and social care, Matt Hancock, got the ball rolling with ‘addiction and crime are inextricably linked’ and followed up by pointing out that Priti’s bung was ‘the largest increase in drug treatment funding in 15 years’. While being true, it said more about the savage cuts of the last 15 years than anything else.
The esteemed minister was rapidly followed by Priti herself, who reminded everyone that she was determined to cut crime. She was especially keen to announce her personal war with county lines gangs, who are rapidly becoming the folk demon du jour. Priti suggested she was ‘restoring confidence in the criminal justice system’ so that people could live their lives knowing their family, community and country is safe – from drug users. Thankfully she remembered not to say the last part out loud!
Next up at the podium was the headlining act, the grand fromage himself, the prime minister. Boris, as ever, blustered on about making the streets safe and tackling criminal gangs by ‘cutting the heads off snakes’ amongst many other favourite platitudes from drug policy and/or treatment speeches over the years. Boris finished up with ‘I am determined to fight crime’. The whole event, the policy release and speeches engendered nothing more than mild depression, just like the last policy release, the one before that and all the others – just more of the same thoughtlessness that has been failing for years. It’s just more criminal justice solutions with some ill-defined recovery thrown in to make the policy palatable. I swear, if politicians were banned from mentioning crime in a discussion on drug use they’d be forced into silence.
Depressing though all of this may be, it is of value because it perfectly illustrates a fundamental flaw in drug treatment and policy that really does need commenting on, because it’s the root cause in much misunderstanding. It’s this – drug treatment is not for drug users, rather it is an attempt to protect society from drug users. I appreciate some readers might be wincing or exhibiting anger at this point, but hear me out.
Let’s look back over the last few decades to the ’80s when I first stumbled into treatment with a grade A heroin habit and a whole host of illusions just waiting to be shattered. The treatment system back in the ’80s featured injecting or rather the desire to stop injecting – the reason for this was nothing to do with healthcare for drug users and everything to do with stopping drug users spreading HIV to polite society.
In the ’90s the arrival of New Labour – tough on crime, tough on the causes of crime – moved the aim of treatment onwards, and now maintenance prescribing became vogue. Scripts and script sizes multiplied and grew to ensure drug users were nodding at home rather than out robbing your car. Again, the change in policy was more to do with cutting crime statistics than improving the lives of drug users. As an aside, if you described a society in which dissidents were made to take a heavy psychoactive drug, like methadone, you’d presume the country was some Eastern European cold war dive, not England. Yet it happened here.
Then came the coalition government and their recovery agenda which – call me cynical – I believe was mainly about reducing the cost of treatment by producing economically productive members of society out of drug users, no matter how hard it was to force drug users into sobriety, and productivity, as the graveyards attest.
Project ADDER and the above pronouncements suggest current changes will be a case of it being, in the words of the late, great Yogi Berra, ‘deja vu all over again’. It’s yet more policy from politicians who don’t really care about something they don’t understand or really care to understand, and its aim is most definitely not about helping drug users. It’s not really surprising drug use and users are always an afterthought for politicians – there aren’t enough of us (about 300,000 in treatment) when compared against other vulnerable groups.
As well as being short of numbers, drug treatment also falls victim to being short of time too. Policy runs on a four-year electoral cycle and many changes to drug treatment won’t bear fruit quickly enough – if you’re the minister for health or the home secretary what’s the point of enacting policy, often at great expense, if it doesn’t show positive results before the next election?
Nick Goldstein is a service user
Whatever the reasons, it’s clear that drug treatment is primarily about protecting wider society. If ADDER is good for anything it’s as an illustration of policy aims which are yet more of the long-failed criminal justice-based policies. ADDER might be new, but it’s philosophy and aims are old as the hills.
Any considerations of the needs of drug users are secondary – an afterthought. Here’s a parlour game to prove the point. Get a pen and piece of paper and design a basic treatment system that promotes drug users’ health and wellbeing. I bet it looks fuck all like the system we have. A system that hopelessly fails drug users on any reasonable terms, and ironically doesn’t do much for wider society either. It might be time for an honest conversation about the true purpose of drug treatment, for everyone’s sake.
Forward’s director of employment services Asi Panditharatna reflects on the company’s achievements in the past year, as well as ways forward for the employability sector.
Happy Employability Day 2021. Today is an opportunity for the employability sector, our employers and partners to celebrate our efforts in supporting jobseekers to both find and thrive within the world of work.
Employability Day 2021 takes place during a global pandemic, which has led to uncertainty in the labour market for many.
It has been a challenging year for the employability sector, employers and the people we support. However, we still have many success stories to celebrate.
Challenges in the labour market
The Covid-19 pandemic has had a significant impact on the UK economy and taken a particular toll on the low-paid and those in less secure work. According to the Institute for Employment Studies (IES), “low-paid employees were also more than twice as likely to leave their jobs – with around one in twenty doing so each quarter compared with just one in fifty of those not in low pay”.
The greatest impact has been felt by the most disadvantaged. This includes those in low-paid work, the low-skilled, some ethnic minority groups, and our youngest and oldest workers. A recent Resolution Foundation commissioned study highlighted that older workers who lose their jobs tend to take longer to return to work and are likely to earn substantially less than in their previous job.
Who really funds drug treatment in residential rehabs, asks James Armstrong.
It’s obvious isn’t it? In state funded rehab the state pays, don’t they?
In community settings, the Local Authority pays for drug treatment as part of a responsibility to provide social care. In prisons and secure settings, the NHS pay as part of healthcare provision.
But, for people who need the combination of multiple services (often substance use, mental health and homelessness) that are best met in a residential setting, who pays?
Local Authorities certainly pay for some of the cost. Although, in many areas they have devolved the responsibility to the community treatment provider. Sometimes this funding is ringfenced, and sometimes it is not. Knowing this, we can be fairly sure it is either the Local Authority or the community drug treatment provider paying for rehab, can’t we?
Detox and rehabilitation facilities play an important role in support. A mixed model is emerging in a complex treatment landscape, says Nye Jones.
Grace* started using drugs at the age of nine. Growing up in London, she describes herself as a “street kid who struggled to get into the swing of life”, with drugs helping numb the pain of her difficult upbringing. Fast forward a few decades and Grace had moved to Cornwall. She was a mother, holding down a good job, but still using heavily. She describes it as “like spinning a hundred plates at once to try to stay sane, it was my dirty little secret, I wasn’t going to rehab.”
But eventually her secret got out. She started working with With You in Cornwall’s community service before her worker referred her into the residential rehabilitation centre in Chy, also run by With You. Chy is an 18 bed centre situated in a historic building and gardens just outside Truro. Residents go through a twelve week programme focusing on building people back up, with interventions like counselling and art psychotherapy. There are even kennels so residents don’t have to be split up from their dogs, with service manager Miriam Brenton describing it as a “therapeutic community.”
Acorn Academy teacher Derek Fredericks has been awarded the Teaching Excellence Award at this year’s Educate North Awards.
Fredericks, an academy manager at Acorn Academy (part of the Calico Group), scooped the award as recognition for his fantastic work with learners who are dependent on drugs or alcohol.
The win comes as over 80% of learners who attended courses in 2018/19 reported progressing into employment, volunteering and/or further learning.
Delivered by Acorn Academy and funded by Stockport Continuing Education, Fredericks and his team provide training courses that support learners to progress to other learning, volunteering and/or employment. Courses cover topics such as peer mentoring, emotional intelligence and counselling, and are made possible thanks to funding from Greater Manchester Combined Authorities’ Adult Skills Budget.
Individuals come from a wide range of backgrounds with addiction as the common factor. Fredericks uses his direct experience of addiction to inform his approach and the content of the courses he delivers. This lived experience allows Fredericks to break down barriers with learners and deliver courses that are challenging but never judgmental.
Learners asked about Fredericks’ courses and the support he provides characterised him as ‘inspirational and charismatic’. Others also talk about his ‘compassion and no-nonsense approach’.
‘Derek’s style is very much reflective and challenges perceptions in a way that allows them to gain insight into the issues of addiction,” commented Sean Burke, service manager at Stockport Continuing Education Service, who nominated Fredericks for the award.
‘Always interesting and thought-provoking but never patronising or dismissive, Derek is a mentor and friend to many.’
A 2018/19 survey found that 81% of students achieved positive progression, meaning they went on to employment, volunteering or further learning. Furthermore, a Stockport Continuing Education Service survey reported that 90% of course participants saw improved health and wellbeing and improvements in their ability to socialise, work, communicate and actively participate in society.
The Educate North Awards 2020 were announced via a live stream on YouTube on Thursday 22nd April 2021 – postponed from the previous year due to the coronavirus pandemic.
The judges on the night said: ‘Derek has made an outstanding contribution in a very challenging area. This entry is very positive, highlighting the good work of the Acorn Centre and Derek in particular demonstrating initiatives taking place which have produced worthwhile results.’
As we slowly ease out of lockdown this month, there are many valid worries and fears that you may be experiencing. Turning Point offers some quick tips to help handle post-lockdown stress triggers.
1. I don’t feel ready to see people again
The lockdown has made some of us realise that we actually quite enjoy our own company, and not having to reach out to, or deal with others.
