Local authorities will receive £10m in cold weather payments to help keep rough sleepers safe over the winter, the government has announced, with an additional £2m earmarked for faith and community groups to provide emergency accommodation.
The money is ‘on top of over half a billion pounds the government is already spending to tackle homelessness and rough sleeping this year alone’, says the Ministry of Housing,Communities &Local Government.
Comprehensive guidance, produced in partnership with PHE, Homeless Link and Housing Justice, will also be issued to the homelessness sector to support shelters to open more safely, providing communal facilities only if there is no alternative. ‘As we approach winter, we are focusing on the best way to protect rough sleepers from the cold weather and coronavirus,’ said communities secretary Robert Jenrick. ‘The funding and guidance I’m announcing today will mean that working with councils and community groups, some of the most vulnerable people in society are given support and a safe place to stay this winter.’
Crisis chief executive Jon Sparkes, however, stated that the money falls short ‘of the bold action we need’ to keep people safe. ‘Back in March the government rightly decided that night shelters and hostels were not a safe environment for people during the pandemic. It’s completely unacceptable that this approach should now change as we go into winter when the threat remains the same. We must not force people to choose between freezing on the street or a shelter, when both needlessly put lives at risk.’
The government needed to provide local authorities with the money to ensure everyone forced to sleep rough has access to safe, self-contained accommodation as happened in March, he stressed. ‘Anything but this is risking lives. We urgently need the government to see sense on this matter and keep winter night shelters closed.’
Crisis chief executive Jon Sparkes – the money falls short ‘of the bold action we need’ to keep people safe.
Crisis is one of 18 health and homelessness organisations – including the BMA and royal colleges of physicians, GPs and psychiatrists – to write an open letter urging the government to provide suitable alternative accommodation due to the high risk of COVID transmission in night shelters. ‘Housing is a social determinant of health; living on the streets or without a stable home makes you more vulnerable to physical illness, poor mental health and drug and alcohol problems,’ it says. ‘These health inequalities, with the added health impacts of coronavirus and the cold, mean that failing to protect people in unsafe living conditions over the winter months poses a grave risk to life and will place an enormous and avoidable pressure on the NHS.’
The exploitation involved in ‘county lines’ is an urgent call for action, as DDN reports.
Read the full article in DDN magazine
The brutal killing of a 16-year-old boy shook his community in Shropshire. How had this happened on the streets of Shrewsbury? As the investigation began, a picture emerged that took all of the support services by surprise.
Michael had been living in the county, miles away from his home in Merseyside, for 18 months. Not only was he hidden from sight; his life had been taken over – and ended – by a drug dealing network that has become known as ‘county lines’.
‘What we uncovered was a turf war battle between two gangs,’ says Sonya Jones, service manager and safeguarding lead at We Are With You, Shropshire. ‘Michael was killed as part of a turf wars gang.’ In the days that followed, Jones and her colleagues discovered ‘many active lines’ in the county: ‘It changes on a regular basis – between ten to 20 lines are running actively at one time in Shropshire. As soon as one is taken out by the police, another one springs up,’
‘Youth justice is set up to work with perpetrators – but what we know is that these children are not perpetrators, they are actual victims of crimes themselves. They are victims of modern slavery.’ Sonya Jones
The term ‘county lines’ was coined in 2015 and has become recognised as a business model. County lines evolved as a result of market saturation, where gangs from London, Manchester, Birmingham and Liverpool began to work out of regional markets, says Jones. Children are used because they are an ‘easily controlled and quite an inexpensive resource – often referred to as Bics, as in Bic razor, because they are so disposable’.
The business model is built on exploitation – of vulnerable adults as well as children. Properties are taken over, or ‘cuckooed’, and the young people are used to ‘run’ the drugs, travelling between urban and county locations to replenish stock.
Recruitment usually takes place using free or extremely cheap cannabis, to entice children into the gang. The grooming starts at about 13, and many of the children are previously unknown to services, explains Jones. Before they know it, they are ensnared by debt bondage – a police ‘stop and search’ or a fake robbery removes £60 worth of cannabis – and they are trapped in the gang, ‘modern day slaves’.
‘Gangs are always looking at ways to keep them within their control and power, dehumanising their thoughts about the adult service users who they would be selling to,’ she says. ‘Once they are in debt bondage, the distribution of class A drugs really takes hold and the children have no control of anything.’
Some of these children are ‘vulnerable’ – young people with complex mental health needs, with ‘looked after’ status, excluded from school, or experiencing poverty and family breakdown. But equally, it can happen to anyone’s child.
‘I spoke to a father yesterday who had paid off two thousand pounds of a drug debt to a gang,’ says Jones. ‘His son is 16, an A level student who started smoking cannabis. He was offered free cannabis to sell to a friend, took that opportunity, and has ended up in debt which his parents have paid off.’
Over the past few months, however, COVID has changed the business model. A heightened police presence has prompted the 16- and 17-year-olds who have become quite well known to local police – and who are still in debt bondage themselves – to recruit younger children of 12, 13, 14, to do the drug running. ‘County lines are becoming increasingly hidden,’ says Jones, with many young people being moved around the county under the cover of darkness.
Dr Paul Andell, senior lecturer in criminology at the University of Suffolk, is in a position to give further insight into gang culture, having interviewed young people and gang members in three regions, on six sites, over ten years, and undertaken numerous policy reviews.
Clacton, Essex, 6 February 2020. Essex Police execute county lines drug dealing search warrants across Essex and London, resulting in a number of arrests and seizure of class A drugs and cash. Credit: Ricci Fothergill / Alamy
The transition of some gangs from ‘street-based collectives’ to organised crime networks has raised important safeguarding issues, he says, where young people are both perpetrators and victims of crime.
‘Young people were committing horrendous acts on each other and there was a culture of violence emerging because globalised gangster culture was playing its part on how people should behave, mediated of course through social media,’ he says. He mentions scaldings with sugared water, slashings which were videoed, and people being bundled into the boots of cars and kidnapped.
The workforce has a structure, with junior members kept in check with ‘symbolic violence’ – they are given a beating, and everyone gets to know about it. If somebody robs the line or encroaches on custom, it becomes more extreme. ‘We’ve seen an increase in these violent acts,’ says Andell.
Lethal violence is prompting many of the ‘smarter’ kids to leave the drugs business, which leaves ‘a pool of more vulnerable young people’ taking their place. The incentives are social capital, bonding, a need to belong and be part of a family and a social network, he says, as well as ‘the promise of a glittering future in the drug-dealing world, the promise of riches’. Coming from a background of social exclusion can increase the odds, when ‘young people might not make it in the legitimate economy, so they try their luck in the illegitimate economy’.
His research matches Jones’ experience that cannabis is usually the access drug: ‘Cannabis markets are the talent pool,’ he says. ‘If you can be trusted in the cannabis market, you can be trusted in the class A market.’ The other element is the ‘boyfriend model’, which involves young girls through ecstasy: ‘The girls think that the perpetrators are their boyfriends and often this happens in a party setting, hence the high level of party drugs used by the young females,’ says Jones.
Dame Carol Black’s Review of drugs (DDN, February, page 4) talks of young people and children being pulled into the drugs supply on an alarming scale, especially at the most dangerous end of the market. This very violent business model earns profits of more than £800,000 a year from an individual line, she says, with ‘the rise in the county lines business model a major factor in increased drug-related violence’.
Much of this chimes with The Lammy review (September 2017) and its recommendations for the youth justice system. Joining the cross-party parliamentary group discussion, shadow justice secretary David Lammy said there was nothing new about adults recruiting young people into organised crime.
‘When we talk about these young people caught up with knives and drugs, the poverty and austerity that led them into that, we must realise that this is nothing new – it’s old. All you need to do to understand that is to read Oliver Twist.
‘Until we get serious about dealing with organised crime – and resource it – we’re not going to crack the problem,’ he added. This meant reforming prison and probation systems, because ‘recidivism rates are the worst in Europe. There’s something not working when there’s a cycle of crime and people are committing crimes over again and the system is not rehabilitating them.’
While waiting for national strategy reform, there is also much that can be done to improve knowledge locally with stakeholders, says Anders. There needs to be ‘a focus on situational and social prevention – interventions which bring about neighbourhood improvement’ and eradicate childhood poverty, ‘because many of the young people involved in county lines come from relatively deprived neighbourhoods’. Social and agency interventions need to move away from incarceration – ‘those recruitment grounds for gangs’ – and towards community supervision and peer-led work.
Just as Shropshire’s services learned from the shocking case in their county, there are important lessons for all concerned with youth justice and safeguarding. ‘We need to re-examine the traditional victim-perpetrator dynamic because it’s more complex than that,’ says Anders, and has ramifications for training and practice across all the services.
Supporting the ‘absolutely crucial’ multi-agency approach, Sonya Jones points to the ‘quite unique’ role of substance misuse services in having the knowledge and expertise to work holistically and without judgement.
‘We are not social services, we are not youth justice, we are a service where young people feel that they want support… we become their advocates,’ she says. ‘Youth justice is set up to work with perpetrators – but what we know is that these children are not perpetrators, they are actual victims of crimes themselves. They are victims of modern slavery.’ DDN
Discussion in this article took place at the latest Drugs, Alcohol and Justice Cross-Party Parliamentary Group on county lines, gangs and youth justice.
Picture credit, top photo: 28 February 2020, London. British Transport police in operation as part of operation Sentinel, tackling drug crime. Credit: Paul Iwala / Alamy
Giving families a clear and consistent route to help makes all the difference, as DDN reports.
Read the article in DDN Magazine
‘When you work with families in an uncoordinated way and you’ve got lots of different professionals trying to address issues separately, it doesn’t work,’ says Teresa Leitäo, senior policy advisor at the Troubled Families Programme. ‘It’s very overwhelming for the family and can be quite ineffective for the services involved.’
Contributing to a ‘parental alcohol and drug use’ webinar, she shared experience from the programme, which had been designed to support families with multiple vulnerabilities – mental and physical health problems and other interlinked issues.
‘…you’ve got lots of different professionals trying to address issues separately, it doesn’t work.’ Teresa Leitao
Services needed to work together to make referral procedures easy, spot problems early on, and put the right support in place as soon as possible, she said. This coordination would make it easier to measure data and track outcomes, and make sure that the right services were involved – including bringing together the ‘two worlds’ of family guidance and substance misuse support.
Discussing adverse childhood experiences (ACEs) had resulted in some strong partnerships, said Sheena Carr, deputy head of the Children, Young People and Families Team at Public Health England. But we needed to consider that ACEs ‘sit within a broader context of vulnerability’. A public-health informed approach was helpful in looking at causes of inequality and circumstances where activity should be prioritised, she said, and making sure children had supportive networks around them was important in helping them to deal effectively with stresses they might encounter at home.
Dr Wulf Livingstone, reader in social science at Wrexham Glyndwr University, talked about multiple vulnerabilities which often overlapped – child protection relating to substance misuse, domestic abuse and mental health. Issues such as school exclusion, food poverty and the responsibility of being a young carer – with maybe a parent that is entering end of care through drug and alcohol use – were bound to have an impact.
Often it was impossible to determine where the starting point was, or the trigger, and ‘it’s probably not helpful to look for whether or not one causes the other,’ he said. But we could be sure that ‘merely the stopping of substance use in itself is never really a solution… if that’s all we concentrate on we will probably just return people to the very difficult situation that they live in without a coping mechanism.’
Strength-based interventions were vital instead of ‘negative, deficit-based conversations’, with screening tools used whenever possible. The other really important element – as the previous speakers had said – was to work inclusively with the entire family, even if work took place independently with different members. Putting this time in would help to kick-start the appropriate interventions and identify the ‘practical day-to-day barriers’ to progress, such as no food on the table or a leaky bathroom – things that needed to be solved to create the capacity for change.
The recurring conversations about a ‘multi-agency approach’ were frustrating, he added. After all the reports that had been produced, ‘it shouldn’t really even be a conversation anymore’. We were still having people being referred to as ‘hot potatoes’ and still having families experiencing 18 hours from 18 agencies instead of 18 hours of interventions from one or two workers and agencies. Good communication should be coupled with ‘greater levels of respect between agencies and disciplines’ to bring about holistic family interventions, he said.
The Building Bridges project in St Helens, Merseyside, shared some techniques from their programmes working with families. James Mawhinney and Kayah Woods of the social work team at Change Grow Live explained that they focused on ‘behaviour and behaviour change as opposed to specific substances, because that allows us to address a realm of issues.’
One effective tool was to use the Simpson family (the Matt Groening animated sitcom) to help people understand the roles played within the family relating to addiction, as it was much easier to talk about a family other than their own. Homer was the person experiencing addiction, with the other family members feeling powerless to make any positive change themselves. Marge was in the ‘enabler’ role, while trying to hold the family together; Bart was the clown, deflecting attention from the addiction; and Maggie was the lost child, left in the background.
Talking in this way had helped families with extremely complex needs to understand their situation and the perspectives of others in the family, and talk about what support they needed. The programme was achieving very positive results in improving family relationships, giving children the confidence to engage with school again, and helping adults to stop their alcohol use.
A key part of this success was the positive focus on a strength-based approach, which was cancelling out feelings of shame and stigma. Lesley Davies, senior manager in prevention and early help at North Tyneside Council, added to this by explaining positive progress of the Bottled Up project. The North East’s drinking culture meant the area had a reputation as a ‘party capital’ and North Tyneside had ‘the lowest number of abstainers in the North East’, so they wanted to work with a wide variety of partners, including the voluntary sector, to see what they could do differently.
The initiatives that were rolled out aimed to get people talking about alcohol, particularly in families, and enable children to be more open about it instead of feeling they had to hide it. A ‘whole systems pathway’ for North Tyneside included different training packages to include the whole workforce, from brief interventions to a more specialist approach.
Where there were problems relating to drugs and alcohol, the aim was to identify them early and use a strength-based approach with the family, ‘helping them identify what they can do to move on and change things.’
‘…merely the stopping of substance use in itself is never really a solution.’ Dr Wulf Livingstone
Getting to the stage of using evidence-based interventions effectively depended on workers going out to meet the family within the community and forming a team around them from the beginning – a team with ‘a really creative and flexible approach’. ‘We have had some parents that hadn’t engaged in programmes and treatment before,’ said Davies, so going out to do work with them in the community had had ‘a huge impact’.
The situation around COVID had obviously brought challenges with the lockdown restrictions, particularly as there had been no let-up in referrals. But it had also brought opportunities in reaching vulnerable children, as many of them enjoyed having online diary sessions and had started ‘really engaging and getting their voice across’. It had given an opportunity to talk to someone during lockdown about their parents’ drinking, ‘and also to be able to talk to other people of similar ages who are going through the same thing,’ she said.
One of the main themes to emerge from the session was that there was evidence-based practice to implement and no shortage of expertise throughout the health and social care sectors. The challenge was to streamline the approach to the family so they could take one step, then the next, with a consistent professional partner.
The webinar, ‘Children of alcohol dependent parents’, was held by Public Health England. Resources are available at the Innovation Fund Knowledge Hub: www.khub.net/group/parental-alcohol-and-drug-use
While it may be nominally legal, medical marijuana needs to be far more easily available and its use encouraged by treatment services, says Nick Goldstein.
Nick Goldstein is a service user
The curse of COVID makes writing about substance misuse treatment virtually impossible. Not only has localism fractured treatment policy and practice over the years, but now COVID has completely overshadowed everything. Who knows what’s going to come out the other end? We’re seeing society unalterably changed and it’s happening at breakneck speed. Only a fool would claim to have an overview of this chaos and although I’ve been called many things, ‘fool’ was never one of them – yet, anyway.
Nil desperandum though, guys. There are some things that are so large that whatever happens with COVID they will make a significant impact on arrival, and one of those is medical marijuana.
Read the full article in DDN Magazine
Medical marijuana is the use of the cannabis plant and its derivatives for their healing properties. These medicinal effects aren’t exactly hot news. In fact we’ve been using medical marijuana for thousands of years – it’s mentioned in Chinese medical texts from around three thousand years before Christ put in an appearance. The list of ailments it can alleviate and treat is far too long to get into here but it includes many serious conditions and illnesses that really have no other treatments. Medical marijuana’s benefits are great enough for its use to be an accepted treatment in many countries – despite the demonisation and prohibition of cannabis for decades – and even America has seen the light and offers medical marijuana as a treatment choice.
Medical marijuana dispensaries are becoming common in the United States as individual states adopt laws legalising cannabis to treat medical symptoms. Credit: Bdingman, Peter Kim, Jonathan Weiss, Dmitry Tishchenko / Dreamstime.com
For those who’ve been living in a dark cave, marijuana was made available on prescription in the UK in November 2018. But before we all rush off to the doctor’s I should point out that – as is sadly far too often the case – our medical profession wimped out. I guess after all those years at medical school they’re reluctant to risk the ire of the tabloids and the BMA disciplinary committee and have consequently sat on their prescription pads and used the hackneyed excuse that there’s not enough evidence medical marijuana is worthy of treatment on the NHS. They’re right in that there is a shortage of research – drug companies believe medical marijuana will cost them money rather than make it. So, no money, no research and no research, no prescription – we’re back at square one. But to add insult to injury medical marijuana is now legal and available – in theory. You gotta love doctors. What was it, guys? Ah yes, ‘first, do no harm.’
And this deeply ironic state of affairs is how things have been stumbling along for the last couple of years – until recently. At the end of 2019 Professor David Nutt’s Drug Science started the Twenty21 project, the aim of which is to sign up 20,000 patients by 2021. Hopefully this will not only offer relief to the 20,000, but also provide the evidence to enable medical marijuana to be offered universally on the NHS whilst saving the medical profession from requiring a spine.
Carly Barton, a medical marijuana campaigner, has recently produced the ‘Cancard’ which would allow anyone stopped while in possession of cannabis to prove their cannabis was medicinal and not for recreational use and so avoid prosecution – an approach supported by none other than the Police Federation and National Police Chief’s Council. The Cancard aims to reach over a million people who will benefit from medical marijuana by November 2020.
One way or another, like it or not, medical marijuana will soon be a fully integrated medicine and then it’s going to come into contact with substance misuse treatment.
A civilised country with a good substance misuse system would see medical marijuana as a boon and encourage suitable users in need to access it, but we don’t have a good treatment system – and, to be honest, I’m not sure how civilised the country is these days. Anyway, it should be seen as a boon because medical marijuana could play several roles in treatment. Firstly, it can help in recovery. Apologies to all the NA crew, but it’s perfectly sane to encourage those in post-acute withdrawal to take marijuana to relieve the minor aches and pains and, more importantly, offer significant help with the psychological aspects of withdrawal.
Secondly, marijuana can also play a role for those on longer term maintenance treatment where it can be used in conjunction with OST to improve compliance. It’s also worth pointing out that after a decade of sub-optimal dosing many users are struggling on too low a dosage and quietly making the difference up with benzos and booze, which is the most dangerous drug combination out there. Marijuana offers a much safer alternative than central nervous system depressants for those desperately trying to maximise their under-prescribed dose.
On top of the specific benefits, service users are people too. So, all the general advantages that everyone else derives from medical marijuana also apply to them, and considering service users are an ageing group with a whole range of aches, pains and illnesses will only mean a larger intersection between service users’ needs and medical marijuana use.
So, medical marijuana will be a boon, right? Well, maybe – if service users are allowed to use medical marijuana, but that is by no means certain. Maybe I’m paranoid to question treatment providers’ approach to medical marijuana, but history suggests that while I might be paranoid, but they really are out to get me. I won’t be surprised to see treatment providers disapprove of service users also using medical marijuana. Let’s face it, many doctors, key workers and others have a negative, black and white view of drug use. So, perceiving cannabis as medication rather than kicks might be a step too far.
This has happened before. America is years ahead of the UK in regards to medical marijuana and many American substance misuse clinic users are prohibited from using medical marijuana. They face being booted from treatment (even if they pay for it) for using what is essentially a legal medication. I appreciate America is a different land but it would take a brave man to bet against the same blinkered approach happening in treatment services here.
In rising Spice use we already have an example of what can happen when marijuana is poorly classified, and its use punished rather than accepted and even valued. Personally, I’m going to use weed anyway, but as I age my reasons for using change and now I often use to relieve assorted aches and pains. It would be sensible, not to mention compassionate, to let me access medical marijuana legally and openly. To be clear, encouraging medical marijuana use for clients in need should be seen as best practice. Sadly, sense and compassion are in short supply these days.
THE PRESSURES OF THE PANDEMIC are diverting services into new ways of working, with plenty of energy spent adapting systems to ensure continuity of service. But this month’s cover story (page 6) is a reminder that drug dealing is also having to adapt its business model. And unfortunately the varying stages of lockdown have opened up new opportunities – and necessity – for exploitation.
Shropshire’s experience shows that there is no let-up in county lines activity, with lines changing and being replaced regularly. The only way we can tackle this violent and highly lucrative business effectively is by working closely with police and social services – and by realising that substance misuse services have a unique role to play in ‘working holistically and without judgement’ to help young people and vulnerable adults out of a trap that has become modern slavery.
Those young people – anyone’s child – at the receiving end of youth justice, are themselves victims of crime and need our support at this vital time. This could be the crossroads at which they are able to escape from a cycle of crime and get the support they need to leave this terrifying situation behind – and we have to do better than let them join an even bigger training ground in the criminal justice system.
Methadone can be a life saver, both metaphorically and literally. However, many heroin users do not welcome daily methadone consumption – it’s harder to get off than heroin and does not address trauma in the way that heroin does – it doesn’t hit the sweet spot. With methadone, withdrawals go on twice as long, it’s a nastier habit, it hooks you in deeper. Many users want methadone occasionally – it makes complete sense to them – but they must take it every day, or not at all. The treatment system demands it.
In contrast, I was diagnosed with ADHD some years back and after being prescribed Ritalin, I found that my daily dose of the long-acting time-release drug did not suit me, I didn’t want to be permanently medicated. My consultant told me that my prescription was appropriate for my condition and that I should continue with it. I told him that his job was to help me reach my desired outcomes, not have me comply with his regime. He relented, I received a mixture of short and long- acting pills of different strengths, and for many years I’ve used Ritalin at the dose I want and when I need it – I often have days off.
No substitutions
When I was a heroin user, there were times I received a methadone prescription. Like many of my peers, I did not want to substitute heroin for methadone – I wanted methadone for when I could not get heroin, so that I didn’t go into withdrawals. Heroin withdrawal generates a degree of physical and psychological distress that is all-consuming. I wanted methadone so that I did not do crazy things to get money, so that I did not inject other people’s old dried blood clots or crushed up pills, hoping for relief.
There was a time when I was prescribed methadone in a way that worked for me. I went to the chemist weekly to collect my take-home supply. Eighty ml a day was the prescription, and two or three times a week I took some. The unused methadone went into lemonade bottles and was kept under the sink. The dose was ‘a swig out of the bottle when needed’. Some methadone I gave to friends when they were stuck, some I sold to buy heroin or food, but that awful dread of withdrawal was gone – methadone was insurance.
My partner fell pregnant and, worried that her drug use may be reported to social services and risk having our baby taken into care, she disengaged from treatment. Her smaller methadone prescription was stopped. She cut down her heroin use and my methadone was sufficient to both keep her steady and give me an occasional emergency dose.
The service, however, grew increasingly concerned that my drug use was not reducing. My urine tests, when I gave them, were sometimes clean when I was able to manipulate the process – once or twice I would have shown up as pregnant myself – but too often heroin was detected. The service response was to increase my methadone dose to 90 then 100 up to 120ml a day. The service did not understand – and I was unable to say – that my prescription largely served a different purpose to my street drug use.
One day, collecting my script, I was called into a room and given the news that I was to be put on supervised consumption – my daily dose was to be consumed at the chemist watched by the pharmacist as I could not be trusted. Each day I was to consume 120ml of methadone that I did not want or need. My partner was now in trouble. I tried containers in the neck of my shirt to pour the methadone in while pretending to drink my dose, but it didn’t work and I left with methadone dripping down my clothes. The daily ritual humiliation did not last long – I disengaged with the service.
Using on top
Many years later, I was working as the service user coordinator for Camden Council in central London. The commissioners wanted to know why 30 per cent of those on methadone were using on top of their script. I took the question to the user forum, where 50 people with lived experience laughed. Taking a straw poll of raised hands, the majority thought the figure was more like 90 per cent. Reporting back to the commissioners, the issue was dropped – they could not be the first to reveal the emperor had no clothes.
The client wants to be well thought of and definitely doesn’t want to be punished with supervised consumption, so they under-report drug use. The worker wants to think they are doing well and to report success to their manager, so the under-reporting suits them. The service wants to report low drug use to the commissioners who in turn want to perform favourably compared to other areas. So, on one level, the worker says to the client ‘what’s the problem?’ and the client replies ‘I’m not going to tell you, and the worker says ‘great, I don’t want to know’. The therapeutic relationship is too often based on this agreement. I remember service users telling me that when asked for a urine sample, suggesting ‘next month might be better’ often worked.
Death is no deterrent
Methadone is a powerful drug. It is mentioned in significant numbers of drug-related deaths, but those numbers are lower than those mentioning heroin. Those not in treatment are more likely to die than those who are supported by a service, and methadone prescribing is the number one evidenced intervention in reducing drug-related deaths. Supervised consumption may be considered to increase safety, but it drives people out of treatment and prevents people from engaging. I remember a client who was cut off his script for missing three days methadone consumption at the pharmacy and was back on street drugs. He told me, ‘I can die, as long as I don’t die on their methadone.’
Supervised consumption may have a place in the treatment system, but it is over-used – a recent small study questioned how much safety it provides, and many more would consider engaging it if wasn’t a requirement. Methadone is diverted – it is not always the name on the prescription that gets the dose. It is not helpful to consider users as failing to comply with the regime, or showing they cannot be trusted, as too many workers and services do. It is traumatised people helping friends or coping as best they can with the daily emergency of battling withdrawals, anxiety, self-hatred, and the judgement of others.
A breathing space
Standing in the dock at court nearly 20 years ago, I feared the worst. The judge sentenced me to two years in prison, but before they could take me down, I swallowed the methadone from a bottle in my pocket that a friend had given me. I was not going into withdrawals alongside the shock of the sentence. It gave me breathing space before I was seen by prison healthcare the next day – methadone met my need perfectly.
There are some good services and drug workers. I like to think somewhere a user is saying to a drug service, ‘Your job is to help me meet my desired outcomes, not to get me to comply with your regime’, and the drug service saying, ‘Sure, how can we help?’
My son is happy and healthy and has just finished his first year at Bristol University. We rarely see his mother – she is still a chaotic drug user. Every now and then she engages with a drug service, but she cannot do the supervised consumption. Some days she is stuck in bed, some days she has enough drugs – she never lasts more than a week or two.
Leanne Smullen-Bethell is head of house at Phoenix’s National Specialist Family Service, where people can seek treatment for their substance use problems while staying together as a family. She tells us about her role.
Read the full article in DDN Magazine
I’ve worked here for 11 years. I have a passion for supporting people with addiction problems and the opportunity to work with mums and dads who are trying to overcome addiction really interested me.
The day starts by checking how the parents are feeling. We discuss activities for the day and arrange appointments. There will be a group session of therapy followed by lunch. The children will be cared for by our lovely childcare team whilst the parents take part in the therapy session. Afternoons can vary – sometimes there will be a one-to-one session with a key worker, activities like bowling, swimming, walks to the park or parent and child play sessions. There may also be appointments with midwives, health visitors or social care professionals. Children are settled in the evening for adults to take part in recreational group sessions and relaxation time before bed.
Our family service provides comprehensive care focused on assessing child development and wellbeing, as well as making observations around parenting. The work done by our childcare team is crucial in helping us deliver our programme. Our nursery is Ofsted registered, and rated ‘outstanding’.
We give parents a chance to come to our service with their children– this is unusual as we are the only service in the UK that supports dads as well as mums. We really believe in giving all parents an opportunity to be with their children, and for children to be with their parents. There are 2.9m lone parent families in the UK and 90 per cent of those are children with an absent father.
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We help families to stop using drugs or alcohol dependently and become more stable parents. We offer support through the later stages of pregnancy, childbirth and into the early stages of parenting. We work with mums and dads to work through difficult emotions and daily challenges so that they no longer feel the need to use substances to function.
When we see people come to the service completely broken, desperate for help, we offer them a safe place to work on their recovery with their children. Without the work that we do most of those kids would end up in the care system. We give hope to families where they may have had none – and the programme works.
The service has a really high success rate – 85 per cent of families successfully recover and leave the service with their children, which is a wonderful thing – particularly considering the national average success rate for residential treatment is 57 per cent.
Christmas is just around the corner and it’s a really magical time here at the family service. We have a big Christmas lunch with presents and lots of food and activities. We decorate the house and everyone really gets involved. We really try to create opportunities for families to make memories.
If there’s one thing I would change it would be to give more chances to enter the service. Access to a specialist residential service such as the one I manage in Sheffield is really hard – not because we can’t or won’t accept more families but because accessing the opportunities for parents with addiction problems can be more challenging. A big fear for families is that if they ask for help they are at risk of their children being taken into care. If more local authorities invested in supporting mums and dads to improve their lives earlier, that may prevent parent and child separation further down the line through the courts.
To anyone considering a similar career, I would say: if helping people is your passion, then go for it. A career in addiction services can be the most rewarding job of all. Knowing that you can help someone who is broken to rebuild their life is just amazing. You get to meet lots of really interesting people and have the privilege of hearing their stories and being a part of their recovery journey. What can be better than that?
Every September Change Grow Live celebrates Recovery Month. From poetry, to carpentry, film-making to walking, their services have been getting creative as they mark the occasion this year.
Hull – Recovery Street Film Festival 2020 winners. It’s the first time a Change Grow Live service has won the festival, so it’s an especially big achievement for everyone involved.
West Sussex – recovery poetry and art. The creative writing group has continued over Zoom and featured incredible poems from people at all stages of their recovery.
Manchester created ‘a road to recovery’ bench. Volunteer Anthony has been getting creative by building a bench and table. His creations will be placed in the garden at Bradnor Point, the same service hub that Anthony used to attend.
Hertfordshire – Words of wisdom. Service users from Spectrum in Hertfordshire have shared some of their experiences of recovery.
Blackburn – a breath of fresh air. At Inspire Blackburn with Darwen, staff organised a series of walks to get everyone out and about in the fresh air.
Find out more here more about their brilliant Recovery Month 2020 activities and personal experiences of what recovery means to the people they support.
England’s addiction services are not equipped to deal with the ‘soaring numbers’ of people drinking at high risk levels during the pandemic, warns the Royal College of Psychiatrists (RCPsych). Treatment services should be given ‘a multi-million pound funding boost’ in the upcoming spending review to reverse years of harmful cuts, it states.
Almost one in five adults were drinking above the recommended weekly guidelines in June – around 8.5m people – up from just one in ten in February, while the number seeking help for opiate issues is at its highest level for five years, according to RCPsych’s analysis of data from Public Health England and NDTMS. People with alcohol use disorder are also more likely to develop serious complications if they become infected with COVID-19, including acute respiratory distress syndrome, the royal college warns.
Prof Julia Sinclair: Government needs to act quickly or death rates will ‘rise exponentially’.
‘COVID-19 has shown just how stretched, under-resourced and ill-equipped addiction services are to treat the growing numbers of vulnerable people living with this complex illness,’ said chair of the royal college’s addictions faculty, Prof Julia Sinclair. ‘There are now only five NHS inpatient units in the country and no resource anywhere in my region to admit people who are alcohol dependent with co-existing mental illness. Drug-related deaths and alcohol-related hospital admissions were already at all-time highs before COVID-19. I fear that unless the government acts quickly we will see these numbers rise exponentially.’
‘It is understandable that the government is focussing on the most immediate harms of the pandemic,’ added executive director at Change Grow Live, Nic Adamson. ‘However, it is now essential that the government acts to address this increase in higher-risk drinking. The stakes have never been higher. Unless we have the capacity to reach and support over 3m more people who are now higher risk, the long-term implications for public health will be disastrous. As the UK’s largest national provider of drug and alcohol treatment services, we are calling for the government to urgently prioritise the support people need in the next spending review.’
Leading drug and alcohol charity WDP has renewed its partnership with City Lit, one of the country’s top destinations for evening, weekend and daytime courses, for a third successive year.
City Lit will be offering WDP service users access to an array of online and face-to-face courses across a wide range of subject areas, in exchange for their hard-won Capital Card points.
The Capital Card is an award-winning reward card scheme which empowers WDP’s service users and helps them on their recovery journey. They can earn points by engaging in drug and alcohol treatment and spend their points on positive activities and products in their local community at Spend Partners, such as cinemas, gyms or eateries.
Some of the fantastic feedback from service users who have had already had the opportunity to attend courses at City Lit includes:
‘After 18 months of hard personal work, being given something that I would not have done for myself made a big difference to my confidence.’
‘Learning a new skill and discovering something that I thought I could not do was magical; when you are working through really difficult/painful experiences to be reminded that you can learn new skills and succeed is a huge prize.’
‘It’s given me more confidence to be amongst other people, reason to get up in the morning and look forward to my day, it lifted my depression and has also given me a different perspective on life.’
WDP chair Yasmin Batliwala
Yasmin Batliwala, chair of WDP, said: ‘We are delighted to be continuing our partnership with one of our first Spend Partners, City Lit. This collaboration will provide a vast range of opportunities for our service users to learn new skills, develop their interests or take up a new hobby. To be able to look ahead to the future and have these options is hugely beneficial and invaluable in supporting our service users in their recovery journey.’