It is fine to feel this way, however it is important to start thinking about coming out of our own hibernation. Taking small steps can help you to gradually ease back into things. Start one day with a drive out somewhere for a secluded walk, build up to a quick food shop, and sit and have a coffee with someone you trust and feel comfortable with. From there, you can start to build up your confidence again to meet with people.
Maybe you have really enjoyed the reduction in social interactions, less time spent on social media, or have put more time into positive hobbies. If so, continue with this if it makes you happy. Try and find a good balance.
The easing of lockdown may feel like a threat to your current situation, if you are suffering with mental health issues and feel more comfortable the new routines you have established at home. Speaking to your workplace, and any support networks you have in place will be important to you if you want to feel secure again.
In May 2020, Forward launched its first ever live-chat service: Reach Out. Amy Lucas, Reach Out Service Coordinator, describes how the service has grown in the past year.
Nearly a year ago, on 1st May 2020, Forward launched its first ever online chat service: Reach Out. Plans for such a service had been in the works for a while, but accelerated dramatically when the pandemic hit.
We were mindful that a lot of vulnerable people, both our current service users and those not currently getting help but struggling, would be looking for sources of support at what was an incredible lonely and anxious time, and Reach Out seemed to be one small way in which we could help.
It took a while for people to learn about the service, but – with funding from the National Lottery’s Coronavirus Community Support Fund and from J Leon Group to help with marketing and promotion – it has become increasingly popular and we’ve seen a 500% growth in call volume since November of last year.
Although Forward delivers a range of different types of support, including employment and housing, we’re most well-known for our drug and alcohol services. So we thought it was likely that the vast majority of people contacting us would do so to chat about issues with substances. And, to begin with, they did.
With reforms to health and social care on the way, policymakers have a unique opportunity to embed and strengthen what we know works, says Felicity Simpkin.
Commissioning health services is a complex task. How it is done, who is responsible for it, and how success is measured has changed many times in recent years. Navigating these changes in an era of long-term disinvestment and local variation in budget and service quality has been a big challenge for those who commission services.
Commissioning is also grappling with the impact of procurement processes that can undermine the success of the very services being delivered. Tendering can be resource intensive and lengthy, distracting from the day-to-day running and development of existing services. At its worst, this disruption can result in inflexibility, stifle innovation and be costly.
While many areas have lengthened contract terms, and are working to align contracts across a system, services for people with multiple and complex needs are also too often siloed, commissioned separately and to separate time-frames.
A new round of national reforms are now underway and the processes used to commission services are under the microscope of policymakers.
The Government has published new plans to reform public procurement, there’s a new White Paper outlining the biggest NHS reorganisation since 2012, and Public Health England is about to be abolished and functions folded into the Department of Health and Social Care (health improvement) and a new UK Health Security Agency (health protection).
The sector is also awaiting the publication of the Dame Carol Black Review of Drugs and a new Government Addiction Strategy. All these processes will have something to say about how services are commissioned and delivered.
Problem drug use is neither ‘a lifestyle choice nor a personal failure’, states a new manifesto published by the Scottish Drugs Forum (SDF). A culture change in drug treatment is needed to give people the services they want, urges Drugs: policy and aims – a manifesto for Scotland.
Preventing problem drug use means ‘addressing its origins’, the document says, not least the country’s poverty-related social and health inequalities. More support is also needed for families and vulnerable young people, while the views of people with a drug problem should be a key driver of change. ‘A recognised, voiced, empowered presence for people with an active drug problem in making decisions that affect their lives,’ is crucial, it says, and also calls for ‘workforce development activity’ to allow staff to identify and challenge stigmatising practices and improve relationships with their clients.
Among the document’s other recommendations are reviewing the effectiveness of the ‘not fit for purpose’ Misuse of Drugs Act and decriminalising possession of all drugs, expanding use of alternative-to-custody programmes and establishing consumption room facilities across Scotland. This could be done by circumventing the existing legal barriers through ‘the powers of the Lord Advocate’, it says.
The numbers in treatment should be doubled so that 70-80 per cent of the people ‘who could benefit from treatment are actively engaged’, it says, while successful local harm reduction initiatives should be rolled out nationally, with increased investment for HIV and hepatitis testing for anyone with a history of injecting drugs. Services for women also need to be urgently improved, says SDF, to help reduce deaths and ensure mothers are ‘empowered and supported to parent their children’.
Scotland has seen its annual rate of drug deaths – the highest in Europe – continue to grow in recent years, although Nicola Sturgeon’s government has pledged more money for drug services (DDN, February, page 4) and appointed a dedicated minister to lead on the issue (DDN, February, page 5).
David Liddell: cautious optimism in the face of a crisis
‘Very recent changes, including political leadership and investment, are very welcome,’ said SDF CEO David Liddell. ‘We need to build on this and use the current momentum to deliver change. Key to that is developing the capacity to listen to and involve people with a drug problem in the development of better services and strategy. We believe there may be an emerging consensus to address the poverty and stigma which are at the root of the challenge we face in Scotland. We can also see that a consensus on the benefit and need to improve treatment is well established – there is reason for cautious optimism in the face of what remains a public health crisis.’
Manifesto available at www.sdf.org.uk – read it here
A survey by With You has revealed the ‘huge impact’ of COVID-19 on alcohol consumption in Scotland, with 49 per cent of respondents saying the pandemic has led to them drinking more than usual.
The survey of almost 5,400 people also found that 30 per cent were consuming ten or more units ‘on a typical drinking day’, with the same proportion reporting using alcohol to deal with stress and anxiety. Researchers found that more than a quarter of respondents’ drinking fell into the increasing risk, higher risk or possible dependence categories, with a third reporting concerns about their drinking during lockdown. Almost a third of respondents said they were drinking more than four times a week, with a quarter also reporting that they were concerned about a loved one’s drinking.
While not representative of the whole population the size of the survey ‘provides a thorough snapshot’ of current drinking levels, says the charity, with respondents given a score based on the Alcohol Use Disorders Identification Test. Almost 95 per cent of those who responded said they’d never accessed support for their drinking.
Although 2019 had seen a major year-on-year fall in alcohol-related deaths in Scotland, the pandemic has the potential to ‘undo this progress’, said With You’s director in Scotland Andrew Horne. ‘These are really tough times for everyone. Uncertainty and anxiety cloud our lives while the necessary restrictions to control the virus have left lots of people socially isolated. It’s no wonder many are drinking more as a way to cope. The number of people regularly drinking ten-plus units in a single session, often as a way of dealing with mental health issues, is concerning, as is the number of people judged to be at risk.’
‘As lockdown eases, it’s important people know that all our services are open and you don’t have to worry about placing extra strain on the NHS. A great start is talking anonymously to an advisor via our online webchat service at www.wearewithoyu.org.uk.’
Adfam’s National Forum on inclusion saw discussion around barriers to inclusion, as well as the changes needed at service and policy levels to help the substance use sector meet the needs of the UK’s diverse population.
It is widely acknowledged that some communities are underserved by substance and mental health services; however the scale of the problem remains a persistent data blindspot.
The Government’s annual Substance Misuse Treatment Statistics Report, informed by the National Drug Treatment Monitoring System (NDTMS), doesn’t collect data on ethnic identity.
The emergence of specialist treatment services for people who are Black, Asian, or from another minority ethnic group, such as Kikit and the Shanti Project indicates that mainstream services need to do more to meet the needs of different communities.
Though there is no official data on who is not accessing services, or their ethnicity, the clues are there: in 2019-20 almost half the people in treatment for alcohol, and over half of those in treatment for crack and opiate use, were living in areas ranked in the 30% most deprived areas. Most minority groups are much more likely than people in the ‘white British’ ethnic grouping to live in the most deprived areas in the UK (Gov.UK ‘People Living in Deprived Neighbourhoods’, 2020).
There is no reason to believe that people from ethnic minority groups would be immune to the conditions that produce a higher prevalence of substance related harm in deprived communities, and so it is likely that mainstream substance use and family support services are missing some of the most vulnerable groups in our community.
Chantelle, a peer mentor from Croydon Recovery Network Drug and Alcohol Service, writes about her own recovery journey and the challenges posed by three lockdowns.
My name is Chantelle, I’m from Croydon and I’ve been in recovery for almost seven years now. I live with son who is studying at college at the moment. I have a lot of mutual aid around me, my support network is my work, church, gym, friends and family who are all there to communicate with and help me when I need.
Before the pandemic I would drop my son at school, then go to the gym in the morning before going on to work. Later I would go back to pick up my son from school and go to the gym for a second time for an evening work-out class. Every Sunday I’d attend church where my aunties and uncles are elders, knowledgeable and experienced member of the church. Most Sunday afternoons I’d go and have dinner with my dad or someone else from my family.
Once the restrictions hit, they really hit me hard. My day-to-day routine went completely out of the window, I just wasn’t able to live my normal routine anymore!
Eighteen new homelessness outreach services, employing 130 staff, have been launched across England by Change Grow Live. Alongside access to drug and alcohol treatment, the specialist teams will offer wraparound holistic support including wider mental and physical health, as well as help with housing and benefits.
The teams will provide street interventions for people sleeping rough – with no requirements to attend appointments – in locations across London as well as in Birmingham, Brighton, Cambridge, Luton, Manchester, Northamptonshire, Peterborough, Preston, Reading, Southampton and Southend. People will be able to access support straight away with no need to wait for referrals from a third party, says the charity. Funding is being provided by the Ministry of Housing, Communities and Local Government, with support from Public Health England, as part of a two-year programme to help rough sleepers who have a drug or alcohol dependency.
The teams, which include psychologists, homeless recovery workers, prison link workers, complex needs navigators and assertive outreach nurses, will build on the strong links already established with rough sleeping communities through the government’s Everyone In scheme (DDN, September 2020, page 6) and vaccination programmes.
The opening of the new services represented a ‘landmark moment’, said Change Grow Live’s national homelessness lead, Lesley Howard. ‘Each service will help us to provide effective, evidence-based support for people struggling with homelessness and substance misuse. One hundred and thirty new specialist staff working pro-actively across England will increase the visibility of substance misuse services and make it easier for individuals sleeping rough to access wraparound support. Our outreach teams are trained to engage and build relationships with people with multiple, complex needs, to increase levels of engagement with vital treatment and enable people to get the help they need to rebuild their lives off the streets.’
Tony Lee: The impact will be life changing.
‘This project is the first fully wraparound offer I have seen for homeless people,’ added national lived experience volunteer Tony Lee. ‘The care and thought that has gone into the design has been brilliant to be a part of. As a person who was homeless for 12 years in London, I can also say that the impact an approach like this will have will be life changing. Homeless people will be engaged in their own environment and not asked to come into an office or building. Just this alone will increase the engagement tremendously and better engagement means better outcomes. It’s one of the most exciting and innovative programs I have been involved with, and I feel really privileged to be a part of it.’
After six years, the ‘Drink Wise Age Well’ programme is ending. These are the stories of people supported by the project.
Born in 2015, Drink Wise Age Well was a project, funded by the National Lottery Community Fund, to support people over 50 to make healthier choices around alcohol. From training nearly 10,000 professionals to better support older adults, to holding 1,300 alcohol awareness workshops with people over 50, the programme has left a big imprint in communities across the UK.
But beyond the statistics, there are personal tales of lives changed and new chances. Here, four beneficiaries of the programme share their stories.
Alan: “I learnt a new language — a life without alcohol”
When my long term relationship broke down I ended up living alone in Glasgow. I started to binge drink as I had nothing else to do, quickly shifting from being a social drinker to drinking at home alone.
SIG Penrose has announced a partnership with the East London Foundation Trust (ELFT) to deliver an exciting new pilot project that will support timely and effective discharge from Bedfordshire’s mental health wards.
The project launched on 8th April 2021 and will run for 15 weeks.
SIG Penrose is working in partnership with the ELFT to deliver a short term pilot project, The Coppice, supporting the timely and effective discharge from Bedfordshire’s mental health wards, for those who are clinically ready to be discharged, but are facing delays in returning to their accommodation/homes. The service is a seven-bed unit in Bromham which has previously been used as a learning disability residential unit.
SIG Penrose’s head of services and specialist lead Emmeline Irvine said: “We are pleased to be working in partnership with ELFT in the provision of this vitally important service. SIG Penrose is in the unique position to be able to provide staffing as well as therapeutic engagement for the service users.”
A new service to provide support for young people with drug or alcohol issues is set to be launched across North Yorkshire.
Photo by Amir Hosseini on Unsplash
The service, commissioned by North Yorkshire County Council and delivered by national charity Humankind, is aimed at reaching young people aged 18 and under (and 19 – 24 with special educational needs and disabilities) who need support around drugs and alcohol.
Damien Frain, young peoples and families manager at Humankind said: “It’s great news that North Yorkshire County Council has committed to invest in a high quality young people’s support service.
“We look forward to delivering this service to ensure that young people across North Yorkshire have access to help and advice around drugs, alcohol and associated support needs. We will work closely with the adult North Yorkshire Horizons service to ensure seamless links for pathways into treatment when they reach 18 years of age where appropriate.”
Psilocybin, the active compound in ‘magic mushrooms’, could be at least as effective in treating depression as a leading antidepressant medication, according to a study by Imperial College. Researchers compared a six-week course of escitalopram – a widely available selective serotonin reuptake inhibitor (SSRI) – with two sessions of psilocybin therapy in 59 people with moderate to severe depression, and found that reductions in depression scores happened more quickly and were more pronounced in the psilocybin group. The psilocybin group also reported fewer cases of side effects such as anxiety, dry mouth, drowsiness or sexual dysfunction.
The study is the ‘most rigorous trial to date’ assessing the potential of psychedelic compounds in mental health treatment, says Imperial College’s Centre for Psychedelic Research. Volunteers either received a high dose of psilocybin and a placebo, or a very low, ‘non-active’ dose of psilocybin plus escitalopram. All volunteers on the study received the same level of psychological support, the researchers stress, with people receiving an oral dose of psilocybin while listening to music and being guided by a support team including psychiatrists. The report’s authors also warn against people with depression attempting to self-medicate with psilocybin in an unsupported, non-clinical setting.
There have been increasing levels of research in recent years into the potential of psychedelic compounds to treat depression without side effects, but the Imperial College team acknowledges that longer trials involving more patients will be needed to determine if psilocybin can perform more effectively than established drugs. Magic mushrooms were re-classified as a class A substance in the UK in 2005.
‘These results comparing two doses of psilocybin therapy with 43 daily doses of one of the best performing SSRI antidepressants help contextualise psilocybin’s promise as a potential mental health treatment,’ said head of the Centre for Psychedelic Research, Dr Robin Carhart-Harris. ‘Remission rates were twice as high in the psilocybin group than the escitalopram group. One of the most important aspects of this work is that people can clearly see the promise of properly delivered psilocybin therapy by viewing it compared with a more familiar, established treatment in the same study. Psilocybin performed very favourably in this head-to-head.’
As awareness of homelessness in our communities continues to be a priority following the pandemic, the Calico Group reflects on progress made across its Burnley communities that has seen over 400 homeless or at-risk individuals housed in the past 12 months.
We continue to actively stand by our pledge: to ensure that housing and support services remain focused on supporting those who are homeless, fleeing their homes due to abuse, or are at risk of losing their homes.
Calico Homes has continued to prioritise homeless or at-risk individuals during the pandemic, letting a total of 57 properties to accommodate these groups in the last 12 months.
The Group has also provided emergency accommodation and support for those adversely affected since the pandemic struck last March.
The team at Phoenix Futures discusses the current focus on stigmatising language.
Photo by Jeremy Yap on Unsplash
Quite rightly there is a current focus on stigmatising language. Use of language frames the way we think. Non-judgemental, people-first language is important to reduce stigma but it is equally important that we consider the subtle use of language that disempowers, judges and marginalises the people who use our services.
These are some of the common arguments we hear to justify the de-funding of residential services:
There is no demand for rehab
We frequently hear the reason for reduced detox and rehab access is that people don’t want it. This simply isn’t true. We frequently speak to people desperate for rehab, we are told they have had to ‘fight’ and ‘beg’ to even be considered for a placement. We know the lack of demand is due to lack of awareness, and that is understandable – why would frontline treatment staff make people aware of a treatment option that isn’t funded?
The Forward Trust has announced it has been awarded the contract to deliver psychosocial substance misuse services at HMP Chelmsford.
Photo by Rene Böhmer on Unsplash
The service goes live on 1st April 2021 and has been awarded by NHS England and NHS Improvement England.
The service will be delivered in partnership with CRG, which delivers the wider healthcare service at the prison.
The contract expands The Forward Trust’s existing delivery of primary mental health (IAPT), clinical substance misuse and employment services at Chelmsford. As such, it enables The Forward Trust to provide integrated, wrap-around support for clients with related mental health, substance misuse and employment needs, increasing the organisation’s ability to help more people achieve productive and fulfilling lives – with improved mental and physical health – free from crime, drugs and alcohol.
The use of violence in the illegal drugs trade has ‘escalated notably in recent years’, according to Europol’s European Union serious and organised crime assessment – EU SOCTA 2021. Competition between suppliers has intensified, leading to an increase in both the frequency and severity of violence, it says.
The SOCTA, which is published every four years, identifies shifts in serious and organised crime activity based on analysis of thousands of cases and intelligence provided to Europol. The COVID-19 pandemic and ‘potential economic and social fallout’ could create ideal conditions for criminal organisations to thrive and expand, it warns, with serious and organised crime posing a greater threat than ever before. ‘A key characteristic of criminal networks is their agility in adapting to and capitalising on changes in the environment in which they operate,’ it states. ‘Obstacles become criminal opportunities.’
Around 40 per cent of criminal networks are active in drug trafficking, the report states, with the production and distribution of drugs by far the EU’s largest criminal business. The scale of money laundering from drug supply and other activities has also been previously underestimated, it adds, with launderers establishing a ‘parallel underground financial system’ and using ‘any means to infiltrate and undermine Europe’s economies and societies’.