Phil Chamberlain, executive director of external engagement at City Lit
Phil Chamberlain, executive director of external engagement at City Lit, said: ‘I am thrilled that we are continuing our partnership with WDP. Building on the success of our long-term partnership, we’re excited to offer WDP service users access to an array of online and face-to-face City Lit courses in exchange for their hard-won Capital Card points. Together we will be able to support WDP service users in their recovery journey by rebuilding confidence, helping to regain a wellbeing equilibrium or upskilling to increase employability. This is the latest offer in a long collaboration between our two organisations and we look forward to developing our partnership further in the future.’
A new UK-wide alcohol strategy is now ‘required urgently’, according to a report from the Commission on Alcohol Harm. It should be evidence-based and science-led, and include targeted measures to support families and protect children, including from alcohol-related violence, the commission states.
Baroness Finlay: ‘For too long, the onus has been on individuals.’
The strategy should also include measures on affordability – such as minimum pricing – as well as on restricting advertising and marketing and improving treatment provision and consumer information. The commission – which is made up of cross-party MPs and peers as well as health experts – also wants to see the strategy ‘changing the conversation and challenging alcohol’s position in our culture’, including addressing the stigma around harmful alcohol use.
The report includes input from hospitals, treatment providers, homelessness organisations, children’s charities and the alcohol industry itself, among others, as well as more than 140 responses from the public. Alcohol is ‘inflicting long-lasting harm across all areas of society and family life’, the commission states, with children living with an alcohol-dependent parent twice as likely to develop alcohol dependence themselves and three times as likely to consider suicide.
More than 300,000 children are now living with an adult drinking at high-risk level in England alone, it says, while 75 per cent of children referred for adoption medicals had a history of antenatal alcohol exposure. Alcohol is now the leading risk factor for ill health and early mortality among 15-49-year-olds, responsible for around 12,000 cancer cases a year.
‘Alcohol harm is a hidden health crisis that impacts us all – in families, our communities, and throughout society,’ said commission chair Baroness Finlay. ‘For too long, the onus has been on individuals, with drinkers urged to “drink responsibly”. We need to finally acknowledge the true scale of the harm caused by alcohol, which goes far beyond individuals who drink, and put the responsibility squarely with the harmful product itself. By doing so we will help to do away with the stigma and shame that surrounds those who are harmed by alcohol, and often stops them from accessing the help that they need.’
The efforts to get homeless people into emergency accommodation must not be wasted, as DDN reports.
Homelessness has been long been regarded as complex, difficult, inevitable – and easy to ignore. The substance misuse sector has struggled to maintain outreach services in the face of disappearing funding and has tried to create care pathways with varying levels of success.
A conference on homelessness and addiction last year (DDN February 2019, page 16), raised many questions – why don’t we take notice of the evidence to stop ‘thoroughly preventable’ drug poisoning deaths with simple and cost-effective harm reduction measures such as naloxone? Why are we still discharging from hospital onto the street? Why are care pathways so fragmented? Why aren’t we creating routes out of dependent drinking? Why is there no help for smokers?
While COVID-19 has thrown everyone’s life into disarray, there is one group of people who might actually benefit as a result. Things couldn’t have seemed much worse for the street homeless population when housing minister Robert Jenrick announced £105m to provide interim housing to take thousands of rough sleepers off the street during the pandemic, including £16m for people in emergency accommodation to access specialist help for substance misuse. The money is also aimed at helping rough sleepers to secure their own tenancies, as part of the government’s commitment to ‘end rough sleeping for good’.
‘I am clear that there can now be no going back to the streets as people begin to move on from the emergency accommodation…’ Dame Louise Casey
Dame Louise Casey, chair of the COVID-19 Rough Sleeping Taskforce called the ‘Everyone in’ initiative an ‘extraordinary effort’ and an ‘extraordinary opportunity’ to turn lives around if we get the next steps right. ‘I am clear that there can now be no going back to the streets as people begin to move on from the emergency accommodation that has been put in place,’ she said.
In London the initiative has taken shape through the Homeless Drug and Alcohol Service (HDAS), commissioned by Public Health England and the Greater London Authority. The ’pan-London system’ involves the South London and Maudsley (SLAM) and Central North West London (CNWL) NHS Trusts, working with Change Grow Live and Turning Point (who coordinate logistics), We Are With You and Phoenix Futures. A 24-hour phone line is manned by recovery workers from the pool of organisations involved.
Dr Emmert Roberts is clinical lead for HDAS and told DDN how the service was commissioned for three months in March, extended for another three, and is looking likely to carry on for longer. A ‘hodge podge of a system’ at the beginning, it has had to come a long way in a short time, he says. ‘It was chaos – getting people off the streets as quickly as you can. Once they were off the street, we could do more stuff.’
‘We’ve been working with local hotels to provide education and training to minimise risks relating to alcohol withdrawal, naloxone training and how to use e-cigarettes.’ Dr Emmert Roberts
The first challenge was to secure rooms in hotels, and this involved splitting the intake into three distinct cohorts. People with symptoms or who tested positive for COVID-19 needed to be isolated in ‘COVID care’ rooms. The next category was ‘COVID protect’ for those who tested negative but who had medical vulnerabilities. Everybody else was assigned a ‘COVID prevent’ room.
Once this was achieved – which Roberts admits involved ‘abject chaos’ at first, because of the speed everything had to be put in place – there was a chance to tackle ‘the whole suite of drug and alcohol issues’. Anyone could call anytime from the hotels to ask for advice, and many of the calls related to alcohol withdrawals and prescribing issues.
Harm reduction was a high priority, so naloxone was introduced and people were given a workbook of psychosocial interventions to complete in their hotel rooms as a way of bridging the gap left by lack of face-to-face contact. One of the big initiatives has been the opportunity to tackle smoking, with 2,000 e-cigarettes distributed alongside other nicotine replacements – a window to reduce tobacco harm as well as enabling people to stay in their rooms to avoid transmitting the virus.
‘Harm reduction initiatives can really work well with this population, as well as preventing COVID spread,’ says Roberts. ‘It showed that there is willingness among people to reduce their tobacco consumption.’ He hopes that funding being made available for a pan-London coordinator for tobacco harm reduction will improve access for people who are rough sleepers and help them to reduce their tobacco use long term.
As Roberts stresses, each part of the initiative has been a learning curve, so supporting the hotels to house their guests safely has been paramount. ‘We’ve been working with local hotels to provide education and training to minimise risks relating to alcohol withdrawal, naloxone training and how to use e-cigarettes,’ he says.
The other part of the project that needed to be bedded in fast was the strategic working between the partners. Where there were normally ‘turf wars’ between services there had to be a change in approach, so that people could stay with their original treatment providers when they moved location to prevent them from dropping out. The proactive partnership culture was also helpful for feeding into health alliances – the GPs and nurses working in the hotels, as well as the homeless charities steered by St Mungos.
Much of the time and energy has been taken up through facilitating new referrals into treatment, says Roberts, and ‘a lot were people who have never been in the treatment services before or are generally hard to reach. We facilitate their involvement with local services and prevent any bad practice happening in the hotels, including dodgy detoxes and people not understanding about substance misuse.’
While ‘lots of things have gone well’, the team is bracing itself for an ‘uptick in homelessness’. ‘I don’t know what the future holds and we’re not out of the crisis yet so it’s very difficult to know what we’re going to return to or what the new normal is going to be,’ says Roberts. ‘I would hope that we’ve learned some lessons about how we treat homeless people within our services – but given that we don’t know what the lie of the land will be over the next few months, it’s hard to know if this will have any lasting impact.’
Getting people off the streets and into a safe place had to be done very quickly and in an emergency situation, so he is frank about it being ‘chaos’ at the beginning. But through bringing the health teams, homeless charities and substance misuse teams and hotel staff together, they have been able to help with all kinds of issues, including immigration and benefits. Each of the hotels in London has a resident homelessness sector organisation – mainly St Mungos – running the day-to-day life, with HDAS being the central coordinator for the substance misuse sector.
‘It’s been challenging and chaotic, but the fact we’ve been able to come together and have city-wide input has been very useful,’ says Roberts. ‘The government has agreed to try to end homelessness by the end of parliament in 2024 and the work we’ve done will hopefully help that.’
He is painfully aware that ‘the state of funding in the entire sector is quite dire at the moment, with over £250m of disinvestment over the past five years’, and that ‘this isn’t going to rectify that’. The abolition of PHE feels like another hammer blow. But there’s no denying that being plunged into this emergency situation has already had some amazing results for individuals who were invisible before COVID turned our world upside down.
‘This isn’t going to be a substitute for the overall disinvestment,’ says Roberts. ‘But it might go some way towards improving access for this particular population.’ And if you’re one of the 5,000 people in London or 15,000 people nationally who have entered a housing support scheme for the first time, that could feel like a wide-open door.
What proportion of England’s problem drinkers are actually in treatment? And are increasing rates of unmet need the result of austerity-driven funding cuts? Mike Ashton investigates.
How well is England doing at getting people who need help into treatment for their drinking problems?
It matters, because the more of the in-need population we treat, the smaller the alcohol-dependent population and the less the related harm. Drug and Alcohol Findings conducted an examination for England in 2014 when the figures were most reliable (see https://findings.org.uk/ for the full story and references).
Then, about 112,000 drinkers were in specialist treatment. We found rationales for this representing just 7.5 per cent of harmful or at least mildly dependent drinkers, and up to 43 per cent of those who score in surveys as at least ‘moderately’ dependent. In between was a 19 per cent estimate based on a formula constructed for the Department of Health. This aimed to exclude drinkers who, despite a high risk to health, scored as non-dependent in surveys, but to include lower-risk drinkers dependent enough not to remit, even after an extended brief intervention.
The population in need of treatment becomes constricted further if we take into account whether prospective patients actually want or intend to take a treatment route to curbing their drinking, and/or are making what to them seems a rational choice to continue to drink to excess.
Could do better
Though the question of what proportion of the in-need population is in treatment has several answers, what seems sure is that England could be doing better – not least because Scotland seems to be treating proportionately three times as many of its problem drinkers. An estimate for Leeds is that raising treatment access to that level would cut the alcohol-dependent population by nearly a fifth over five years, and save a further 65 lives.
Since 2014, however, things seem to have got worse (Fig 1). Initiated in 2010, the government’s austerity policies are prime targets for the underlying reason why alcohol treatment numbers have been falling despite sustained levels of need – the chart shows numbers falling consistently since 2013-14. The highest line is the number of patients whose presenting substance use problems included alcohol, the lowest those with alcohol as their sole presenting substance use problem. In between are actual or estimated numbers of patients treated primarily for their drinking problems, the basis for the calculations above.
These figures must be married with trends in estimated treatment need to assess whether need is increasingly failing to be met. The methodology which yielded the 19 per cent estimate for 2014 has been used to estimate the alcohol-dependent population in England from 2010-11 to 2017-18. In 2017-18 the estimate was just 1.6 per cent lower than in 2013-14, yet over the same period the patient caseload fell by about 17 per cent – from equivalent to just over 19 per cent of the in-need population to 16 per cent (see chart). The drop was within margins of uncertainty, but was consistent each year from 2013-14. With a presumed substantial pool of unmet need, even if there had been no fall in the proportion of the in-need population being treated, a diminishing caseload would still have been of concern.
Hospital Admissions
Another statistic used to indicate need for treatment is hospital admissions of patients diagnosed with mental or behavioural disorders due to drinking (Fig 2).
As with the alcohol-dependent population, the treatment caseload as a proportion of admissions has fallen each year since 2013-14, from about 32 per cent to 22 per cent in 2018-19, suggesting that treatment has been capturing smaller and smaller proportions of the in-need population since austerity took hold.
So concerned were Public Health England (PHE) at the ‘fall … in the context of high levels of unmet need’ that in 2018 they mounted an inquiry. It spotlighted ‘financial pressures and service reconfiguration’, but also made it clear that the prime service-reconfiguration suspect – integration of alcohol with drug services – was itself mainly driven by ‘reduced local substance misuse budgets’. This change is said to have led to a defocus on alcohol and a less specialist response to problem drinking, as well as possibly deterring drinkers from services which looked and felt like they were for drug users.
Obvious Answers
For one well-informed commentator, the time for PHE’s cautious pointing to austerity was past: ‘Some in the field may feel the answer is obvious – continued cuts to treatment budgets (put at 26 per cent for adult and 41 per cent for youth services) have inevitably led to less resources and a changing landscape with very few alcohol-only services remaining, described as a “crisis” in alcohol treatment.’
These views and that of PHE’s inquiry were reinforced by an Alcohol Change UK survey of alcohol services and allied professionals in England in 2017. Key findings were that most respondents could not say there was sufficient local access to these services, and that the main reason was the funding squeeze. The same year a survey of substance use services in England warned that ‘the capacity of the sector to respond to further cuts has been seriously eroded’. Instead of targeting the ‘comprehensive and high quality services’ needed to actualise the government’s recovery agenda, providers were now concerned about being able to maintain the basics of safety and quality.
Need and demand
Austerity might increase unmet need by obstructing the main routes for converting need into demand for and entry into treatment (Fig 3). That this has been at least partly the case was suggested by a report on alcohol treatment in England in 2011-12 from what was the National Treatment Agency for Substance Misuse (NTA). It was concerned at how few people had successfully been referred to specialist treatment by GPs or A&E departments, despite the fact that around one in five people seeing a GP is drinking at risky levels and about a third of emergency attendances are alcohol-related. If there was cause for concern then, there was even more later: from a peak of 15,900 in 2009-10, by 2013-14 these two sources accounted for 15,132 treatment starts of people primarily treated for their drinking; as a proportion of all treatment starts, the trend was consistently down from 23 per cent in 2008-09 to 19 per cent in 2013-14 (see chart).
Mike Ashton is co-editor of Drug and Alcohol Findings, www.findings.org.uk
Since 2014-15 reports instead record patients with alcohol problems unaccompanied by problems with use of illegal drugs – the ‘alcohol-only’ caseload. However, the trends described above continued. The concurrence between the raw numbers (black lines) and the percentage these represented of all new referrals (orange lines) shows that GPs and A&E departments were not just referring fewer and fewer patients in absolute terms, but also relative to other referral sources. By 2018-19 these accounted for just 12 per cent of all new alcohol-only referrals compared to 23 per cent of patients with a primary alcohol problem in 2008-09.
In the end, PHE’s grounds for concern seem a stronger foundation for policy responses than attempts to assess the met-need versus total-need fraction. For numbers in treatment to be falling when there is some hard-to-pin-down, but perhaps substantial, degree of unmet need suggests something is increasingly going wrong in access to treatment for problem drinking in England.
Our refusal to acknowledge that drugs can be a happy experience is hampering our attempts at treatment, says Nick Goldstein.
Read the full article in September DDN magazine
We’ve all heard enough about coronavirus to last a lifetime. But one of the more positive aspects of the lockdown is that it has given us time and space to sit down and think about the difficult issues that we kick into the long grass. One of the subjects I find repeatedly cropping up is pleasure – our perception of pleasure and our attitude towards it.
The dictionary definition of the noun ‘pleasure’ is a feeling of happiness and enjoyment – a feeling we all know. Pleasure is usually perceived to be harmless – a fringe benefit of existence even – BUT if that pleasure is derived from something society perceives as a negative, all hell breaks loose. And there are few things society regards as negatively as drug use.
Consequently, drug use has become deeply stigmatised and the root of that is ‘intoxophobia’ and faulty misperceptions of pleasure. Intoxophobia, the fear of intoxication, has been around for a long time and exists as a result of ignorance of different, altered states of consciousness. Any behaviour different to our norms creates fear, and no one likes to be scared – in fact fear makes people angry.
The misperception of drug use as purely pleasurable is also the result of ignorance – an ignorance that also ends in anger, but this anger is caused by resentment rather than fear. Think of it as a version of Max Weber’s protestant work ethic – a concept that implies that pleasure must be worked for, striven for, and not bought by the ten bag. So, some poor schmuck wandering around high as a kite doesn’t go down well because of all those misconceptions, misperceptions and outright intolerance relating to pleasure.
Sadly, those misconceptions and misperceptions surrounding drug use and pleasure exist in the substance misuse field too. From key workers to consultants in every treatment agency and treatment provider, it’s lurking. It can be seen in the drugs prescribed (both major drugs prescribed in treatment, methadone and buprenorphine, are perceived to offer little pleasure) and in the limited amounts prescribed, which are subsequently sub-optimal.
Have you ever heard a prescriber say to a struggling client, ‘Oh dear! Your sample is positive. You’re obviously struggling with this dosage/prescribed drug. So let’s increase your dose/change the drug for something you might prefer – something you might actually want to take because you enjoy it.’ No, me neither. The response is much more likely to involve decreasing dosage and increasing restrictions for the client.
Rather than concentrate on Freud’s pleasure principle, it would be far better for us all if more emphasis was paid to a much earlier commentator, Epicurus. Epicurus, who was a noted Greek philosopher, suggested that primarily pleasure was found in relieving pain. At least 50 per cent of substance misuse clients experience dual diagnosis and suffering. The very fact they use drugs and fall into the sphere of substance misuse services is a grim indictment of modern psychiatry, because no one goes into substance misuse treatment if they have another option. Gabor Maté’s ideas around trauma and addiction would suggest an even higher percentage of service users are suffering.
Put simply, people don’t go into treatment to keep the party going, for free dope. Considering the modern treatment service, it can easily be construed that you have to be desperate to sign up. So it would be great if the drugs that enable clients to function and provide much needed stability were not seen as a vice or pleasure, but rather seen as just medication.
I’ll probably be burned at the stake for mentioning it, but demonisation of drugs and the pleasure they can impart is seen far too often in recovery settings. I appreciate the seriousness of recovery, but if your schtick involves demonising drugs and pleasure to maintain one’s own recovery it might be time to find another narrative.
Our negative attitude to pleasure can even be seen to limit the effectiveness of what little harm reduction we practise. The work of Magdalena Harris, associate professor at the London School of Hygiene and Tropical medicine and a leading researcher, suggests that the most effective forms of harm reduction tend to fall around ways to extend pleasurable drug use rather than the much more common and more ineffective ‘wages of sin are death/do this or die’ approach.
A more civilised attitude to pleasure would change things, and our only chance of this is a full and frank discussion around pleasure and our attitude to it. An inability to accept pleasure is the elephant in the room. It leads to stigma, poor drug treatment and poor relationships between services and service users. This, sadly, won’t change until there’s been a debate – and considering the subject, it will be a painful debate.
Nick Goldstein is a service user
My contribution to this debate is this. Since mankind came down from the trees we’ve wandered around, and when hungry we ate some of the plentiful plants. Some plants nourished us, so we kept eating them. Some plants poisoned us, so we stopped eating those. And some plants – special plants – made us feel good… really good. We definitely kept eating them!
You have to accept pleasure is a very human problem, because only mankind would make pleasure a problem. Most animals, wisely, just enjoy it.
‘IT’S ABOUT GIVING PEOPLE MUCH MORE POWER over the choices they make.’ Service providers are telling us that six months into lockdown, there are opportunities in the ‘new normal’ (p12). One of the most exciting prospects is the government’s pledge to ‘end rough sleeping for good’ (p6). Will we get the next steps right to make the most of what Dame Louise Casey calls an ‘extraordinary opportunity’?
Hearing from peer networks (p15) highlights the resources we have for informing treatment – what could be more effective than learning from the experts? Overdose Awareness Day should teach us that harm reduction is not an optional extra, but a matter of life over death. Stigma at home and abroad is standing in the way of essential progress and we must be receptive to wherever we can bring this expertise to the heart of the treatment system.
The new Staywell centre in Derby (page 20) is an enterprise that’s using lived experience to great effect, working alongside over- stretched treatment services to offer many dimensions to recovery and wellbeing – what Recovery Month is all about.
And alongside all the ideas, here’s a thought: do we consider the fact that taking drugs can feel rather nice? I’ll leave you with Nick Goldstein’s article on (p10).
From the heart of the Cornish countryside Bosence Farm Community has been developing ecotherapy, as Tom Packer explains.
Read the article in DDN Magazine
‘One of the main things I wanted was to come somewhere where I could get away from things. At Bosence I feel completely removed from temptation and can focus on my treatment and concentrate on getting well.’
Coming down from London to 22 acres of beautiful Cornish gardens and woodland, Nick found a tranquil environment away from all distractions. Alongside the detoxification, stabilisation and round-the-clock nursing support – including a highly specialised service for young people – Bosence has recently introduced an ecotherapy programme.
Nick can now take part in four individual weekly sessions:
Propagation, providing clients with the necessary skills to learn how to plant seeds and care for plants.
Herbal tea making, which aims to promote wellness and relieve stress by helping participants to achieve a more relaxed state of mind. Those taking part are introduced to a range of herbs and gain an understanding of how they nourish the nervous system and strengthen the immune system.
Nature observation, designed to promote care, respect and understanding of the natural world. Clients learn how to identify different species of wildlife and observe and interpret the environment around them.
Forest bathing and mindfulness, which teaches the basic principles of forest bathing, mindfulness, improving sensory awareness and breathing techniques.
‘In the mornings I’ll often take a walk around the grounds, just to admire the scenery and breathe in the country air,’ says Nick. ‘I’ve really enjoyed the guided nature walks around the nature trail, where I have been able to take part in wildlife surveys, to identify a range of species. I’ve been given responsibility to look after the greenhouses, which I really appreciate as it’s my way of giving back and contributing to the day-to-day running of Bosence. I’ve learnt so much.’
In an age of technology there is mounting evidence to suggest that by pushing away from nature, we have begun to lose contact with a necessary tool for optimal mental health.
Pioneering research carried out by R S Ulrich in the late 1970s examined the psychological influence of scenes of nature on the stress experienced by individuals and medical recovery rates. Ulrich was able to demonstrate that observing ‘natural’ scenes increased feelings of friendliness, affection, joy and playfulness, boosting the production of serotonin without the use of antidepressant medication.
In more recent years there has been a growing recognition of ecotherapy and the vital role it plays in optimising positive mental health, with a clear application in supporting individuals to overcome addiction and maintain long term recovery. Ecotherapy can also give people a sense of achievement and purpose, providing structure and routine to people who might not have these in their lives.
A recent article published in New Scientist explores the importance of outdoor space and nature in recovery and mental health. It describes how in the Shetland Islands, people with a physical or mental ill health are being recommended to ‘take in the sights and sounds of seabird colonies, build woodland dens or simply appreciate the shapes of clouds’.
A New Zealand initiative found that two-thirds of patients were ‘more active and felt healthier’ six to eight months after this ‘green prescription’, it adds, and almost half had lost weight. ’Meanwhile, ecotherapy, which involves participating in outdoor activities such as gardening or conservation, is emerging as a promising treatment for mild to moderate depression.’
These findings are also supported by a study from the University of Essex that found that a walk in the country reduces depression in 71 per cent of participants. The researchers found that as little as five minutes in a natural setting, whether walking in a park or gardening in the backyard, improves mood, self-esteem, and motivation. A reduction in stress has been proven to lower levels of the stress hormone cortisol, reduce pulse rate and lower blood pressure.
The sessions at Bosence are all facilitated by horticulturalist and land manager, Noah Hall, who ensures the grounds are maintained to the highest standard, enabling clients to fully benefit from the incredible natural environment. Over the last few years he has created a woodland nature trail and sensory garden, and is also responsible for an ever increasing harvest of fresh organic produce, grown in several on-site polytunnels and allotments.
To complement the ecotherapy sessions, Noah also provides a weekly cookery session to those enrolled on the residential treatment programme, with much of the produce sourced on site. Alongside the structured sessions, residential clients have the option to help with seed sowing, potting on, planting veg and flowers, weeding, watering, strawberry picking, or whatever needs doing, and also have the opportunity to conduct wildlife surveys.
Feedback from the sessions has been overwhelmingly positive, with participants commenting that they have found them to be both informative and inspiring, while helping them to feel calm and relaxed.
Holly, a local client from Cornwall, says that the ecotherapy project has provided her with a number of new experiences and opportunities. ‘In the last few weeks I’ve acquired the skills to identify a variety of the different types of herbs and through education sessions I’ve gained knowledge on how to combine, prepare and cook different types of tea,’ she says.
‘Since the start of my treatment, I’ve regularly been involved with the planting and harvesting of fruit and vegetables. In particular, I’ve enjoyed taking part in “Vegan Friday”, where I have learnt new recipes and prepared several dishes using only the produce grown on site. When I complete treatment, I will definitely continue to cook these recipes as regularly as I can.
‘I’m looking forward to taking part in mindfulness sessions in the next couple of weeks,’ she adds. ‘I feel so relaxed in such a tranquil and peaceful environment.’
The coming weeks will see the introduction of a formal measurement tool to gauge and monitor client feedback, similar to those we use to evaluate the effectiveness of the various interventions that comprise our treatment programmes. In the longer term, we plan to offer a formal structured 12-week ecotherapy programme that will include sessions such as creative writing and drawing outdoors.
We’re lucky that our spacious and diverse site has afforded us with the perfect environment to incorporate such a varied range of ecotherapy techniques into our programmes.
It’s now almost six months since lockdown revolutionised the way services operate. But could this have actually led to an increase in service user choice? DDN reports.
Read the full article in DDN Magazine
‘I don’t like the phrase “new normal”, but I think what that will be is a blended mix’, Andrew Horne, executive director of We Are With You, Scotland, tells DDN. ‘It’s about giving people much more power over the choices they make. Rather than saying, “Here’s your worker, here’s your one-to-one session, and you travelled 40 miles across the Scottish borders or Cornwall irrespective of what the transport system is like” – now it’s “video me”.
‘We’re getting feedback from workers as well who are saying they’ve never had so much contact with clients’ Andrew Horne
COVID-19 has had a huge impact on service users’ experience of treatment, not least the all-pervading sense of insecurity in the early days of the pandemic. But, as numerous DDN articles have illustrated over recent months, services were quick to adapt and ensure continuity of provision for their clients in exceptionally difficult circumstances. Initiatives adopted have ranged from preparing food for service users to providing them with smartphones, and one of the most significant changes – as with most other sectors – has been the large-scale shift from face-to-face to online activity.
Scripts and pick-ups
Inevitably, a key area to be affected has been provision of substitute medication, with many pharmacies – particularly in the early days of lockdown – either closing or operating significantly reduced hours. This meant service users being moved from daily to weekly or fortnightly pick-ups, often with little or no notice.
‘If local lockdowns come into place we’re fully prepared – we can be very flexible in what we do.’ Tony Lee
‘There was a lot of uncertainty in the first couple of weeks, and real concern about continuation of scripts,’ says national service user representative for Change Grow Live, Tony Lee. ‘What my service was able to do was move everybody to a 14-day pick-up, and in the first couple of weeks that did create some anxiety. People were thinking, “Oh my God, will I manage?” But by the time it came to the second pick-up two weeks later that seemed to have gone away.’
Feedback has shown that the move away from daily pick-ups has actually improved some people’s relationships with partners and children, he says, and has been particularly welcome for anyone looking after an elderly parent. ‘Now they don’t have to go to a chemist every day with the risk of bringing COVID back into the house. A lot of people have been really, really complimentary about the service taking that chance of giving them a 14-day prescription. It improves choice, it improves flexibility. We’re not getting anything negative on that front at all. I’m a national rep – I speak to people all over the UK – and it’s the same feedback every time.’
His service user council has now taken steps to ensure that no one is moved back to daily supervised consumption without good reason, he states. ‘We demanded some safeguarding measures be put in place, so the person has to go through two processes to be put back on supervised consumption. That’s really helpful because it reassures the client and brings them into that decision, so nothing’s decided without their input. And we’ve created an appeals system where we can respond rapidly to anyone complaining that they’ve been put back on supervised consumption needlessly.’
In control
We Are With You has found much the same, adds Horne. ‘We moved as many people as we could across to fortnightly pick-up, and the feedback has been very interesting. When we did our service user survey, 70 per cent said they didn’t want to go back to daily pick-up. Two or three people said it was the biggest trigger point for relapse, because they were constantly in contact with people who were carrying illicit Valium or whatever. People also felt much more in control of their lives and how they dealt with dosage – instead of having to go to a chemist and drink 120ml of methadone they could spread that over the day.’ His organisation changed all its prescribing options, with a lot more use of buprenorphine, for example. ‘We just gave people options as to what they were more comfortable with. In Scotland we turned all our services into needle exchanges, because we knew people were going to struggle with chemists, we created click-and-collect for needle exchange, and did a lot of video prescribing as well.’
Tailored to need
Not every organisation made the shift to fortnightly pick-ups, however, and instead worked to make sure people were getting a service tailored to their needs. ‘We never went to fortnightly,’ says medical director at WDP, Dr Arun Dhandayudham.
‘If local lockdowns come into place we’re fully prepared – we can be very flexible in what we do.’ Dr Arun Dhandayudham
‘Even before the lockdown we were already risk-assessing each patient individually, looking at all their health risks and pick-up regimes. We were already well advanced in our planning, and the maximum anybody got was one week – we were also working very closely with the pharmacies to establish what kind of resilience they had in terms of cover. So we individualised each service user’s pick-up – some went from daily supervised to daily unsupervised, or from once or twice a week to a maximum of weekly.’
Closer working with pharmacies also provided a chance to stay informed about clients who weren’t coming into services, says his colleague, operations manager Vanessa Duke. ‘We’ve been in pharmacies very regularly dropping off prescriptions and talking about clients that they might be seeing but maybe we haven’t seen. We’ve also taken in naloxone, safe storage boxes and leaflets around public health campaigns like World Hepatitis Day.’
Online support
One of the most significant changes across the sector has been the move to online support, which is not something that everyone thought would necessarily work. ‘A really interesting stat among our service users is that 56 per cent were able to use online groups from a standing start, which is huge,’ says Horne. ‘Everybody said, “It’ll never work – they just won’t do it.” But a huge amount of people have asked if we’ll continue with the online groups after lockdown, because they like the blend of both.’
‘My service has been a skeleton workforce, but it depends on what you want to put in – that’s what you get out of it,’ Barry, a service user based in Essex, tells DDN. ‘You’ll hear people complain, but it all depends on the individual and if you’re determined to get help. My script’s always there, I can always message my key worker to answer my questions or sort out any problems, and there’s online support if you need it. It’s down to your own determination.’
The overwhelming majority of clients understand completely why these changes had to be made, stresses Duke. ‘And many of them have enjoyed the opportunity to work in a different way. That’s had some really positive outcomes, but some have struggled with the more limited one-to-one contact. And of course for some clients it’s been a reduction in face-to-face contact across multiple services. Where that’s been the case we’ve worked with them and identified if it’s ok to bring them in to service – where they’ve got complex needs or are significantly socially isolated, or if there are particular risks in the home environment.’
While many clients have enjoyed the opportunities offered by online support, it’s been ‘a mixed picture’, agrees Tony Lee. ‘We have a lot of clients who don’t have access to the internet – one of the things we’ve been trying is giving out phones so at least we can contact them and have a conversation. We can have a conference call and bring them into the meeting, and we’ve taken it further than a therapeutic approach, with social evenings, quizzes and talent nights. So we’ve definitely been able to broaden the scope of what’s on offer – people are really happy with that extra choice of having a phone call or going on Zoom.’
Improved engagement
One of the recurrent themes of an ongoing Change Grow Live survey has been the choice aspect, he points out, and not just from service users. ‘We’re getting feedback from workers as well who are saying they’ve never had so much contact with clients, especially the hard-to-reach people who would never come into a service. They’ll pick up a phone, so the engagement side with these clients has been so much better.’
In some cases, the new ways of working have sped up the implementation of initiatives that organisations were already thinking about. ‘I think the big thing is that there’s an appetite for change and a different way of working,’ says Horne. ‘For example, we’re very conscious of the importance of the first four weeks in people’s recovery journey. Traditionally you’d call somebody in for an assessment and then try to get them into treatment. But an appointment in a week’s time is very little use – people want an appointment tomorrow and the next day and the next. We really increased contact, so we’ll still have physical meetings but interspersed with maybe three or four 15-minute chats – by phone or video or maybe just WhatsApp, “How are you doing, what’s your plan for today, how did you get on yesterday?” We lose a lot of people in the first four weeks across the sector, and we really need to engage – this has allowed us to do that. So a lot of what happened during lockdown has allowed us to unlock what we were thinking anyway.’
The charity has also been able to reach out to people who wouldn’t normally access services, he adds. ‘Attending appointments online or via the phone can take away anxiety and logistical challenges, and we’ve completely revamped our web pages to give much more clarity of advice. We would often have people come on a web chat to say, “I think I need to do an alcohol detox but I’m a primary school teacher – I’m not going to a drug and alcohol service.” We know there’s this massive proportion of people out there who are struggling but never come near services, so we’re really trying to open up.’
Flexible approaches
So with the new ways of working now bedded in, how are people feeling about the long-term options? ‘At the beginning there was a lot of insecurity, a lot of uncertainty, but it’s now a way of life,’ says Dhandayudham. ‘Early on we were very focused on the complex patients, the risky patients, the ones who had needs around safeguarding, but as time’s gone on we’re trying to bring back a lot of our normal interventions – the BBVs, the alcohol detoxes, and face-to-face work even for non-complex patients. But it’s very much a flexible approach, so if local lockdowns come into place we’re fully prepared – we can be very flexible in what we do.’
‘I’m fairly optimistic,’ says Tony Lee. ‘I’m a client myself, I still access services, and I like my options now, I really do. Some days it’s not always possible to go into a service so to be able to say, “Can I have that by Zoom or a phone call?” is tremendously helpful. It takes the pressure off me, and off the service.’