While the online trade in drugs continues to grow and has potential to expand further, it remains limited compared to traditional forms of supply. Global manufacture and seizures of cocaine remain at record levels (DDN, July/August 2019, page 5), with purity of the drug at retail level also the highest ever recorded. More criminal networks are moving into the huge European market for cocaine, says the report, attracted by higher prices and lower risks than in North America.
The booming cocaine market has increased the number of killings. Image by kerttu from Pixabay.
‘Latin American criminal networks are expected to continue collaborating with international EU-based criminal networks,’ the report states. ‘In the EU, high cocaine availability, low wholesale prices and a high level of purity are expected to remain features of the market in the short term. The booming cocaine market has entailed an increase in the number of killings, shootings, bombings, arsons, kidnappings, torture and intimidation. The nature of the violence appears to have changed – a growing number of criminal networks use violence in a more offensive way.’
‘The 2021 SOCTA report clearly shows that organised crime is a truly transnational threat to our societies,’ said European commissioner for home affairs Ylva Johansson. ‘Seventy per cent of criminal groups are active in more than three member states. The complexity of the modern criminal business models was exposed in 2020 when French and Dutch authorities supported by Europol and Eurojust dismantled EncroChat, an encrypted phone network used by criminal networks. Organised crime groups are professional and highly adaptable as shown during the COVID-19 pandemic.’
Around 2.5m people are in prison for drugs offences, at least 475,000 of which relate to personal use only, while the annual drug-related death toll now stands at 585,000. Only one in eight people with drug dependence has access to treatment, the document states, while billions have limited or zero access to pain relief ‘due to repressive drug laws’.
While the 1961 Single Convention on Narcotic Drugs represents ‘the legal foundation’ of international drug control, this month is also the fifth anniversary of the 2016 UN General Assembly Special Session (UNGASS) on drugs, which saw countries commit to a ‘public health, rights-based’ approach to drug policy (DDN, May 2016, page 4). Comparing these commitments with evidence on the ground reveals ‘a widening gap between rhetoric and reality,’ says IDPC.
Ann Fordham: ‘Draconian policies’ have had a ‘catastrophic impact’ around the world.
Enforcement of drug laws continues to disproportionately affect women and ethnic minority groups, fuelling poverty and inequality, the report says. ‘Women who use drugs are particularly vulnerable to health harms, but their access to gender-sensitive harm reduction and treatment services has not improved over the past five years. Stigma, criminalisation, fear of loss of child custody and other punitive measures play a major role in deterring women from accessing the services that do exist.’ Globally, around 35 per cent of women in prison have been incarcerated for drug offences, it points out.
The report is calling for a full review of drug laws and policies to ‘remove all punishments for drug use and possession for personal use’ and ensure proportionate sentencing and ‘meaningful’ alternatives to incarceration, with prison used ‘only as a means of last resort’. All health interventions should be voluntary, evidence-based and ‘respectful of the rights and dignity of those wishing to access them’, it adds.
‘The 60th anniversary of the global drug regime gives us little cause for celebration’ said IDPC executive director Ann Fordham. ‘In the past five years, some progress has been made, as countries moved to adopt welcome initiatives on the decriminalisation of people who use drugs, and the legal regulation of cannabis. However, in most parts of the world, governments remain wedded to draconian policies that have had a catastrophic impact on communities, and have resoundingly failed in their stated purpose of eradicating drug markets, or reducing illegal drug use.’
Meanwhile a new report from INPUD states that ‘it is time to disrupt the misconception that decriminalisation efforts unquestionably represent progress when they have been developed with little or no consultation with people who use drugs’. Decriminalisation is often discussed as if there is a single model, says Drug decriminalisation: progress or political red herring? In the overwhelming majority of countries people who use drugs ‘continue to be criminalised, punished, and stigmatised’ despite decriminalisation, it states, and calls for people who use drugs and their organisations to be involved in all stages of reform processes, along with expansions of access to harm reduction and social care.
A new search engine for people to find information about needle and syringe services in their area has been launched by With You.
Users simply insert their address or postcode to find the nearest services
Accessible via the organisation’s website, the tool provides full details of local NSPs sorted by postcode.
The charity has also released a new series of online harm reduction advice, including on safer injecting, responding to an overdose, using naloxone correctly, and safer use of other drugs such powder and crack cocaine and steroids. It also offers advice to those worried about someone else’s drug use.
NSP services were ‘often the first step on the road to accessing treatment’, said With You volunteer Richard Townsend. ‘With the restrictions of the pandemic it can be really hard to know what’s open and what isn’t. At the same time the enforced isolation has led to more people using drugs on their own, so I think this new needle and syringe exchange finder will be really helpful for a lot of people.’
‘When we first went into lockdown, our data showed the number of people visiting pharmacies or specialist services for new syringe packs was down by 50 per cent,’ said With You’s deputy chief executive Laura Bunt. ‘We were concerned as this may mean many people were re-using equipment and not getting advice to help reduce the risk of harm. We know people are much more likely to use drugs alone at the moment due to social distancing measures, meaning there is less likely to be someone else present to call the emergency services if something goes wrong. Our new find a needle and syringe service can help many more people access the equipment and support they need, while our new online advice will help keep them as safe as possible.
‘Drug related deaths are at record levels in the UK, while the enforced isolation of the pandemic has been really tough on some people, with drugs offering an escape,’ she continued. ‘This is about following the evidence of what works while treating people who use drugs with compassion.’
A national naloxone and overdose awareness campaign has been launched using posters of people who have been personally affected by overdose and now carry naloxone themselves.
The first set of billboards will be displayed across London and Manchester, with more to follow later in the month in Birmingham, Bristol, Cardiff, Edinburgh and Glasgow.
The campaign highlights the importance of making naloxone available to anyone at risk of opiate overdose – or likely to witness one – as well the need to properly understand overdose risks. Everyone featured in the campaign has been fully trained in overdose prevention. The high-profile campaign is designed to encourage wider public debate and challenge the stigma so readily applied to people who use opiates.
‘What this campaign demonstrates beautifully through its anti-stigma approach is the human face of people with real lived experience,’ said Release executive director Niamh Eastwood, whose organisation has long advocated for wider naloxone provision. ‘It is this humanity that is often ignored by politicians, the media and other agencies who seek to dehumanise and “other” this vulnerable population, and this allows for their lives to be seen as expendable. This has to end – we must recognise that stigma kills.’
One of the posters features harm reduction activist and regular DDN conference volunteer Lee Collingham. ‘I was losing friends and going to funerals. They were poorly attended and the word heroin was omitted – there was shame,’ he said. ‘It’s all about educating the public and until we’ve got a full national programme for naloxone provision it’s the simple things that matter – phoning an ambulance and doing chest compressions can save a life. Everyone can relate to that.’
Join in the campaign by posting your photos of the billboards with the hashtag #naloxoneposter
People with chronic primary pain should be offered a range of treatments to help manage their condition, says new guidance from NICE, rather than being started on drugs such as benzodiazepines or opioids.
A new Office for Health Promotion will help to ‘design and operationalise a step change in public health policy’
Chronic primary pain is defined as pain lasting more than three months and where the cause is unclear – pain caused by an underlying condition such as arthritis or ulcerative colitis is known as chronic secondary pain. The guideline emphasises the importance of shared decision making and ‘putting patients at the centre of their care’. Treatments known to be effective in managing chronic primary pain include exercise, cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT).
People who have been prescribed drugs for chronic primary pain are not being asked ‘to simply stop taking their medicines’ without being provided safer alternative options, stresses NICE. Anyone prescribed drugs not recommended in the guideline should ask their doctor to review the prescription ‘as part of shared decision making’, it says, with options including continuing to take the medicines at a safe dose, or reducing and stopping with any issues around withdrawal ‘discussed and properly addressed’. NICE will publish guidelines on safe prescribing and withdrawal management of medicines associated with dependence later this year, it says.
‘People with chronic primary pain should not be started on commonly used drugs including paracetamol, non-steroidal anti-inflammatory drugs, benzodiazepines or opioids,’ said director of NICE’s Centre for Guidelines, Dr Paul Chrisp. ‘This is because there is little or no evidence that they make any difference to people’s quality of life, pain or psychological distress, but they can cause harm, including possible addiction. This guideline is very clear in highlighting that, based on the evidence, for most people it’s unlikely that any drug treatments for chronic primary pain, other than antidepressants, provide an adequate balance between any benefits they might provide and the risks associated with them.’
Meanwhile, a new Office for Health Promotion will help to ‘design and operationalise a step change in public health policy’, the government has announced, including tackling issues such as alcohol use, smoking and mental health. The office, which will encompass most of the functions of Public Health England and launch in the autumn, will sit within the Department of Health and Social Care (DHSC) and recruit an expert lead who will report to the health secretary and chief medical officer. ‘It will enable more joined-up, sustained action between national and local government, the NHS and cross-government, where much of the wider determinants of health sit,’ the government says, with more details to be released later.
Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain at www.nice.org.uk
Organisations and peers have risen admirably to the challenge of continuing the hep C elimination fight during the COVID crisis, heard delegates at LJWG’s annual conference. But the final steps towards elimination will be the hardest. DDN reports.