‘I’ve got COPD so I have to be careful,’ says Barry. ‘Where it used to be going to see your key worker fortnightly it’s now monthly, and you’re sitting two or three metres away. But I’ve not found it to be a problem, and if there is any issue I call or text and things get sorted. If you go in daily you’re drug tested and alcohol tested, whereas if you’re having a conference call there’s nothing to stop you drinking or using drugs after – but the only person you’re lying to is yourself. I get all the help in the world, and it’s because I want that help.’ DDN
This article has been produced with support from an educational grant provided by Camurus, which has not influenced the content in any way.
‘As an individual or particularly if you’re part of a LERO, a local community group or a local service, this is the time to get out and engage with your new MP. Get to those surgeries, talk to them about what you do, invite them to your projects and events, and get their support. Get in there before everybody else.’ Forward trust CEO Mike Trace told the DDN conference 2024.
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Sign up to DDN Bitesize here to receive the latest issue each month along with news, updates and the latest jobs (your details will not be duplicated if you have already signed up for this). We will also be providing advice, suggestions and ideas on how to lobby politicians to ensure drug and alcohol treatment is high on their agenda..
The Capital Card Shop on Wheels initiative was set up to provide Capital Card users with access to essential items during the coronavirus pandemic.
Some of the books available via Capital Card Shop on Wheels
Users of the Capital Card earn points by engaging in drug and alcohol treatment and spend their points on positive activities and products in their local community at Spend Partners, such as cinemas, gyms or eateries, or at their local WDP service’s pop-up shops.
The idea behind the Capital Card Shop on Wheels scheme was to help service users who couldn’t leave their place of residence, because they were self-isolating, shielding or had mobility issues, to safely place orders for essential items that they would usually ‘buy’ in their local WDP pop-up shop, such as toiletries and non-perishable items.
While WDP services have remained fully operational, social distancing guidelines have dictated that the pop-up shops cannot currently open on-site. Also, many Spend Partners were closed during lockdown as well.
Continuing the Capital Card’s strong theme of innovation, the team looked for new ways to support our vulnerable client group during this challenging time.
The Capital Card Shop on Wheels initiative started in April 2020, with the first order placed on 28 April. As of 10 August, there have been 1,282 essential items delivered to vulnerable service users, owing to 231 orders.
This number does not include the 100 mobile phones sent through the initiative, donated by Tesco Mobile with preloaded SIMs, helping service users stay connected during lockdown and beyond.
Orders have been placed by service users in Barking and Dagenham, Brent, Cheshire West and Chester, City of London, Greenwich, Hackney, Harrow, Havering, Merton, and Redbridge.
The new partnerships brokered to make this happen are with:
Hermes – supported us by making doorstep deliveries of the essential items.
InPost – provided us with access to their secure lockers, helping us get the essential items to our service users safely.
Booker Wholesale – gave us donations of non-perishable food items.
Also, our current spend partner Bluebird, a non-fiction imprint at Pan Macmillan, has supported us with additional book donations for the scheme. Their authors include Joe Wicks, Russell Brand, Prue Leith, Jack Monroe, mental health campaigners Jonny Benjamin MBE and Natasha Devon MBE, and many more.
The feedback from service users has been great…
‘I am over the moon to have my new smartphone.’
‘A huge thank you for a lovely parcel full of goodies, it has made my day.’
‘I am so happy to finally have a Smartphone which enables me to do things such as research as I am hoping to secure an apprenticeship soon.’
‘Thank you Capital Card team for a bag of goodies, I have even got a funny birthday card for my mum.’
‘I would strongly suggest that you all read this great book (Kindness Method) as I have thoroughly enjoyed it.’
‘I love receiving parcels full of goodies, the variety of items is wonderful and also the surprises.’
‘Thank you ever so much Capital Card for helping both myself and my child to get through those difficult times.’
‘It is very important for me to know that there is somebody out there thinking about me as I have been shielding since March 2020. Thank you for the lovely parcels.’
The Councils are currently planning their approach to recommissioning Substance Misuse services that will become effective from 1st April 2026.
To assist with this work, the two Councils are keen to hear from potential providers of service(s) who currently deliver substance misuse services within the UK, as well as providers who don’t currently deliver in this sector but who would be interested in doing so in future.
As such, the Councils are interested in speaking to all potential providers, whether clinical, LERO, recovery support, mental health, or any other provider who feels they can make a positive impact within this area of work.
Providers are invited to consider the information pack and book in a confidential and informal discussion by emailing John.Salisbury@cumbria.gov.uk (please do not use the expression of interest link within Chest – contact John directly as per the information pack).
For more information and a provider engagement pack click here
The government is to abolish Public Health England (PHE), it has announced. A new organisation, The National Institute for Health Protection (NIHP), will instead bring together PHE and NHS Test and Trace and focus on a ‘rigorous science-led approach to public health protection’.
Matt Hancock: ‘A new organisation with a new approach’
Although the new body is to start work immediately it will not be formalised until next spring in order to ‘minimise disruption’, the government says. NIHP’s responsibilities will include the COVID-19 testing programme, emergency response and preparedness, and specialist epidemiology and surveillance of infectious diseases. ‘To give ourselves the best chance of beating this virus once and for all – and of spotting and being ready to respond to other health threats, now and in the future – we are creating a brand new organisation to provide a new approach to public health protection and resilience,’ said health secretary Matt Hancock.’
As the announcement was made it was unclear what the exact arrangements would be for the Alcohol, Drugs & Tobacco part of PHE’s Health and Wellbeing Directorate. In a speech to the Policy Exchange Hancock said that PHE’s prevention and health improvement agenda would be ‘embedded right across government’, with a consultation to follow. ‘I’ll be saying more on this over the coming weeks,’ he stated. DHSC will also be organising an external stakeholder advisory group to support this and ‘provide expert advice from leading thinkers in public health, health care and local government’, the government says.
Interim executive chair of the new organisation will be Baroness Dido Harding, while the interim chief executive officer of PHE will be Michael Brodie, currently CEO of NHS Business Services Authority. Outgoing PHE chief executive Duncan Selbie will take up a post as senior advisor to DHSC on global and public health.
Phoenix Futures chief exec Karen Biggs addresses the myths and legends of residential rehab and highlights the tangible truth.
Phoenix Futures chief executive Karen Biggs
Over the course of the last 30 years we have developed a robust set of treatment interventions in the UK, based on evidence, research and practice. Delivered by a range of professionals with expertise from different disciplines, they are summarised in drug misuse clinical guidance and referenced by the National Institute for Health and Clinical Excellence (NICE). It isn’t an exaggeration to say they are the envy of many in our sector across the world.
So why are we finding, at a time when we need to rely on that expertise, on the tangible truth, that we resort to myths and legends – stories once upon a time we believed to be true and were held so vividly in the minds of some, used to explain something beyond their comprehension?
‘There are forces at play to get everyone who has a drug problem into rehab’
As with any good legend this is often a cautionary tale used against arguments to increase access to rehab for anyone. ‘Not everyone can go to rehab’ is the cry – a response no one would disagree with. Many people could benefit from rehab but it is most appropriate for the 3-4% of people with the most complex of issues. In many areas of the UK, rehab just isn’t an option. Funding is never ‘awarded’, pathways don’t exist.
‘Rehab is expensive’
This is possibly the tale that best exposes the discrimination against people in addiction. Residential rehab, or addiction care homes, are – together with inpatient detoxification facilities – the most intensive form of addiction treatment for people with high needs and at high risk.
View the DDN Residential Treatment Guide for more information and details of residential services.
Look to any other healthcare needs and we have accessibility to healthcare based on the science. NICE exist to make those decisions. And NICE says:
The range of therapeutic approaches employed in residential treatment makes some programmes especially suitable for those with the most complex needs and for those who ‘have not benefited from previous community-based psychosocial treatment’ (NICE 2007). However, there will be some people who desire to go directly into residential treatment and some may benefit from doing so. Such decisions will need to rely on a best clinical judgement.[1]
…but still local officials, civil servants and health care professionals decide that someone with the most complex of needs isn’t worthy of the funding. Why do we allow stories that try to lure us into a reality where cheapness wins?
Last week Turning Point made a submission to the 2nd phase of the Dame Carol Black Review on the state of provision of treatment and recovery services for drug users and prevention of drug misuse among adults and young people. As a significant national provider of substance misuse services, supporting 59,393 people last year across our drug and alcohol services, we believe that we can provide a unique perspective.
At Turning Point we believe that effective drug treatment policy affects multiple political agendas, from reducing social exclusion, improving health and tackling homelessness to creating safer communities and reducing health inequalities. This makes drugs policy a challenging policy area, because it requires input and outcomes across many different areas, but it also means it can deliver substantial rewards.
Julie Bass, chief executive, Turning Point
The third sector delivers the majority of substance misuse support across England to a high standard, with robust organisational and clinical governance. Social enterprises and charities have been at the heart of innovative and effective practice for decades and continue to provide routes to creating stronger, healthier communities. Turning Point combines clinical quality with a person-centred ethos that recognises that friends, family, work, education, skills and housing are all paramount to a person’s recovery. We believe that the public have confidence in our ability to deliver health services.
The home secretary, Priti Patel, has written to the ACMD seeking its advice on formally exempting alkyl nitrates – or ‘poppers’ – from the 2016 Psychoactive Substances Act. There has long been confusion about the exact legal status of the substances, and as the lawfulness of the their supply remains uncertain, the home secretary is ‘minded to remove this uncertainty by explicitly exempting’ the substances from the act, she states.
Priti Patel: Seeking ACMD advice on ‘poppers’
Although an initial proposed amendment to exempt alkyl nitrates from the Psychoactive Substances Bill was defeated, the ACMD later advised then drugs minister Karen Bradley that in their view the substances would still fall outside of the scope of the act as they did not have a direct effect on the central nervous system (DDN, April 2016, page 4). A 2018 Court of Appeal ruling, however, stated that substances that only have an indirect psychoactive effect could still be covered by the legislation.
The home secretary’s letter also seeks the ACMD’s advice on the drivers of increasing powder cocaine use among young people and drug sales on the ‘dark net’.
We want people of all genders and sexualities to know they’re welcomed and respected in our services. At the same time, we recognise that for members of the LGBTQ+ community it’s not always that simple. Many people in this group might have had negative experiences with healthcare providers and/or experienced discrimination in their lives, both of which could make it more difficult to reach out.
So how do we better understand the needs of the LGBTQ+ community? And how do we better support them with their alcohol or drug use? Alongside existing projects, we set up an LGBTQ+ working group and we’re working with members of the LGBTQ+ community to look at how we can answer these questions. We’re still at the very beginning of what will be an ongoing and evolving project, but it’s an aspect of our work that we know is worth doing better.
A recovery charity is delivering a free pregnancy support service for women in Greater Manchester.
Acorn Recovery Projects, a charity providing a range of recovery services across the North West, is offering confidential advice, guidance and reassurance for anyone concerned about alcohol consumption during pregnancy.
Acorn will be working with Greater Manchester Health and Social Care Partnership (GMHSCP) to support women and their families throughout Bury, Rochdale, Oldham, Tameside and Glossop. The partnership forms part of the wider Alcohol Exposed Pregnancy (AEP) programme.
The free support service is aimed at women aged 18-44 and their partners or support network. The service provides a safe, non-judgemental service for women and their families to receive mentoring, counselling and education on issues surrounding alcohol consumption and pregnancy. Support is not limited to women who are currently pregnant, but also those who are sexually active and identified as at risk of unplanned pregnancy.
Support can be accessed virtually and includes online counselling, group sessions and support from peer mentors. These services can also be delivered by phone, text and email where required. Despite misconceptions, the guidance from the UK chief medical officer advises that there is no safe level of alcohol consumption during pregnancy. Although the advice is clear, the UK currently has the fourth highest level of prenatal alcohol use in the world with 41 per cent of women drinking alcohol during pregnancy.
Recent research shows an alarming rise in alcohol consumption among drinkers since the beginning of lockdown, raising concerns around a potential increase in alcohol exposed pregnancies.
One in five (21 per cent) current and former drinkers said they were drinking more often during lockdown – Alcohol Change UK.
Issues surrounding access to contraception during the pandemic have stoked fears that the proportion of unplanned pregnancies could be set to increase. Department of Health and Social Care figures show that 2019 had already seen a 21 per cent rise in unplanned pregnancies throughout Lancashire. Across the country, Public Health England report that around 45 per cent of pregnancies and one third of births in England are unplanned or associated with feelings of ambivalence.
Louise Whitworth, Alcohol Exposed Pregnancy (AEP) Service Lead
‘We’re excited to be working in partnership with Greater Manchester Health and Social Care Partnership to raise awareness of the issues surrounding alcohol exposed pregnancy. We’ll provide a range of person-centred services to support women and their families before, during and after pregnancy.’
Acorn’s pregnancy support service is available immediately and can be accessed through health visitors, maternity services, children’s centres and health centres. Alternatively, you can self-refer by calling 07583 052 031 or email lwhitworth@acornrecovery.org.uk
A surge in illicit prescription drugs has been linked to a number of overdoses in the UK, warns drug, alcohol and mental health charity We Are With You.
The drugs are made to look like benzodiazepines such as Xanax and diazepam and often come as coloured tablets in blister packs or labelled pharmacy pots.
A national alert has been issued by Public Health England and Public Health Scotland, with We Are With You treatment services across the UK reporting increasing numbers of overdoses linked to these illicit substances.
Improving our understanding of benzodiazepines would save many lives, says Kevin Flemen in his recent DDN article which you can read here.
Testing of some seized tablets has shown they don’t contain any of the drugs they purport to be at all, instead containing more dangerous substances that are not used medicinally.
Dr Rachel Britton, Director of Pharmacy at We Are With You, said:
‘You can’t get Xanax prescribed on the NHS so if someone offers it to you it’s extremely likely to be illicitly produced. Testing has shown that these fake pills can often contain different substances in differing strengths, meaning the chances of overdose are far higher.
‘Due to the dangers, we are urging people to avoid taking these drugs. Unlike opiates, there is no readily available overdose reversal drug for these fake tablets within communities. The drug used to reverse benzodiazepines is carried by ambulance crews and in hospitals so it’s vital that anyone feeling unwell after taking these tablets seeks medical help.
‘However, if you do decide to use these drugs, take a very small amount to start with to gauge the effect. Also avoid mixing with other substances including alcohol as this increases the chance of overdose. Finally, never use these drugs alone and if anyone shows signs of overdose call emergency services immediately.’
Signs of overdose include:
Problems with breathing
Confusion, disorientation and feeling dizzy
Uncontrolled eye movements
Muscle weakness or tremor
Lack of coordination
Slurred speech and extreme drowsiness
Slowed heart rate
Britton went on to urge people concerned about their drug or alcohol use to access support:
‘If you are concerned about your own drug or alcohol use, or that of someone you know, it’s really important to know support is out there. Our services are free, warm, non-judgemental spaces where we work alongside people to help them make changes. You don’t need to worry about placing extra stain on the NHS. Alternatively, you can talk anonymously to a trained advisor via our website – www.wearewithyou.org.uk.’
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.
Northern Ireland is to launch a ‘full consultation’ on minimum unit pricing (MUP) for alcohol, its health minister Robin Swann has announced. The decision follows a review of its alcohol and drug strategy carried out last year.
Robin Swann: Impact of alcohol misuse is being felt by too many families and communities
Northern Ireland’s new substance use strategy, Making life better – preventing harm and empowering recovery will be issued for consultation in the autumn, with the MUP consultation to follow within a year of its publication. Although the proportion of adults in Northern Ireland drinking above the recommended guidelines fell from 26 per cent to 20 per cent between 2010-11 and 2017-18, alcohol-related deaths have continued to rise while hospital admissions increased from just over 9,500 in 2008-09 to more than 11,500 in 2016-17. MUP has already been introduced in Scotland and Wales.
‘The impact of alcohol misuse is being felt by too many families and communities across Northern Ireland on a daily basis,’ said health minister Robin Swann. ‘We need to consider fully every option available to us to reduce this blight on our society. I have been closely following the Scottish Government introduction of minimum unit pricing on alcohol since 2018 and have been noting with interest the early positive evaluation reports. My department has been working in conjunction with key stakeholders on developing a new substance use strategy and this will be issued for public consultation later this year. As part of the strategy, there will be a commitment to holding a full public consultation on the introduction of minimum unit pricing for alcohol in Northern Ireland within one year.’
Prof Sir Ian Gilmore: MUP will hugely benefit communities
The announcement was a ‘positive step forward’, said chair of the Alcohol Health Alliance, Professor Sir Ian Gilmore. ‘If the measure is introduced in the north, then MUP will hugely benefit communities across the whole island of Ireland. Alcohol harm costs Northern Ireland £900m a year. By implementing MUP to raise the price of the very cheapest and strongest drinks on the market, the devastating impact of alcohol harm on families and communities across Northern Ireland can be reduced.
MUP already exists in both Scotland and Wales and legislation has passed for its introduction in the Republic of Ireland. England now risks being left behind in the race to tackle the alcohol harm crisis.’