‘The last year has been incredibly tough for everyone, but it’s been inspiring to see how different organisations have come together on this issue despite the pandemic,’ London mayor Sadiq Khan told the London Joint Working Group on Substance Use and Hepatitis C’s (LJWG) annual conference – an online event this year. Just one example had been the ‘enormously successful initiative to offer blood-borne virus testing to homeless people housed as part of our Everyone In scheme (DDN, September 2020, page 6), which spread awareness about the virus and the treatments available’.
Stores of Hope
While the situation was still ‘incredibly challenging’, said event chair Vicky Hobart – the Greater London Authority’s (GLA) head of health – there were ‘real stories of hope’ in what could be achieved with effective joint working. The Routemap to eliminating hepatitis C in London (DDN, May 2020, page 10) steering group had continued to meet, while the initiative to roll out BBV testing for homeless populations in temporary accommodation had been ‘a flagship moment’.
More than 1,000 people had been tested – 7 per cent with active infections – and more than 40 had already started treatment, she said, with partners now looking at how this approach could be applied to other settings. Future priorities would include multi-morbidity testing and diagnosis, opportunities for co-commissioning and ‘real efforts and pressure towards faster testing and turnaround of results’.
World leader
London had been a world leader in its response to hep C, chief executive of the World Hepatitis Alliance, Cary James, told the conference. The alliance had launched a survey to measure the impact of the COVID crisis, with responses from more than 30 countries. ‘Just about everyone said that their services had been interrupted, but everyone was talking about how they’d been working to overcome these barriers – that shift was really inspiring to see.’
While Eastern Europe had reported significant problems in terms of people being able to access services, it was far less of an issue in the west, he said. ‘People and organisations in London really were leaders in that. Even before the COVID crisis, London was a leader globally in terms of its response to hepatitis C – the routemap being launched was a very strong indication of that – and what’s happened since COVID has hit has really reinforced it. We always hold up the great work being done here, especially around peer-to-peer services and the huge role community has in making elimination a reality. It’s something that’s really helping to educate the world.’
Globally, however, stigma remained a significant challenge, he said. ‘There’s generally a lack of compassion for people living with viral hepatitis. On paper, hepatitis elimination is such a no-brainer, but there’s a lack of empathy from the people who have to pick up that elimination plan and give it to their finance minister to pay for it. That’s one of the biggest challenges we face.’
Devastating impact
Public Health England (PHE) was about to publish a document showing the pandemic’s ‘devastating impact’ on testing, said PHE consultant epidemiologist Dr Emily Phipps. ‘We saw a huge drop-off, particularly in the early days of lockdown.’ While this was the case across all settings, drug services had been hardest hit, and despite immense efforts from the Operational Delivery Networks (ODNs) treatment numbers had also fallen. ‘But without those efforts they really would be rock-bottom – so the ODNs really are to be commended’.
In terms of the impact on people who inject drugs, there had also been concerns around people being able to access injecting equipment and substitute medication, as well as ‘reported changes in risk behaviours’, she said, with one in six people surveyed by PHE reporting injecting more frequently.
‘But despite all the doom and gloom we’re still seeing a reduction in cases, and there are some very exciting numbers coming out of London in particular,’ she continued. ‘But as we come closer to elimination it’s going to become even harder to identify people remaining to be tested and treated,’ and optimising available data would be key to this. ‘There are still people in London who don’t know about direct-acting antivirals – not just patients, but also professionals including GPs – so there’s definitely communications work to be done as well.’
Revolutionary strategy
While the events of the last year had tested everyone to the limit, said clinical lead of the pan-London street outreach Find & Treat service, Dr Al Story, the Everyone In strategy had been ‘quite revolutionary – it was an amazing achievement to get so many people off the street and into accommodation.’ Rough sleeping had been increasing in London for almost a decade and had become ‘one of those problems that people had been conceiving as intractable and impossible – but it’s amazing what can be done with the political commitment’.
Having thousands of people in accommodation represented ‘amazing opportunity’, he stated. ‘We were given the green light to seize this opportunity and offer a full BBV screen to as many people as we could’, in partnership with a number of other organisations. The model was peer-led diagnosis and treatment initiation, ideally within a day – ‘and the vast majority of people we’ve engaged with have started treatment within 48-72 hours. We’ve been trying to take what was once a war of attrition – multiple appointments – and squash it into an outreach encounter that can be done in literally a few hours.’
In terms of the data, what was most striking was the ‘staggering number’ – almost half – who had never been tested, he stressed. ‘We know the population we work with can present some unique challenges but we’ve been delivering tuberculosis services to this same population for many, many years and we achieve outcomes that are better than in the general population.’ The team had also been expanding its work to the street sex worker population, he said. ‘So far just 30 women have been screened but the findings are quite mind-blowing. A very high proportion are homeless, a quarter are rough sleeping and almost half are currently injecting. There’s a very high undetected reservoir of hep C in that population, and a great opportunity to take services to people.’
Want to help in the fight for Hep C elimination? The Hep C Trust have various roles on DDN Jobs
COVID had ‘blown a greater wedge in what were already quite marked health inequalities’, he stated. ‘We’ve seen an increase in rough sleepers, and many people new to the streets are coming out of job loss and loss of housing tenure. And I think we haven’t seen the half of this yet.’ On a more optimistic note, the use of peers offered ‘an amazing opportunity’, he told the conference. ‘They’re not corrupted by medical training, they remain completely open-minded and agnostic and responsive to patients’ needs, and I think with the right tools and support they can lead the revolution here.’
New models
One example was shared by the Hepatitis C Trust’s senior peer support lead, Imran Shaukat. ‘When COVID hit we had to adopt to a completely new model,’ he said. ‘A lot of clinical staff were deployed to ICU wards, meaning the charity had issues keeping the service going, so all the peers got together and almost reinvented the service. We absolutely adapted – we started doing the medication delivery and keeping in touch with people on the phone – and even though the pandemic was psychologically and physically challenging the silver lining was that we were working very closely with our partner organisations and found that co-working was just the way forward. It just naturally happened, and that relationship’s continued. That’s the key to elimination – everyone coming together under one goal.’
Peers were also able to engage very effectively with people not in drug services, he pointed out. ‘But my worry is that as the numbers are going down resources will start to be pulled back and leave us open to further spikes of the virus.’
‘The elimination agenda is a great objective, but these will be hard miles – the last few cases are the hardest,’ said Story. ‘From a co-commissioning perspective there’s real safety in numbers here – it makes great economic and practical and epidemiological sense to join up. And, most importantly, it makes sense for patients.’
Buying alcohol for people with severe dependence during lockdown in Bristol has been a lifesaver, says Rachel Ayres.
Read it in DDN Magazine
On 26 March 2020 our city streets changed dramatically. Shops shut overnight, people went home and the world retreated. Bristol’s outreach workers became concerned at the speed with which vulnerably housed or homeless people with hazardous levels of alcohol consumption were catapulted into withdrawal, and unable to meet their drinking needs in the usual ways – nowhere to beg, shop or shoplift. As services retreated, retail outlets vanished and social distancing was enforced, people were left high and dry.
In Bristol, the government’s Everyone In scheme saw 427 people moved into emergency accommodation. Needs assessments indicated 35 requiring immediate alcohol treatment, 115 needing drug treatment and 24 with concurrent drug and alcohol dependency, and by April outpatient and inpatient detox facilities had closed, and GP appointments dried up. Dr Mike Taylor from Bristol’s Homeless Health Service and Dr Ben Watson from the ROADS alcohol and drug treatment service agreed that medically assisted detox within the new accommodations could not be managed safely – elective alcohol detoxification would not be possible for the foreseeable future and emergency admissions for delirium tremens would increase.
In an attempt to reduce the inevitable impacts, a simple alcohol harm reduction information sheet produced by the South London and Maudsley NHS Foundation Trust was adapted and distributed across the city via all available channels. However, severely dependent people remained chronically unwell, and some outreach workers confided to buying alcohol in small quantities as a life-preserving intervention. Something had to change. A donation of £5,000 to Bristol Drugs Project and a decision was made to provide the essential items needed to enable ‘at risk’ individuals to follow the harm reduction advice – to not stop drinking.
Two experienced outreach workers led the Essential Items Project – Darlene Wheeler from the Bristol Street Intervention Service (SIS) and Nicky Auguste, diverse communities link worker from BDP. The idea was to identify the highest risk guests from the Everyone In accommodation, and provide the alcohol needed to prevent precipitous withdrawals during lockdown.
Something more surprising emerged, however – a small cohort of people whose severe dependence on alcohol had previously been a barrier to secure accommodation found themselves with a safe place to live, round-the-clock support, food, and their alcohol needs met. Strong relationships with project workers and hostel staff, and reliable supplies of alcohol fostered autonomy and a desire for change, and the unexpected outcome was successful alcohol detox for 12-13 project participants.
The principles of the project were to buy people’s alcohol of choice and to use person-centred and trauma-informed approaches and the usual harm reduction tools to promote stable drinking and support safe reductions if requested. With clinical support from ROADS alcohol specialist Dr Janine Hale-Brown, Darlene and Nicky planned stabilisation regimes for hotel guests who were drinking 50-plus units per day. Darlene’s caseload included people previously known to her from street outreach work and Nicky’s caseload remained within his diverse communities remit, supporting people from Poland, Lithuania, and Italy, four of whom required a translator.