In the past five years the number of people thought to have hepatitis C in the UK has reduced dramatically.But, on World Hepatitis Day, drug, alcohol and mental health charity We Are With You in Lanarkshire says more needs to be done to meet the UK’s target of eliminating the virus by 2025.
Hepatitis C is a blood borne virus that can infect the liver, with 92% of infections through injecting drugs. Hep C is often symptomless until it reaches the chronic stage – and if left untreated, it can be fatal.
The number of people thought to have hepatitis C in the UK has reduced from more than 182,000 in 2015 to around 143,000 in 2019. However there is still a way to go for the UK to meet its target set by the World Health Organization of eliminating the virus by 2025.
In Lanarkshire, drug and alcohol workers at We Are With You are working hard to get more people tested and into treatment and support.
Helen Hampton, who is We Are With You’s lead clinical nurse for blood borne viruses, explained: “An important part of our charity’s work is taking outreach, diagnosis and treatment for hep C into the community and away from hospitals. By continuing to do this, we can reach, test and treat more people and ultimately help WHO achieve global elimination.”
Jackie (not her real name) accessed treatment for hepatitis C. She said:
“My ex-partner died from hepatitis C. I watched him die what was quite a painful death and it got me really worried about my own health, so I approached We Are With You to get tested.
“I thought it would be painful but it was just a pinprick; I barely felt anything. The staff were really supportive throughout. All I had to do was take a tablet every day for three months. That was it. When I came off the treatment I was concerned the virus may return but I’m now cured and feel better than ever.
“I would urge anyone who thinks there’s a chance they may have it to get in touch with their local drug and alcohol service. It’s just one step and it will save your life.”
Marc Simpson, who works at the We Are With You service in South Lanarkshire, said: “We launched our Positive Support service in 2011 to help people across Lanarkshire get hepatitis diagnosis, support and treatment. As 92% of hepatitis C infections are caused by injecting drugs, we have the specialist knowledge to be able to support the majority of people who have the condition.
“We work closely with NHS harm reduction teams, who put people in the community in touch with us. We take over their care at this point – which could be anything from testing them for hepatitis, free of charge, to taking them to hospital appointments and giving them emotional and practical support. We work with more than 100 people a year in Lanarkshire and it’s amazing to see them progress through treatment and go on to live full and healthy lives.
“Medicine has come so far in recent years that it’s possible to treat and cure hep C with easy-to-take tablets in 8 to 16 weeks. Everyone’s situation is different, so we work closely with hospital staff and consultants to take people on the treatment paths that are right for them.
“Anyone who’s concerned they might have hep C should give We Are With You in Lanarkshire a ring on 0800 599 9774, or you can speak to a trained advisor online via our webchat service. Just visit www.wearewithyou.org.uk.”
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.
The Humankind charity has launched a new national Hepatitis C Action Plan to mark World Hepatitis Day on 28 July.
Stacey Smith, Nursing Director at Humankind.
The action plan aims to further increase testing for Hepatitis C across all Humankind services, ensuring specialist pathways and onsite treatment for the virus.
‘Hepatitis C is most commonly spread through blood-to-blood contact, such as sharing needles,’ said Stacey Smith, Nursing Director at Humankind, which has drug and alcohol recovery services across the country.
‘The government have recently identified that people are not getting access to needle and syringe services as they should in this country. At Humankind, we are picking up that challenge. We really need to further embed hepatitis testing and treatment within our services so that there is no closed doors.’
She said testing was vital as there can be no noticeable symptoms in the first stages of infection, although it can cause major health problems.
Among a list of pledges set out in the plan, the organisation states it will:
Invest in staff to increase testing rates and re-testing rates of people at risk
invest in training for staff to ensure we have a skilled workforce
allow time for data inputting
ensure testing provision is across the whole treatment system
reach out to people who are not registered with its services
commit to listening to what people who use its services say on how best to tackle the issue.
Meanwhile, Humankind is joining a national campaign to raise awareness of Hepatitis C and the fact it can now be cured by a simple course of tablets.
On World Hepatitis Day, the organisation, along with a range of other charities, NHS Trusts and the Hep C Trust are backing the Hep C U Latercampaign online and within its services.
‘Our message is that this virus can be treated and can actually be cured easily!,’ said Stacey Smith. ‘It’s not like the old treatment which lasted for months and sometimes had side effects. The success rate for this short course of tablets is much higher and it’s unlikely you’ll feel ill.’
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NHS Tayside in Scotland has become the first region in the world to effectively eliminate hepatitis C, with 90 per cent of patients diagnosed and 80 per cent of infected cases treated by the end of last year.
Prof John Dillon: The idea of treatment as prevention – the project began in a single needle exchange.
NHS Tayside has diagnosed almost 2,000 people since testing began, and treated more than 1,800 – more than 90 per cent of the estimated prevalence of hep C, meeting the World Health Organization’s elimination target 11 years early. The NHS Tayside project, which was developed in partnership with the University of Dundee, began in a single needle exchange and eventually led to a redesign of services with a focus on testing people who use drugs before they enter treatment.
‘Previous thinking had been that a community of people who inject drugs and their lives are too chaotic to allow for the sort of sustained treatment that hepatitis C needs to achieve a cure,’ said consultant hepatologist Professor John Dillon. ‘However, our view was that with the right approach, supported with appropriate resources, we could tackle what is a very significant problem and reduce the rates of hepatitis C infection. If you can offer treatment at a very early stage, while people who are infected are still actively injecting –when they have contact with other people who inject and share equipment with other people – their chances of transmission disappear because they’re not infected any more. It’s the idea of treatment as prevention.’
Rachel Halford: ‘No one is untreatable.’
‘Getting such a high proportion of people treated is a huge achievement by NHS Tayside,’ said Hepatitis C Trust chief executive Rachel Halford. ‘People who inject drugs often struggle to access treatment due to barriers like stigma around the virus and drug use. NHS Tayside has shown that it doesn’t have to be this way and that everyone can be treated for this virus. No one is ‘untreatable’. If services adapt to patients, everyone can clear the virus and we can make sure we leave no one behind.’
A new digital media campaign has also been launched by Hepatitis Scotland to mark World Hepatitis Day. #BeHepCFree aims to re-engage people who have yet to access specialist treatment and encourage people who may have been at risk to come forward, and highlights the availability of effective tablet-only medicines with minimal side effects.
The government will launch a consultation on plans to provide calorie labelling for alcohol, it has announced. The consultation, which will be launched before the end of the year, forms part of the government’s new obesity strategy designed to ‘beat coronavirus and protect the NHS’.
A cocktail can be the calorific equivalent of a cheeseburger
Other measures in the strategy include a ban on TV adverts for unhealthy foods before 9pm and a requirement to display calories on menus, which could also include ‘hidden liquid calories’ for alcohol drinks. The strategy has been launched alongside a new Better health campaign from Public Health England which is calling on people to ‘embrace a healthier lifestyle’.
Around 80 per cent of people are unaware of the calorie content of alcoholic drinks, the government says, with alcohol consumption estimated to account for almost 10 per cent of calorie intake for those who drink. Around 3.4m people are consuming an additional day’s worth of calories per week, it adds.
Prof Sir Ian Gilmore: ‘Alcohol is a factor in more than 200 health conditions.’
‘The government’s plans to consult on ending the current exemption for alcohol products from calorie labelling requirements are very welcome,’ said chair of the Alcohol Health Alliance, Professor Sir Ian Gilmore. ‘When the calorie equivalent of a large glass of white wine is the same as a slice of pizza or a cocktail is the equivalent of a cheeseburger, it is clear why alcohol products should be included in the government’s plans to tackle the obesity crisis.
‘Alcohol is a factor in more than 200 health conditions and is the leading risk factor of death among 15-49 year olds in England,’ he added. ‘Labelling on all alcohol products with prominent health warnings, low risk drinking guidelines and information on ingredients, nutrition and calories would help equip the public with the knowledge they need to make healthier decisions about what and how much they drink. If we want to build a healthier, more resilient society we need to wake up to the harm alcohol does to people’s health.’
More than a million people in the UK have stopped smoking since the start of the COVID-19 pandemic, according to research by ASH and UCL.
Another 400,000 have attempted to stop during the same period, the organisations say. The figures are based on a survey of more than 10,000 people.
Quitting rates are around twice as high among younger people, with 17 per cent of 16 to 29-year-olds giving up (around 400,000 people) compared to 7 per cent of over-50s (240,000 people). Around 400,000 30 to 49-year-olds have also stopped, translating to 13 per cent of smokers and ex-smokers in this age group.
A new stop-smoking campaign funded by the Department of Health and Social Care (DHSC) is also being launched, with a particular focus on older people as they are at risk of worse outcomes from COVID-19 through smoking-related conditions such as COPD. It will also the target local authority areas with the highest rates of smoking.
‘Over a million smokers may have succeeded in stopping smoking since COVID-19 hit Britain, but millions more have carried on smoking,’ said ASH chief executive Deborah Arnott. ‘This campaign is designed to encourage those who’ve not yet succeeded to wake up and decide today is the day to stop smoking.’
A supervised injecting facility (SIF, also referred to as a drug consumption room or DCR) is not the only answer to reducing drug-related deaths, but could fit into ‘a multi-component strategy’ to reduce vulnerability, overdose risk and fatal outcomes from overdose. Introducing an online session, Professor Alex Stevens of the University of Kent wanted to discuss the evidence, the obstacles and a way forward for making SIFs a reality.
‘Not only do they save lives, they help people to improve their injecting technique, access treatment and harm reduction services, and address other vulnerabilities in their lives,’ he said.
Niamh Eastwood, executive director of Release
looked at whether a SIF could be legal. With the government ignoring the ACMD’s recommendations and continuing to oppose such a facility, three offences relevant to a DCR/SIF stood out in particular – possession, encouraging or assisting a person to commit an offence, and contravening the Anti-Social Behaviour Act.
With legislation unlikely to change anytime soon, she suggested that a way forward would be through multi-agency agreements between the police, local authorities, PHE, health providers and prosecution services. ‘Letters of comfort’ could be provided by police to allow local services to provide harm reduction equipment such as citric acid and foil. ‘The impetus comes from local activity,’ she said.
DCI Jason Kew gave thoughts on working with the police to open a SIF. His strong view was that it was a health matter – ‘a medical facility, a harm reduction facility’ – and it wasn’t the police’s place to lead on this work. The data on drug misuse deaths showed ‘a clear picture of where we need to act sooner,’ he said. With 78 legalised DCRs operating in Europe without a single drug-related death, we needed to ‘humanise the statistics’. ‘Is there really the public interest in prosecuting a healthcare professional trying to safe somebody’s life? Absolutely not,’ he added.
Health authority staff members work at SafePoint, a supervised injection site in Surrey, Canada. Credit: Xinhua/ Alamy
‘DCRs attract a great deal of emotion for or against them,’ said Rudi Fortson QC. A local memorandum of understanding was the best way forward, he suggested. ‘One has to look at the reality of the situation, which is that despite 14 years of campaigning to even pilot a DCR within the United Kingdom, we haven’t got one. Why not? It comes back to those fundamental issues of public acceptability of a DCR on their doorstep.’
Saket Priyadarshi, medical lead at Glasgow Alcohol and Drug Recovery Service, had been closely involved in making the case for a DCR in the city – a move provoked by an outbreak of HIV in people who injected drugs. A formal health needs assessment by public health colleagues had resulted in recommendations for a heroin-assisted treatment service (HAT) and a SIF. Glasgow’s health and social care partnership – which included police and people with lived experience of using drugs in public places – had accepted the recommendations and asked for a business plan for a SIF in the city.
The model they proposed was co-located with HAT and a very low threshold service ‘to capture as many of our target population as possible’, including pregnant drug users. The large fixed-site model ‘would manage the clinical governance concerns being expressed’ and it included an aftercare area.
The project is currently snagged by ‘a constitutional stand-off between Edinburgh and Westminster’ but they have made plans around public engagement to manage local concerns and ‘have an evaluation and research agenda in place’. A HAT service has already been implemented in the interim, and they anticipate that the SIF will be a ‘scaled-up version’.
Health authority staff members work at SafePoint, a supervised injection site in Surrey, Canada. Credit: Xinhua/ Alamy
The West Midlands had also been developing a model, as Megan Jones, head of policy for the Office of the West Midlands Police and Crime Commissioner, explained. The office had begun by looking at the scale of the drug problem in the region, with the cost of heroin and crack cocaine users calculated as £1.4bn and the cost of crime committed by the average heroin or crack user as £26,000.
A drug policy summit had involved the public in looking at a new approach, with the drivers of reducing harm, reducing crime, and reducing cost. The eight recommendations had included DCRs, and an independent report – Out of Harm’s Way, written by Ernie Hendricks in March 2020 – covered evidence from the UK and across the world. Its two main recommendations were to develop a business case through a multi-agency steering group, and to work with government and the steering group to support a DCR pilot site in the West Midlands.
We had to be led by the evidence, take the public with us and have an ‘open mature conversation about drug policy and its failings,’ she said. It needed to be done with existing treatment providers and people with lived experience, be linked to the homelessness agenda, and be done through a partnership approach.
Martin Blakebrough had been asked to talk about developing a model for Wales, and as CEO of Kaleidoscope he had experience of an early SIF model. In the ’70s and ’80s Kaleidoscope ran a club that also had a needle and syringe exchange in it, with a methadone dispensing system and doctors and nurses: ‘In many ways it was a drug consumption room, but it wasn’t actually publicised as that.’
Looking at other places, such as Cardiff, ‘we know there are unofficial consumption rooms there, in hostels,’ he said. ‘So it’s not quite right to say we don’t have consumption rooms – but we don’t have DCRs that can call themselves that, or that are recognised in law.’
Martin Blakebrough, CEO of Kaleidoscope
The idea that the facility had to be an expensive option was ‘ridiculous’, he added. ‘In Wales we’re saying “it’s just a room”. The idea that we need to create ridiculously safe spaces that are sterile is also difficult – would you want to be drinking beer in a sterile environment? We have to create services that are hugely attractive to the people we want to serve. And they need to be involved in the design and development of that service.’
Peer mentors were the best people to advise someone on how to inject drugs, and the idea should be around creating a space for service users to help each other – ‘and if it’s part of a drug service or adjacent to it, I don’t really see the public outcry,’ he said. ‘Let’s make this happen by using the skills and passion of our drug using community and champions’, giving them the money to run the services, the legal cover, and the clinical assistance they needed to run the place safely.
Mat Southwell, technical consultant specialising in community mobilisation for people who use drugs, agreed on the value of peers’ central role and added that it was really important to give drug users choice around a highly medicalised model or a drop-in style community centre approach. ‘If you involve people in the design of a project they’re going to have more investment,’ he said.
Mat Southwell, technical consultant specialising in community mobilisation for people who use drugs
It was important to think about their inclusion in staffing too, as part of an ‘empathic committed service’. Drug user groups had been ‘pivotal’ to delivering NSP around the country and different parts of the world and were well placed to carry on managing many DCR environments, as they did already.
‘It’s not about saying either nurses or peer educators, but saying what’s the combination we can put together to maximise the impact of a system,’ he commented.
Summing up the session, Alex Stevens said it was really important to build the evidence base, both in the UK and globally, for whether and how SIFs work. Three clear stages of development, piloting and evaluation could be taken from the Medical Research Council’s framework and ‘all this needs to be done alongside service user involvement from the very early stages’.
DCI Jason Kew
We were not starting from scratch, but had research to build on, including a ‘logic model’ of how these services work from Australia and Canada. A look at costs and benefits could lead to a template that people could plug their local data into.
Joining in the summing up, the senior police representative Jason Kew added: ‘This is depoliticising it, about saving people’s lives, about keeping people safe – it’s as basic as that. People talk about going soft on drugs, but there’s nothing soft about preventing deaths. Nothing.’
Conversations at the moment often come back to feelings of anxiety and isolation, so we’re pleased to be able to keep sharing the ways you’re responding positively to the COVID situation. Forward Trust are among those looking for creative ways to engage their service user community (p10), while Open Road and Humankind are also redoubling their efforts to connect with service users and make sure no one is isolated (p16 and p22).
With lockdown likely to have a disproportionate effect on women (June issue, p9), we have an insight into domestic abuse support (p12), while Kevin Flemen looks out for young people in the summer party season with some targeted harm reduction advice (p9).
As Bill Nelles (p14) would be the first to remind us, harm reduction must stay top of the agenda so we’re pleased to see the cross-sector mobilisation to make injecting facilities a reality (p18) and to support the call for redoubled efforts on eliminating hepatitis C (p11) as World Hepatitis Day approaches on 28 July.
As one of our letter-writers points out (p20) service user involvement should be central to everything we do, so we hope you get involved with the two initiatives from the research team (p6) and PHE (p8) to bring lived experience to the heart of informing treatment.