All the work was face-to-face and mainly outdoors – on walks and in parks – and often opportunistic. Participants completed alcohol diaries and devised SMART goals to map reductions. ‘Pros and cons of using’ and ‘delay, distract and decide’ ITEP maps kept focus and built refusal techniques, while participants recognised their opportunity for change and wanted to detox.
Where possible, alcohol was stored at the accommodation, date-labelled and available when requested. Prompt supervisory responses from clinical leads kept detoxes safe and on track and Darlene and Nicky worked flexibly, often meeting people several times a week. They provided an individualised and self-directed approach to reductions, pausing when people felt the need, speeding up during periods of confidence.
There were real challenges. Purchasing large amounts of the required brand of alcohol week after week required tenacity as shops were often shut and purchases sometimes rationed.
Some innovative provision of alcohol was required – James was drinking 12 litres of 5 per cent cider per day, and he couldn’t drink enough volume to reduce tremors when Nicky met him. By swapping to an alternative brand at 8.2 per cent he halved his fluid intake and could manage his withdrawal symptoms, fully engage with support and start a planned reduction.
Conversely, by the time Ivor had reduced to six cans of 7.5 per cent he was finding the reduced volume difficult – step one was to switch to cans containing 5 per cent alcohol and then to slowly increase the amount of water and soft drinks as the alcohol volume came down. Safety, security and a reduction in alcohol use also gave people space to resolve other barriers to recovery. One 28-year-old man discovered he had settled status and recourse to public funds. With housing benefit in place, onward referral for housing was made and he is now abstinent with his own tenancy.
Despite the challenges, outcomes were impressive. Twelve to 13 detoxed completely – eight of these finished with a brief chlodiazepoxide prescription from clinical leads, two went on to an inpatient detox and two reduced slowly without medication. One person withdrew from the project.
The cost of the project was £8,300. Keyworker time was estimated at £3,300 plus the essential items budget, resulting in a spend of £638 per person – specialist clinical supervision and detox costs are not included here. Each person received an average of 17 separate visits totalling 12.5 hours of harm reduction interventions, with the workers’ involvement with individuals ranging from four to 13 weeks, depending on the speed of alcohol reductions.
The Essential Items Project delivered life-saving harm reduction. It also offered an alternative to people with multiple previous attempts of medically assisted detoxification.
While the long-term outcomes for all of this small group are not known, Nicky met Jan for a ‘reunion’ in February 2021. Six months after detoxing he was still abstinent, attending Polish AA twice weekly and living in a shared house. Jan had been alcohol dependent for more than 20 years, and reflecting on his detox and subsequent abstinence he said, ‘I tried detox many times on my own, like Sisyphus, rolling the stone up the mountain. I was so sick at the hotel that staff helped me drink to stop me dying. Everyone was looking out for me and helping me control my drinking, and everyone was so friendly. Now I’m happy, I feel my power back. I still have good and bad thoughts in my head. I go to Polish AA, I have a room in a friendly house, I have my papers. I am alive.’
Nicky felt the project allowed him to work at Jan’s pace – ‘I had time and resources to work intensively with Jan, to get to know him and build trust,’ he said. ‘I appreciated his commitment and rock-solid desire to detox, through all the ups and downs. In addition to providing his alcohol and working out a reduction plan together we found English classes, and Polish AA.’
Asked how easy it was to buy the vast quantities of alcohol needed for thirteen project participants on a daily basis, at the height of lockdown Darlene and Nicky both laughed – ‘it was a challenge, lots of hunting, but we got it down to a fine art’. But when it came to job satisfaction, they both feel this was a bold initiative, high on reward for those they supported and good to feel effective as workers during such a difficult time.
The idea of buying alcohol for people with severe dependence might seem a strange one to many. The outreach team in Bristol (p6) are well enough tuned to harm reduction to know that their life-saving actions during lockdown have opened up many opportunities. It’s a brave idea and the tangible results of their initiative speak for themselves.
Practitioners know what works – as do many senior figures in police and criminal justice. On the eve of his retirement, PCC David Jamieson reiterated his plea for change to parliamentarians, backed by a clear set of recommendations that are being shown to save lives. Are politicians appreciating the fact that these measures are supremely cost effective in protecting the public and saving money – as well as the lives of so many vulnerable people? What more can we do to get the message across?
Tackling stigma is a very obvious part of this (p12), and we can all do our bit. It’s not just about minding language, but about mutual respect, being wary of making assumptions, and keeping an open mind – from treatment options to considering new ideas. We hope this month’s issue gives food for thought and look forward to your views.
Liam Ward is residential marketing manager at Phoenix Futures
At Phoenix Futures we have been thinking a lot about stigma, rights and treatment access, and we hope these will be key themes in Dame Carole Black’s forthcoming review. There is a sense that we could be on the verge of a period of positive change. But that change can only be maintained if we reflect on some key underlying structural and societal considerations.
Phoenix have been highly vocal on the issues of access to detox and residential services. Over 50 per cent of English local authorities refer fewer than five people a year to rehab, and there is zero access in more and more local authority areas. We know the ‘postcode lottery’ is unfair, but in some parts of the country there is total exclusion from NICE-approved, clinical guideline- recommended treatment.
We are optimistic that the coming year will see a strong upturn in the number of rehab placements across the country, made possible by the government’s commitment to invest a further £80m in drug services in addition to the existing budgets available to each local authority. The sector has received this news favourably on the whole, but there is a collective appreciation that this represents a good start rather than a solution. The funding falls far short of the £900m across three years reportedly recommended by Dame Carol Black, and represents only half of the £160m cut from drug treatment services in the last decade (DDN, February, page 4).
The spending review in which the new funding was announced took the cautious approach of outlining the spending for just one year in light of the ongoing pandemic. It is hoped that a more robust commitment over a prolonged period will follow to give the sector some security when putting long-term plans in place.
There is, rightly, a focus on stigmatising language in the sector. Language frames the way we think, and while non-judgemental language is important to reduce stigma, it’s equally important that we consider the subtle use of language that disempowers, judges and marginalises the people who use our services. Here are some of the common arguments we hear to justify the de-funding of residential services:
There’s no demand
This simply isn’t true. When we speak to people desperate for rehab, we’re told they have had to ‘fight’ and ‘beg’ to even be considered for a placement. We know the lack of demand is due to lack of awareness, and that is understandable – why would frontline treatment staff make people aware of a treatment option that isn’t funded? The ‘no demand’ argument places the blame firmly on the people seeking treatment. It sounds like a simple statement, it passes in conversation as if it offers some form of insight, but it is just blatant victim blaming.
Rehab’s too expensive
People with multiple needs require more comprehensive treatment – this is true in almost all forms of healthcare. The ‘too expensive’ argument is nothing more than a moral judgement and the subtle implication is that some people are worth more than others.
We can’t put everyone in rehab
This is one we hear often, and often where there is no suggestion that rehab is for everyone. Behind it is a classic use of passive language that creates an image of people waiting to be put somewhere, like pieces on a chess board.
Rehab is not right for some people
The UK clinical drug treatment guidelines make it clear who rehab is most likely to be suitable for, and this statement deflects from the reality of rehab being underutilised by subtly implying that the treatment on offer would be ineffective for those who miss out anyway.
Rehab providers should do more to market their services to funders
A seemingly innocuous statement, but behind it is the implication that defunding is always someone else’s problem and not a systemic issue.
All these statements feed a narrative that addiction is fixed, that addiction is a choice, that people can’t or don’t want to get better, that people are passive and helpless. The combined message is ‘it’s your fault that you are not well and you are not worthy of help’. If we are to improve treatment access for people with multiple health and social disadvantages we need to confront this subtle stigma-driven language. We need to return to the simplest of concepts, namely that people should be made aware of all treatment options and that health is a human right. The NHS was on the principle that good quality healthcare should be accessible regardless of wealth, but people with mental health and addiction treatment needs are still waiting for that to ring true.
The continued underfunding of the sector means that every year more and more people are excluded from rehab. If we are to make the most of the possibility of a genuine end to austerity for the treatment sector we must address the subtle stigma that shames and blames people seeking help, and move on from a funding-led approach, not just to a demand-led approach, but to a rights-led approach to healthcare. The Care Act, Equality Act and Human Rights Act offer rights to people with mental health and addiction treatment needs, and we sincerely hope that the Dame Carole Black report will support the upholding of those rights.
Rehab can be fun despite being tough
Behind the stigmatising views that often exist lie groups of happy, positive and motivated people working hard and committed to overcoming a multitude of problems. Photos courtesy of Phoenix Wirral residential rehab.
Simply cutting off the supply of benzodiazepines to people who’ve been prescribed them for years is far from appropriate, says Bill Nelles.
Winter is almost over, but here in Qualicum, British Columbia (BC), we tend to be like the animals around us. We hibernate from November until mid-March, when we hear the roar of the tree frogs calling out for mates in our local pond.