One of the key tasks of the national recovery champion role is to bring people together within the addictions field to tackle a common goal – overcoming the pain and misery that addiction can bring. People with lived experience of addiction have a crucial part to play in recovery-oriented systems of care, and it is important that their voice is heard when policy is being developed. This is particularly so as the country adjusts to the changes imposed by the COVID-19 pandemic, and as the next phase of Dame Carol Black’s review of drug treatment services begins (news, page 5).
The SURE Recovery app offers a new mechanism for supplying anonymised feedback on important topics relevant to the development of good quality treatment services. Each month users of the app will be invited to respond to a key question that will be developed by the recovery champion working with the app development team, which includes researchers from King’s College London and people with lived experience of addiction. Researchers from the app team will analyse the data from those who consent and share the anonymised findings with key policy makers, including Public Health England and NHS England. The sharing of anonymised data is completely optional, and people can use the app without answering any research questions.
Read the full feature in DDN magazine
SURE Recovery is available to download for free from Google Play and the App Store. The work to produce SURE Recovery was undertaken in collaboration with people using alcohol or other drugs, in treatment and in recovery. It was also supported by an addiction service user research group linked to a London-based peer mentoring service called the Aurora Project.
A wide range of other people were also involved in developing SURE Recovery, including addiction clinicians, Create Recovery (a small arts charity that supports people with experience of addiction issues to develop their creativity) and Mindwave Ventures (an app developer that focuses on user-centred digital design). The work was generously funded from various sources, including Action on Addiction, the Alexander Mosley Charitable Trust, the Mackie Foundation, and the NIHR Maudsley Biomedical Research Centre, King’s College London.
In developing SURE Recovery, the project team followed a co-design process to make sure that the app would meet the needs and expectations of people experiencing addiction. They conducted interviews and focus groups with people who were using substances, in treatment and in recovery, in order to better understand the process of recovery and how an app might support this. Successive versions of the app were also reviewed and tested by people with lived experience of addiction to make sure that functionality was optimised, the meaning of all text was clear, all graphics and images were appropriate, and there were no bugs or system crashes.
Download the app from Google play and The App store
Not everyone has a smartphone or tablet computer, but there is evidence that people who use substances increasingly have good access to mobile technology. Mobile health apps, such as SURE Recovery, tend to be easy to download and cheap to use. They can therefore be an additional valuable resource for people who may not be in contact with services, and for people who may be thinking about, or working on, their recovery. We know that people do not generally use mobile health apps in a sustained way for months and years – instead they tend to be used as and when people feel they meet their current needs. This is how the development team expect that SURE Recovery will be used.
It seems likely that different features of the app will appeal to different populations at different points in time and with different effects. For example, the recovery tracker, with its personalised feedback, may ‘nudge’ people to reduce their substance use, change their behaviours, or encourage those who are not in treatment to enter treatment. The artwork feature may have a therapeutic effect, enhance self-esteem or appeal to those who find it difficult to express themselves in words. Meanwhile, the naloxone feature may increase engagement with take-home naloxone and improve overdose management competency, so potentially saving lives.
We encourage anyone with lived experience of addiction and an interest in recovery to download the app and give it a try. If you like it, we ask that you tell other people so they know about it too. If you think it can be improved, please let the research team know. People with experience of addiction have a right to good mobile health apps just like any other population, and the aim is to ensure that the SURE Recovery app is a resource that can help as many people as possible.
If you have an Android device, the SURE Recovery app can be downloaded from Google Play. If you have an iOS device, the SURE Recovery app can be downloaded from the App Store. People can also follow and communicate with the SURE team via Facebook, Twitter (@SURE-Recovery), Instagram (sure-recovery) and YouTube.
SURE aims and features
SURE Recovery is intended for people who are using drugs or alcohol, in recovery, or thinking about recovery. It has five main aims and six key features. The five aims are:
1. To enable people to track and monitor their own recovery journeys
2. To enable people to recognise when they might need help
3. To enable people to identify sources of support
4. To enable people to find inspiration from others in recovery
5. To generate new data that will help researchers and policy makers better understand substance use and recovery
The six key features are:
1. A recovery tracker: this allows people to monitor their own recovery using a co-designed validated outcome measure called the Substance Use Recovery Evaluator (or SURE). Once SURE is completed within the app, personalised feedback and a score are generated. Weekly, monthly and yearly scores can then be viewed in a graph, allowing app users to view and track how their scores change over time.
2. A sleep tracker: this works in a similar way to the recovery tracker. App users can complete a co-designed validated scale of sleep problems called the Substance Use Sleep Scale (or SUSS). This will then produce personalised feedback and a score that also allows app users to monitor and review their sleep problems over time.
3. A diary function: this provides a private space where people can record their thoughts and feelings.
4. Artwork: the app provides a platform for people to share their artwork with the recovery community. App users can submit their artwork for possible display in the banner on the home screen of the app.
5. A naloxone resource: this feature provides instruction on the use of naloxone in the event of overdose. There are also informational resources, including a training video and a knowledge tracker which uses the Opioid Overdose Attitudes Scale (OOAS), a validated measure of overdose management competency.
6. Reading material: app users have free access to the book The Everyday Lives of Recovering Heroin Users, based on the lived experiences of people in recovery.
• Ed Day is national drug recovery champion and clinical reader in addiction psychiatry at University of Birmingham.
• Jo Neale is professor in addictions qualitative research at King’s College.
• Alice Bowen is research assistant at King’s College.
Summer weather and lack of other entertainment mean that young people are once again turning to outdoor partying on a large scale. Drug services are going to have to get creative about harm reduction, says Kevin Flemen.
In many post-apocalyptic films there’s an unbearably naff sequence where everyone has a party. It’s like The Matrix Reloaded ‘Zion dance party’ and usually involves everyone getting into tribal drumming and showing off their tattoos. It turns out that all these scriptwriters were, in fact, absolutely on the money. While the COVID-19 pandemic is nowhere near over and social distancing is still in theory the order of the day, we’re at the Zion dance party stage of proceedings.
A few weeks ago I ran a ‘young people and drugs’ webinar and one of the things I flagged up was the likelihood as we exited lockdown of unlicensed events becoming a bigger issue. One participant highlighted that it was already happening in Bristol – that was a month ago. Since then the prediction has come to pass and there has been a massive upsurge in house parties, block parties, illegal raves and spontaneous open-air events. Some of these have made the national news, but the media attention has so far mostly been on litter and conflict with the police – the issue of drugs and safety has not yet been discussed so widely.
The upsurge in unlicensed music events should come as no surprise. Pubs are only now reopening on a restricted basis, nightclubs won’t be reopening for the foreseeable future and organised festivals have been cancelled. A cohort of people who have been furloughed, have lost work or are entering the summer unclear if they are going on to higher education are bored and craving social interaction and entertainment. And the weather’s hot. Partying outside is very clearly going to be the order of the day.
The drug harm reduction input at some organised events pre-lockdown has been very successful in making festivals and clubs much safer. Onsite drug testing, festival welfare, trained staff and harm reduction interventions were helping to raise awareness of, and reduce the risks from, high-strength pills and powders and pills containing unknown and possibly dangerous cuts, as well as providing help to those in distress. The best of these were collaborative exercises between promoters, police and welfare services.
This festival harm reduction doesn’t translocate to illegal events quite as easily, especially in the current climate. Clandestine events may be organised online with the final location announced at the last minute. Organisers are understandably wary of engaging with any statutory bodies – wariness that is likely to extend to drug services. Even where workers or volunteers could gain access, their own safety needs to be ensured in terms of COVID-19, personal safety and not getting caught up in any enforcement action. There had been concern that scarcity of precursor chemicals could mean a shortage of MDMA and the re-emergence of more dangerous compounds such as PMMA. Conversely there have also been reports of extremely high-potency pills, with peak doses in excess of 350mg being reported.
Kevin Flemen runs the drugs education and training initiative www.kfx.org.uk
Without any doubt, as we exit lockdown, the explosion in unlicensed events will be the issue to contend with and drug services need to engage with this fast, creatively and at a grassroots level, if they are to provide much-needed input.
Given that unlicensed events are going to be one of the issues over the summer months, interventions are essential. And the ‘how to’ for working with unlicensed events means revisiting earlier harm reduction and being less reliant on permitted access and high-tech onsite testing.
It’s going to need to be more grassroots, including:
• production of clear accessible literature
• use of testing sites such as WEDINOS, Pill Reports and The Loop to promote awareness of contaminated pills, high-strength and other dangerous products
• safety advice about use of nitrous oxide
• engaging with promoters via social media so that they can make events safer – water onsite, access for emergency services, trained volunteers and engaging with drug services to provide outreach if possible
• peer education – as, more often than not, drug services won’t be on site it’s essential to equip those attending events with the resources and tools to manage critical incidents. Making sure attendees know how to spot signs of MDMA overdose and manage it is critical
• using What3Words to ensure that emergency services can locate people at outdoor events with pinpoint accuracy
• general harm reduction with a view to addressing COVID-19 spread including the sharing of snorting tubes, spliffs, drinks and balloons
• legal advice cards such as Release ‘Bust Cards’ so that people detained during enforcement activity know their rights and can access legal advice and personal safety advice
Now in its 30th year, the Unlinked Anonymous Monitoring Survey is a vital tool for harm reduction, says Emily Phipps.
This year the Unlinked Anonymous Monitoring Survey (UAM) of people who inject drugs celebrates its 30th anniversary in England and Wales and 18th anniversary in Northern Ireland, making it the longest running annual survey of this cohort in the world.
Coordinated by Public Health England (PHE), the survey consists of a self-completed questionnaire and biological sample that is anonymously tested for HIV, hepatitis B and hepatitis C to monitor trends in blood-borne viruses (BBVs) and behaviours that impact transmission, such as needle sharing, testing and treatment uptake. No identifiable information is collected, and the survey or test result cannot be traced back to an individual, making it easier for us to ask questions about risky behaviours that might otherwise go unanswered.
The UAM is a powerful tool for advocacy and service planning, both nationally and locally. Each centre undertaking more than thirty surveys each year is provided with a free, detailed report of their responses to help them understand what the key priorities for their clients are. Nationally, the report feeds in to key annual publications such as Shooting up and Hepatitis C in the UK. The survey data is also shared internationally with the World Health Organization and European Centre for Disease Control to support global BBV elimination initiatives.
In current times, championing the needs of people who inject drugs and ensuring continued access to services is incredibly important. There are valid concerns that reduced uptake of BBV testing and difficulties in delivering the same level of needle and syringe provision during the pandemic will lead to an increase in infections among this group. The UAM, now more than ever, is an essential tool for understanding the impact of COVID-19 on people who inject drugs, and to keep track of progress as services recover.
Dr Emily Phipps consultant epidemiologist at the National Infection Service, PHE.
The UAM team would like to say a huge thank you to all of our volunteers and participants who have been undertaking the survey during the last few difficult months – the data you have collected is absolutely vital. If you would like to join the UAM survey, or have taken part previously and would like to restart, the UAM team would love to hear from you. Every survey completed is a hugely valuable source of information on this population group who are otherwise often under-represented in policy and statistics. For further information, please contact Claire Edmundson, at claire.edmundson@phe.gov.uk.
Louise Hansford, regional hepatitis C elimination co-ordinator for the South of England
Dr Emily Phipps is consultant epidemiologist at the National Infection Service, PHE. She prepared this work with Megan Bardsley, HIV/STI surveillance and prevention scientist, and Claire Edmundson, senior scientist, at PHE
‘We have had a phenomenal number of responses to the Unlinked Anonymous MonitoringSurvey, which provides us with a wealth of information about our clients – the addition of a finger-prick test for the anonymous blood sample part gives us another opportunity to offer diagnostic testing. Through this testing done alongside the survey, we have picked up 47 cases of hepatitis C that we may not have done otherwise.’ Louise Hansford, regional Hepatitis C elimination coordinator.
Even in the most difficult circumstances recovery is always possible, says Jody Leach.
Read the full article in DDN magazine
We are a local charity supporting those struggling with addiction across Essex and Kent. Together with our main substance misuse provisions, some of the other projects we also deliver to support vulnerable populations include our work within a specialised women’s refuge, the Essex Appropriate Adult service, our targeted housing support service and our ‘SOS Bus’ services.
Mirroring previous articles on the ‘new normal’ of delivering substance misuse provision at this time, the pandemic and its restrictions have had an unprecedented impact on all our services and how we have been able to evolve to continue supporting those most vulnerable. While it’s hard not to, rather than detail all the amazing work our teams, wider treatment system partners and the local community have undertaken to help continue supporting our service users, I feel it’s important to share the voice of some of those service users and examples of positive recovery at this uncertain time.
Coping with change
For the majority of those we support, change is not popular and can be anxiety provoking at the best of times. We have worked tirelessly to help manage the imposed uncertainty that the pandemic has created, by continuing to offer the structure and support that is normally provided as standard. We have been impressed with how our service users have accepted and adapted to the required changes – not only have they worked with us to support our teams, many have told us that elements of our new ways of working are actually preferred to practices we had been doing for some time. COVID-19’s impact is tragic, but we are indebted to our service users for their investment in what we do to share these valuable insights. The following examples highlight how the measures we have taken over the last three months have been experienced positively by those using our services.
In response to many refuges excluding those with substance misuse needs, we deliver a specialist service within a refuge to ensure these vulnerable women are supported into potential recovery. One of our service users told us that while being addicted at any time in life was difficult, ‘adding COVID-19 to the situation poses a whole new dimension to overcome. Having resided at a women’s refuge since January, I have had first-hand knowledge of the detrimental effect COVID-19 has had on others. Lockdown has taught me that I can be patient and content with my own company and it has pushed me to try and learn new things.
‘I am very lucky to be working with Open Road and my worker has been nothing short of brilliant,’ she continued. ‘She has thought of me at every turn and introduced me to meetings all over the county, including many new opportunities. She is fully aware I am not a huge fan of attending meetings, so having Zoom meetings has actually aided my recovery journey and allowed me to meet others all over the county in similar situations as myself. The amount of pressure Open Road have endured in the current pandemic must have been monumental, and without any previous experience to draw on, they have been fantastic.’
Appropriate services
Our Appropriate Adult (AA) service supports many held in custody with additional substance misuse needs. We are proud to have continued delivering this crucial support throughout the lockdown – despite its challenges – thanks to the passion and commitment of our teams. Essex Police’s custody commander said of the service, ‘Of a special note is the fact that Open Road have continued to provide support to detainees – something that is almost unique in my experience in the AA world at this present time.’
Given the impact of the lockdown on the night-time economy, our usual SOS Bus services have not been needed. Instead, in collaboration with the local council, our staff used the service’s minibuses to transport local homeless residents to temporary accommodation.
Pandemic complications
Our housing support service has been extremely busy supporting service users that are being negatively impacted further by the pandemic. One was referred into the service following the death of his brother whose funeral he was unable to finance. Our worker liaised with the relevant housing association and welfare rights advisor to enable the tenancy to be transferred, and an intensive package of support was made available. Had this work not been undertaken, our service user would have remained isolated and alone during a heartbreaking situation that was made all the more difficult by social movement restrictions. The implications for his ongoing recovery are obvious, but we are happy to report that he is continuing to do well with his reduction in substitute prescribing and abstinence from illicit drug use.
One of our young service users has particularly struggled during lockdown and found it hard to get into the new routine of not seeing friends at school and being at home constantly. He is classified as high risk as he self-harms regularly and feels he can’t disclose his self-harm experiences to other professionals. He now looks forward to the increased telephone and video calls from his worker that are helping him to manage his self-harming and drug-using behaviours.
This example highlights the recovery-focused passion that our workers continue to share despite the circumstances, and how we are always trying to put the needs of our service users first. One of our workers spent time speaking with a treatment-naïve individual that just happened to be waiting in the street for a friend that was attending an appointment with our service. This person was street-homeless and had been using heroin and crack since the age of 14. Despite the strict guidelines in place to avoid transmission, the worker was able to safely organise an initial assessment, as she felt that if the person was offered a time to return the opportunity may be missed for them to follow through on their apparent desire to access treatment.
He was extremely grateful for this quick thinking and left the service with his first-ever prescription for substitute medication, and was also issued with – and accepted – naloxone. He was supported to register with a GP and referred into OCAN [Offenders with Complex & Additional Needs] provision and the DWP to access benefit assistance.
It will get better
Jody Leach is quality and treatment manager at Open Road
One of our recovery support service users perfectly sums up how they have experienced our response during the lockdown: ‘I miss everyone at Open Road and can see how important the service is even more now through the COVID-19 pandemic. I have always isolated myself and shut myself away, feeling like a burden or a pathetic weak person who cannot even sort themselves out. Open Road helps me to feel like I am able and can try again and not give up.’
To our fellow service providers and service users who may be reading this, things will get better. Until this new normal allows us to fully resume helping even more people struggling with addiction, we will keep trying to showcase to others that recovery continues to be a possibility for anyone that seeks support at this most unusual time.
With World Hepatitis Day on 28 July, now is the time to redouble our efforts towards hepatitis C elimination, says Rachel Halford.