We have a saying here, ‘Don‘t poke the bear’ – aside from its obvious meaning as a wilderness warning it also means avoiding a discussion of something that is controversial and likely to end in arguments. I heard this expression for the first time last year on a Zoom call with the BC Provincial Opioid Task Force. Benzodiazepine (BZ) policy for people on opioid agonist treatment (OAT) was on the agenda but time was running short. As we moved to the last item one of my colleagues drily observed, ‘I’m not poking the bear when there’s only 20 minutes left’.
Bill Nelles is an advocate and activist, now in Canada. He founded The (Methadone) Alliance in the UK
The bear here is, of course, prescribing benzodiazepines to people who are on opiate agonists for their opioid use. So I’ll start with three clear statements: benzodiazepine use increases drug-related poisonings and mortality when taken in quantity with alcohol or opioids; these risks start to increase as you get older, so avoid excessive use; and, it is reasonable for doctors to decrease your dose.
And sincere congrats if you have done the stopping or helped someone else to do this.
But things can go too far. Four years ago we adopted a strict no benzo policy – actually prohibition – for people on OAT in this province. Doctors face serious misconduct proceedings for stable dose prescribing except in end-of-life care, and prescriptions are reviewed through a real-time network called Pharmanet so concurrent prescribing is flagged. Only tapering is permitted, as long as it is reasonably fast. This policy came in rather suddenly, and some doctors have tried hard to contain the deep distress that this caused to many patients.
But the key word here is excessive. For more than 50 years, BZ drugs have been a much safer alternative to barbiturates and other stronger sedatives. Taken on their own, they are remarkably safe. And they were often thrown at users – and I do mean scripts thrown across the doctor’s desk – as ‘shut-up’ pills by doctors who wouldn’t provide OAT.
It’s also been forgotten that BZ drugs are specific anti-anxiety and hypnotic medicines. They are not anti-depression drugs like SSRIs, although these have now become the ‘go to’ drugs for anxiety, which is not quite the same as depression. More problematic is the use of atypical anti-psychotics such as quetiapine ‘off-label’ as hypnotics, despite the manufacturers’ warning that they should not be used as sleeping medications.
Some of you will already have read about a programme in Scotland to provide access to genuine benzodiazepines as ‘safe supply’, led by no less a figure than Professor Roy Robertson – widely known as the Scottish doctor who, in a seminal study in the Lancet in 1985, alerted the UK to the high levels of HIV among injecting drug users in his Edinburgh practice. I think this is a reasonable response to current circumstances, but we can’t do it here – yet.
I can live with a policy of reducing their use in general, but people prescribed these drugs for years who cannot live without a small amount should not be cut off. By all means don’t start people on them, but have a care for those who cannot stop them and who are now purchasing toxic fakes instead. Absolute bans are rarely appropriate, tempting though they may be. Leave some wiggle-room for those who are suffering and avoid our approach.
Behavioural couples therapy for alcohol dependence can both strengthen relationships and reduce problematic drinking, says Kate Thompson.
Although behavioural couples therapy has been recommended in NICE guidance since 2011 for ‘harmful drinkers and people with mild alcohol dependence who have a regular partner who is willing to participate in treatment’, counselling and therapy that focuses on the couple and parental relationship has never formed any significant part of the alcohol treatment service landscape.
In 2009 Tavistock Relationships was commissioned by the NHS to develop a couple-based treatment for depression – known as couple therapy for depression or behavioural couples therapy – a talking therapy which year-on-year achieves some of the highest rates of recovery from depression and anxiety within IAPT (improving access to psychological therapies) services nationally. So, when the ‘children of alcohol dependent parents’ funding stream was announced by the Department for Health and Social Care in 2018, we were keen to take on the challenge of delivering training to practitioners in behavioural couples therapy for alcohol dependence (BCT-AD) to see whether this treatment could be introduced and embedded into existing treatment services.
Kate Thompson is couple psychotherapist at the Tavistock Centre for Couple Relationships
To this end, in 2019, Tavistock Relationships delivered a total of three sets of training – in Leeds, Bristol and London – to 29 practitioners from a range of professional backgrounds including counsellors and drug and alcohol workers. We then supervised these trainees as they set about identifying suitable couples experiencing alcohol dependence who would become their ‘training cases’, over a period of eight to 12 months.
Playing to Strengths
As with couple therapy for depression, a basic premise of BCT-AD is that the strengths of the couple relationship can, wherever possible, be utilised as a resource to enable positive change, leading to either improvement in mental health or reduction in dependence on alcohol. The model also explores with the couple the possible functions of the drinking within their relationship and what it enables and disables between them. By reducing damaging interactions, BCT-AD aims to build emotional openness and closeness between the couple, improve communication and behaviour, and help the couple cope with the ordinary and not-so ordinary stresses that arise without such a high degree of dependence on alcohol.
So, how did our trainees get on? And to what extent can we feel confident that we have made inroads into changing the way that people in alcohol treatment services are treated? All practitioners on the training recognised that this way of working addressed a gap in their expertise, and while changing the focus of their work to think about the couple relationship presented a number of conceptual and practical challenges, the practitioners were all very positive about what was essentially a new way of working to them. So far, so good.
Difficult deliveries
The difficulties that our trainees faced in actually delivering BCT-AD to clients subsequent to the training, however, were many and various. The pandemic didn’t help matters, of course, with some trainees finding couples that they had begun to work with face-to-face not wanting to continue their sessions via Zoom, and some services simply not being able to function during the lockdown periods.
Some practitioners found it was difficult to identify couples who were suitable for this approach – either because the assessment process unearthed issues around domestic violence which would have made delivering this therapy too risky – or, more commonly, because the alcohol treatment service simply wasn’t set up or commissioned to work with couples. As we progressed, service managers began to identify important sources for future referrals, such as social care or probation services, but needed more time to establish these.
Additional challenges included the precarious nature of the services in which the alcohol practitioners were working, with funding being withdrawn from many and several subsequent redundancies or resignations among the cohort of people that we trained, as well as the relative lack of clinical training for practitioners working in this sector. Taking on board and incorporating skills around working with couples presented a significant issue for some trainees – as one of our supervisors observed, many felt that such was the focus on the individual within their services that they had to effectively generate a completely new pathway to make a success of this new way of working.
Emotionally closer
On the positive side, many BCT-AD trainees have found that the couples they worked with benefited from this approach. One couple, for example, said some way into the therapy that their sexual relationship had resumed as a result of the work they were doing together (they had been too ashamed to admit it had been nonexistent before), their depression and anxiety had reduced, and they were finding space and time to do things together as a couple. According to practitioners, other couples became emotionally closer and more open and more empathically attuned to one another, calming the atmosphere at home – which their children had begun to notice.
New challenges
In conclusion, this pilot project was positive, but presented services and practitioners with challenges, and it’s too soon to say how successful the project’s ambition to provide an alternate way of reducing alcohol consumption by improving the couple relationship has been. We are buoyed by the fact that while the alcohol treatment service of one of our trainees was decommissioned during the time period of this project, that person is now working in the NHS as an addictions practitioner helping to design services for people with dual diagnosis and has ambitions to include behavioural couples work in that service’s care pathway. So the legacy continues, albeit in a small way, and we hope that more services will appreciate the value that working with couples can bring to the lives and experiences of people struggling with alcohol dependence.
To find out more about this project and about behavioural couples therapy for alcohol dependence, contact Kate Thompson at kthompson@tavistockrelationships.org
With You launches first easily accessible ‘find a needle and syringe’ service to address escalating safety concerns sparked by the pandemic.
Needle and syringe services operate out of a range of spaces including pharmacies, drug and alcohol treatment providers and other services.
With drug related deaths in England at record levels, drug, alcohol and mental health charity With You is launching the first easily accessible service to find needle and syringe exchanges, in a bid to help people who use drugs stay as safe as possible during the pandemic and beyond.
The tool, which can be accessed via With You’s website, is the first search engine where people can find information solely about their local needle and syringe services in England, with advice about how to reduce harm.
Needle and syringe services have operated in the UK since 1985. They operate out of a range of spaces including drug and alcohol services, community settings, pharmacies and homeless centres and services. People can pick up fresh equipment used when taking drugs, such as needles, as well as the opioid overdose reversal drug naloxone. People can also deposit used equipment, meaning it isn’t left on the streets. Staff who work in needle and syringe services also regularly give out potentially lifesaving advice to help people reduce harm, while studies have shown they are effective in helping people access drug treatment and in reducing the spread of bloodborne viruses like Hepatitis C.
At the same time, With You is also releasing a host of online, diagram based harm reduction advice to encourage people who use drugs to do so more safely, including advice on how to use the opioid overdose reversal drug naloxone, how to inject drugs in the safest way possible, what to do if someone overdoses and advice for safer steroid use.
Laura Bunt, Deputy Chief Executive at With You
Laura Bunt, Deputy Chief Executive at With You said: ‘When we first went into lockdown, our data showed the number of people visiting pharmacies or specialist services for new syringe packs was down by 50%. We were concerned as this may mean many people were re-using equipment and not getting advice to help reduce the risk of harm. We know people are much more likely to use drugs alone at the moment due to social distancing measures, meaning there is less likely to be someone else present to call the emergency services if something goes wrong.
‘Our research has shown that people really value needle and syringe services but aren’t sure what is and isn’t open at the current time. Our new find a needle and syringe service can help many more people access the equipment and support they need, while our new online advice will help keep them as safe as possible.’
‘We know people take drugs. We don’t condone it, but nor should we bury our heads in the sand. Drug related deaths are at record levels in the UK, while the enforced isolation of the pandemic has been really tough on some people, with drugs offering an escape. This is about following the evidence of what works while treating people who use drugs with compassion.’
Richard Townsend, a volunteer at With You in North East Lincolnshire, said: ‘When I was using drugs, needle and syringe exchanges were so important. Going into a pharmacy can be very transactional; you go in, get your medication and leave. In a needle and syringe exchange it’s much more personal. It’s not just a space to pick up fresh equipment, you develop a relationship with the staff who give really good advice on how to stay as safe as possible when using drugs. It’s also often the first step on the road to accessing treatment.’
‘With the restrictions of the pandemic it can be really hard to know what’s open and what isn’t. At the same time the enforced isolation has led to more people using drugs on their own, so I think this new needle and syringe exchange finder will be really helpful for a lot of people.’
We Are With You’s needle exchange finder is available here
DDN magazine is a free publication self-funded through advertising.
We are proud to work in partnership with many of the leading charities and treatment providers in the sector.
At the start of the coronavirus pandemic, Change Grow Live quickly adapted services to keep people safe.
We needed to listen to the people who used our services to make sure these changes were working, so in June, we launched our Pulse Survey.
Over the last 12 months, 4000 people across the country told us about their care and how we can support them better. We’ve created a Year of Listening timeline showing the key moments throughout the pandemic to share our findings.
The timeline details what we’ve heard, how we’ve responded, and what we’ve learned during this challenging year.
The Royal College of Psychiatrists (RCPsych) is calling on the government to invest more than £40m in young people’s addiction services to ‘prevent lifelong addiction’.
Most young people accessing services do so for cannabis use
The number of young people in treatment has fallen by 40 per cent since 2014-15, it says, with funding cut by 37 per cent since 2013-14.
Eight of the nine English regions have made ‘real terms cuts’, the college’s analysis says, with London losing £4.6m, the West Midlands £7.6m and the North West more than £9m, part of an overall total of £26m cut since 2013-14. Meanwhile the number of young people accessing treatment across the period from April to January has dropped from almost 15,000 in 2014-15 to just under 9,000 in 2020-21, although the college acknowledges this year’s figure could have been worsened by the pandemic.
Most young people accessing services do so for cannabis use, while almost half have a problem with alcohol – in 2018-19 there were more than 40,000 alcohol-related admissions among the under 24s, over a quarter of which were for mental and behavioural disorders due to alcohol use.RCPscyh wants to see £43m of funding for local authorities allocated urgently to ‘bring spending on youth addictions services back to at least the 2013/14 level’ – equivalent to 2.4 per cent of public health spending.
‘These cuts risk condemning a generation of vulnerable young people with drug or alcohol problems to a lifetime of dependence and poor health, or in some cases, an early death,’ said vice-chair of RCPsych’s addictions faculty, Dr Emily Finch. ‘It’s completely unsustainable and unbelievably short-sighted. We need to wake up to the fact that money spent on addictions services saves the NHS a whole lot more in the long run, whether that’s in A&E or in other mental health services. On top of all this, the pandemic has made a dire situation even worse, as even more young people have been left unable to access services.’
I constantly ask myself what I have learnt from the COVID crisis. This blog outlines my reflections as a CEO on how I have helped Humankind manage the ‘unprecedented’ context brought about by a global pandemic.
Humankind and I have learnt so much and we want to take this learning into the future. I look back on the last year with a huge sense of pride in what we have achieved.
It’s the one-year anniversary of COVID and a good time to pause and reflect on the last year. It has been the most challenging of my working life. Believe me, I have had some challenging ones. We were faced with the worst of scenarios, both as a country and planet and in our communities, homes, and workplaces in the UK. Two weeks before COVID and lockdown we were still not really talking about the pandemic or its implications, at work or anywhere else. In just a week this changed dramatically. I spent this week, before lockdown, travelling to and from London, and we all felt on the edge of a crisis.
Homelessness and unstable housing are associated with a ‘substantial’ increase in acquisition risk for both HIV and hepatitis C among people who inject drugs, according to research by the University of Bristol.
Recent homelessness or unstable living circumstances meant a 55 per cent increase in HIV risk and 65 per cent for hep C risk, researchers found.
Worldwide, an estimated 22 per cent of people who inject drugs reported experiencing homelessness or unstable housing within the last year, with the figure for England standing at 42 per cent. Of the estimated 15.6m people globally who inject drugs, more than one in six are thought to be infected with HIV and more than half with hep C. The study, which was carried out by the University of Bristol’s NIHR Health Projection Research Unit in Behavioural Sciences and published in Lancet Public Health, is the first systematic review and meta-analysis of the link between BBV risk and homelessness, and combines data from 45 previous studies.
Homelessness and unstable housing mean people are less likely to access both harm reduction measures such as needle exchange or substitute medication and HIV or hep C treatment – they are also more likely to have recently been in prison and to engage in higher-risk injecting behaviour. According to the Homeless Link charity, 30 per cent of the homeless population report last-month use of heroin.
Housing interventions for people who inject drugs should ‘address their competing health and social concerns’, the study says, while access to HIV and hep C prevention and treatment needs to be improved. The response to the COVID-19 pandemic – which saw many countries quickly provide safe and secure housing for homeless people – demonstrates that ‘dramatic, if only temporary, changes are possible if there is the political will’, it adds.
‘Our study highlights the overlapping bio-social problems that worsen health inequalities among homeless people who inject drugs,’ said lead author Chiedozie Arum. ‘Expanding access to prevention and treatment services and improving housing provision for this population should be prioritised.’ ‘This research adds to the growing evidence on the damaging effect of housing instability on health and social outcomes,’ added professor of infectious disease modelling at the University of Bristol, Peter Vickerman. ‘A comprehensive policy approach that not only provides housing but also addresses many of the interlinked health and social concerns of this population is necessary in order to reduce HIV and HCV risk.’
Smokers in England will need help with everyday tasks including ‘dressing, walking across a room and using the toilet’ ten years earlier on average, according to a new report from ASH.
While current smokers and people who quit within the last ten years are more likely to need support with all activities than people who have never smoked,they are ‘particularly likely to need support with relatively time consuming, fundamental activities’, says the report, such help with dressing and undressing, having a bath or shower, or getting in and out of bed.
The annual cost to the country’s budget for home and residential adult care is around £1.2bn, the document adds, with more than 100,000 people thought to be receiving local authority-funded care as a result of smoking – 17,500 in residential care and 85,000 in their own homes. While the figure is around 8 per cent of the annual budget for home and residential adult care, it is half of the additional £2.5bn annual cost to the NHS.
Overall, more than 1.5m adults have social care needs as a result of smoking, it says, with more than 1m receiving unpaid care from partners, relatives or friends and 450,000 receiving no support at all. Smokers are 2.5 times more likely to have unmet care needs than people who have never smoked, and 2.7 times more likely to receive unpaid social care support.
Smoking remains England’s leading cause of premature and preventable death, killing almost 75,000 people in 2019. ‘For every person killed by smoking, at least another 30 are estimated to be living with serious smoking-related disease and disability,’ says ASH.
‘This report reveals the shocking extent to which smoking damages the quality of people’s lives, and of those around them, before going on to kill them prematurely,’ said ASH chief executive Deborah Arnott. ‘On average smokers need social care at 63, ten years earlier than non-smokers, so if the government truly wants to extend healthy life expectancy by five years by 2035, ending smoking is a priority. However, achieving the Smokefree 2030 target won’t be easy and requires investment at a time when the government has a massive budget deficit. Tobacco manufacturers on the other hand remain extremely profitable and should be made to pay a levy on their sales as they do in the US, to help make smoking obsolete.’
‘Public health funding has not kept pace with funding for the NHS and this must change if local government is to play a full role in improving the health of the nation,’ added chair of the Local Government Association’s Community Wellbeing Board, Cllr Ian Hudspeth. ‘The forthcoming spending review must be the moment to put public health and social care on a sustainable footing so that councils can continue their vital work in supporting, promoting and improving people’s wellbeing.’
One year on from the first lockdown we are all reflecting back on the year we have just been through.
Our lives have changed so much from how they were in a myriad of different ways with many of us having lost loved ones or facing hardship as a result of the pandemic. The impact on the health and social care sector has been huge.
For a whole year now, health and social care workers have been at the frontline of the crisis facing our country, for this they deserve our undying gratitude. This period has been incredibly difficult but it has also allowed us to learn a lot. I personally want to thank every single member of staff at Turning Point who have continued to work tirelessly in highly challenging conditions since March 2020.
We will use this anniversary to look back at what we have achieved and to reflect on how we can build on our learning and experience to continuously and creatively improve our service delivery to support better outcomes for more people.