Rachel Halford is chief executive officer at the Hepatitis C Trust
World Hepatitis Day this year will be unlike any other we have celebrated before. Hepatitis C continues to have a huge impact on people who inject drugs, with the latest statistics showing the rate of new infections among injecting drug users remains worryingly high. The surge of activity we have seen since last summer when NHS England signed an elimination deal with the pharmaceutical industry – not only to provide medication but also to commission case-finding initiatives – has largely come to a halt as a different virus has taken centre stage.
As with almost all other areas of healthcare, the impact of COVID-19 on services providing hepatitis C treatment has been sudden and dramatic: nurses and doctors were re-deployed overnight, clinics were cancelled, most testing ceased and new treatment starts were generally delayed. HCV Action, a network for professionals working in hepatitis C coordinated by The Hepatitis C Trust, found that around one quarter of the 22 hepatitis C treatment networks (operational delivery networks) were only able to treat patients already on their registers or no cases at all at the end of May, even as clinics began to recover.
Understandably, as many doctors and nurses have had their time diverted from clinics to wards in order to provide much needed additional capacity, some areas were under greater strain than others. Despite these difficulties, a number of services have demonstrated phenomenal creativity and determination to continue to help people. Many of The Hepatitis C Trust’s peer-to-peer support staff and volunteers have been going into temporary accommodation across the country to test people who had been living on the streets. This brilliant partnership working between NHS trusts, other charities, alcohol and drug services, and the hotels and hostels themselves has allowed many hundreds of people who had been rough sleeping to be tested and referred on to treatment – engaging a population for whom the traditional treatment model is often not accessible.
COVID-19 has laid bare the extent of health inequality in this country. In England, people living in the most deprived areas are around twice as likely to die from COVID-19 compared to those in the least deprived. Hepatitis C likewise impacts disproportionately upon the most vulnerable in our society – almost half of the people with hepatitis C who go to hospital come from the poorest fifth of the population.
As health services begin to recover from the strain of increased admittances to intensive care, it is essential we re-focus efforts to address those disease areas which predominantly affect disadvantaged and marginalised populations, of which hepatitis C is one. With easy-to-take drugs that have a short treatment term and high cure rate there is no excuse for the UK not to meet its commitment to eliminate hepatitis C by 2030 – the World Health Organization’s hepatitis elimination goal, which we joined many other countries in signing up to. Progress has been positive on diagnosis and reducing hepatitis C-related deaths, but we have a long way to go before we can viably achieve and sustain elimination.
Even with the persistence of laudable efforts to target those people most at risk of infection, there has been no notable reduction in new transmissions in recent years. Prevention is absolutely vital to achieving elimination and yet currently harm reduction provision does not go far enough, with 36 per cent of people who inject drugs reporting in 2018 that they did not have adequate needle and syringe equipment for their needs, heightening the risk of hepatitis C transmission through sharing injecting equipment. We must ensure people are supported to access needle and syringe exchanges adequate for their needs and so reduce the spread of blood-borne viruses such as hepatitis C.
Do you want to help the Hep C Trust tackle the virus? Click here to see their latest vacancies.
The majority of hepatitis C cases in the UK remain undiagnosed, resulting in potentially tens of thousands of people experiencing health complications including liver damage and an increased risk of mortality. This World Hepatitis Day we must applaud services for their incredible hard work and dedication so far, and redouble our efforts to prevent new infections and expand testing and treatment until we have achieved elimination.
By 1983, the cold war among doctors treating drug users was becoming a lot hotter, and there was still no public health response to drug use.
The Home Office consultants still met regularly, and included private doctors as well as NHS consultants. The NHS doctors felt the private doctors prescribed overly generously, didn’t demand reductions, left their patients ‘still addicted’, and even charged them fees. The private doctors felt the NHS doctors were too rigid and their patients poorly treated. Guidelines on the treatment of drug misuse (‘orange guidelines’) were the first national guidance issued by this group in 1984 – they pleased few. For instance, the guidelines considered that medically supervised detoxification was a ‘simple and short-term process with spontaneous remission possible’, and also stated that maintenance was not acceptable. ‘Evidence-based treatments’ didn’t really exist in addiction medicine at that time.
Ironically, the main use of the orange guidelines was as evidence in 1986 at Dr Anne Dally’s General Medical Council (GMC) hearing. She was a feisty senior private doctor on the working group and one of the signatories of the 1984 guidelines. I gave testimony supporting her at her GMC hearing, having become the drug education officer at the Terrence Higgins Trust (THT) a year earlier, but her verdict was guilty of maintenance! While she was able to still be a doctor, she was never allowed to prescribe controlled drugs again. Her practice evaporated almost overnight.
Because of its policy of avoiding methadone and arresting users for the possession of syringes alone, Scotland was one of the first parts of the UK to see the unusual and mostly lethal illnesses associated with AIDS and injecting drug use. Cheap heroin from Iran and the easy availability of Temgesic, (ironically, an early sublingual form of buprenorphine) had vastly increased the number of people injecting opioids, and police pressure had made clean needles impossible to obtain.
But two factors had yet to reveal themselves. The first was, of course, the AIDS epidemic, with the first Scottish drug user dying in Scotland in 1983. The second was the growing involvement of general practitioners in providing services to drug users and their influence on practice. Britain had not made methadone a drug needing a Home Office licence, and thanks largely to the efforts of dear Dr Tom Waller – an ACMD member who batted it back every time it was put forward – it was never adopted as policy.
These trends intersected in early 1985, when a young GP in Edinburgh published a paper in the BMJ which galvanised me, and many others, into serious action. Dr Roy Robertson, (now the Queen’s physician in Scotland and professor of addiction at Edinburgh University), had been seeing drug users for some years, and maintaining some with dihydrocodeine. He was able to obtain HIV test kits in advance of their national availability, and in late ’84 had taken blood for HIV antibody assay from around 160 patients. He knew they shared used needles, and the paper showed that 51 per cent had already been infected by HIV.
The effect of this news cannot be exaggerated. Research testing in London was showing rates of under 5 per cent positive, so we realised we had a short window to make a difference if we moved fast. By the summer of 1986, teams in London, Liverpool, Edinburgh and Amsterdam and, of course, the US were working very hard to understand what they were facing, and the UK and Holland had already implemented needle exchanges to stop sharing and prescribing to reduce injecting.
But there were still battles to be fought over clean injecting equipment. I had been seconded to the Standing Conference on Drug Addiction (SCODA) from the THT to write a booklet about AIDS for drug users, but in February ‘86 I spoke at a large National Haemophiliac Society meeting in Newcastle at which I represented SCODA and called for a serious examination of supplying clean needles.
This was picked up on Newsnight, and on Monday I found myself called to the office of the director. In fact the Friday before, after six months of abstinence from opiates, I had engaged a private doctor to look after me so that I didn’t resume injecting. He strongly objected that I had supported needle exchanges. I was also told that I ‘looked stoned’ and under no circumstances could someone work in a drugs agency even on legal methadone. That same day I returned to the THT where we concentrated on reducing the risk for drug users through advocacy with politicians, speaking engagements, and writing leaflets. By 1988, the McClelland report in Scotland and the ACMD special report chaired by Ruth Runciman gave the green light to access to clean needles, setting up 15 pilot schemes in England and Scotland. These were quickly expanded when the pilots reported favourably and both reports called for an immediate re-evaluation of methadone prescribing.
GPs had also become more independent and proactive especially if they had no specialist prescriber. West Berkshire Health Authority under Ailsa Duncan, their drugs coordinator, engaged me in 1988 to train a group of around 15 GPs to prescribe methadone. It was a five-day course with a written handbook. Apart from Ailsa, none of the doctors were aware they were being trained by a methadone patient!
I have great respect for all evidence-based treatment including non-prescribing approaches when it’s what the patient seeks. But present policies that deny people such approaches are shameful and should not be tolerated. In the last part of this series, we will look at the golden age of drug services – the first eight years of 2000. And how it all collapsed and we ended up where we are now.
Gavin Strang MP (Edinburgh, East), House of Commons debate 31 March 1988
‘We know that the main method of transmission [of AIDs] among drug takers is the sharing of dirty needles… It was clearly documented in a paper produced by Edinburgh professionals in February 1986. The Scottish Office commissioned a report from a committee chaired by Brian McClelland published in September 1986, which recommended decisively that the government should bite the bullet and provide clean syringes at an exchange centre, where drug injectors would be able to obtain free needles and syringes.
‘The government’s response to that call has been so inadequate as to be positively irresponsible. They sat on the McClelland report for months. Eventually, they announced 15 pilot schemes, 12 in England and three in Scotland. Of course such projects involve problems – the minister may wish to comment on them – but we must make the projects work.’
Miranda Hawtrey is a support worker at Jane’s Place.
Working in a setting supporting those with addiction issues and complex needs is always a delicate balancing act. But when the coronavirus outbreak swept through the UK in March 2020, the team at Jane’s Place in Burnley had an extra challenge on their hands.
Jane’s Place is a somewhat unique service established in 2017 by SafeNet Domestic Abuse Support Services, who provide domestic abuse support to women, men and children. They are also the lead providers for Lancashire Refuges.
Jane’s Place is the only one of its kind in the North West – not only does it help to support women who are fleeing from all forms of domestic abuse, but it also breaks down barriers often posed by traditional refuge. A lack of appropriate accommodation and support for women and families with complex needs who need to escape from domestic abuse often results in outcomes such as women returning or staying with the perpetrator, escalating risk and coping strategies such as increased substance use, a lack of trust in services and sofa surfing, which often results in rough sleeping.
Jane’s Place is named in memory of Jane Clough, who was killed by her ex-partner in 2010. Jane’s parents, John and Penny Clough (pictured), are now SafeNet patrons.
A mammoth task
The challenge of implementing safety measures and managing the extra risk posed by lockdown in this kind of specialist environment has been a mammoth task, and the team knew they had to adapt the service fast to ensure they could keep everyone involved safe and continue to support their residents.
They started by expanding and increasing their safehouse provision to provide safe spaces for those residents who were shielding, showing symptoms and needing to self-isolate. Those with serious drug and alcohol use issues and/or sex working women who found it impossible to adhere to the government guidelines had to be kept safe regardless of whether or not they were able to comply, and the team achieved this by use of separate safehouse facilities with specialist intensive floating support.
Each individual resident had an emergency COVID plan created and tailored to meet their needs. Along with various other measures, such as extra cleaning, PPE and updating residents and checking in to make sure they knew what the guidelines were, the team quickly pivoted the service to offer as much flexibility and support as possible.
This hasn’t come without its setbacks. The team have faced difficulties accessing help from outside agencies that would usually support residents, and accessing healthcare has been made much more difficult by skeleton staff in other agencies and lack of GP appointments. The residents also voiced that they were missing group work; the need for connection during their journey plays a big part in recovery.
Getting creative
Alongside the practical solutions – with staff members collecting methadone for residents daily and assisting with non-molestation orders received via court sessions over the phone with residents – the team got creative. They introduced ways for residents to connect with professionals and loved ones virtually, created online recovery groups and set up online quizzes and games to help boost morale.
With the lockdown also came a devastating rise in domestic abuse incidents, in the UK and beyond. More than ever, this highlighted the need to find other ways to reach victims who were not safe at home. The team introduced a new online chat service via their website to enable victims to safely access advice and support during periods of isolation or when they were confined at home with a perpetrator and unable to use previous routes to safety, manned by trained support workers.
What next?
So what next for Jane’s Place? No one knows how long restrictions will be in place or what the ‘new normal’ will look like, so the team are always thinking ahead and looking at new ways to engage with residents. This includes ‘walk ‘n’ talk’ sessions, encouraging communal gardening as a soothing way to pass the time and, most importantly, continuing to listen to what residents want via their ‘finding our voice’ consultations.
Case studies: Sarah and Kerry
Fleeing trauma: Sarah, aged 34
Sarah had begun taking prescription medication and drinking alcohol at 14 years old as a way to numb the trauma of being gang raped. Both Sarah’s parents had issues with addiction and she felt unsupported in dealing with this horrific trauma. Growing up, she said she always felt ‘unloved’. During her adult life, Sarah was repeatedly subjected to sexual abuse by various males, and her drug use escalated to using heroin and crack daily.
Sarah then was in an abusive relationship and gave birth to two children. The children were subsequently removed by social care due to domestic abuse and substance abuse by both parents. Sarah became street homeless and soon got involved with another abusive male who forced her into sex work to fund substances for them both. Using heroin and crack daily, Sarah’s mental health and physical health dramatically deteriorated and she was also regularly shoplifting to fund substances. Things became too much for Sarah and she attempted to take her own life after a serious assault by her partner. She was then referred to SafeNet and accepted at Jane’s Place Recovery Refuge.
Sarah’s life dramatically changed once admitted to Jane’s Place. Her self-esteem and confidence returned as staff supported her to address health issues and receive support with her mental health. Jane’s Place referred Sarah to Inspire Wellbeing and she was allocated a key worker to help support her with substance use.
Sarah is now abstinent from all substances and back in contact with her children who live with family. She is no longer shoplifting or sex working and wants to start volunteer work after lockdown. Staff referred Sarah for specialist sexual trauma counselling and she also is supported by attending a trauma recovery group.
Sarah has said her drug use was spiralling out of control but she has dramatically changed her life with the support of staff. Sarah says the support she has received to reconnect with her children has been very important to her recovery and motivation. ‘Without Jane’s Place I would be dead,’ she says. ‘You saved my life,’
Escaping violence: Kerry, aged 39
Upon referral, Kerry had been in a physically violent relationship for the past seven years. She had been threatened with a knife and her children had been removed for their own safety, as a result of her addiction and domestic abuse in the family home. Kerry referred herself into SafeNet’s services after trying several refuges who would not accept her as she was using alcohol and substances daily.
Kerry was drinking heavily, using crack and heroin, was on a methadone script, and was also having physical withdrawal symptoms – such as seizures – when she didn’t have alcohol. She was also a prolific shoplifter to fund her addictions, and had spent time in prison as a result.
Kerry was still having regular phone contact with the perpetrator when she arrived, who would often try to manipulate her, use controlling and coercive behaviour, give verbal abuse and threaten self-harm if she didn’t return home. SafeNet supported Kerry to stop contact and she attended domestic abuse groups at Jane’s Place. Extensive safety planning work was done as part of her support plan and as her mental health improved, Kerry was able to focus on her recovery.
While at Jane’s Place, Kerry’s anxiety reduced and she was no longer having suicidal ideation. Kerry completed RAMP (reduction and motivation programme) as part of her recovery support plan and, with the support of Jane’s Place and Inspire Wellbeing, she reduced her methadone and alcohol intake.
Kerry’s physical health greatly improved too – she gained weight, began to take pride in her appearance and was focused on getting fitter and healthier. She also began to rebuild relationships with her family and was then accepted for detox and rehab to complete her journey.
People work for people – whatever your job, whatever the industry, the ultimate aim is to improve people’s lives. Nowhere is this more apparent than in the substance misuse sector and related health and social care fields.
Having the right team enables treatment services to help people change their lives for the better – and in some cases can make the difference between life and death. Healthcare workers are the vital connection between people looking for help and the services and treatment they need; their interventions can transform the lives of not just the individual in treatment, but often their families and loved ones too.
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Find out more about people's experience working in the field.
People working with those experiencing problems with drugs, alcohol and other addictions do not necessarily fit into a neat category. They are likely to be based in a diverse range of settings – the inspirational youth worker; the probation officer who took the time to make a connection; or the housing support team who were able to identify problems and offer an appropriate and accessible route to help.
Substance misuse workers can be the vital link to ensuring that a person accesses the specialist treatment that they need. As well as providing the appropriate direct help, they are part of a network of specialist treatment workers operating in community, residential and, increasingly, online settings.
How I became a substance misuse nurse, by Ishbel Straker
I never thought I would become a substance misuse nurse – law was my initial career choice. But during my training to become a barrister I worked on a dementia ward to pay for my tuition fees. That was when I began to realise that I couldn’t envisage doing anything else.
In line with the varied settings and roles, the staff supporting people come from a range of backgrounds including medicine, social care, psychology and counselling. People with lived experience are an important component of the workforce and, with the right training and work experience opportunities, bring knowledge and empathy to many roles.
Many people have been inspired to work in the field, either by their own personal experience or those of a family member, friend or colleague. Those undergoing treatment say that seeing someone who has been in the same position as them and turned their lives around was inspiring, as well as encouraging.
DDN magazine goes to people working in all areas of the sector and is also read by many of those who are on their own treatment journey. As a free magazine there are no barriers to reading it and contributing to it, and it is the forum for everyone who is involved in addiction treatment.
We want to hear from you!
Your experience informs what we do, so we want to hear your story about working in the sector. Let us know how you came to work in your current job – what inspired you, what is your background, and what do you find rewarding and frustrating? Do you have any advice for anyone considering a similar career? Tell us as much or as little as you want to! Your contribution will be very welcome.
The latest jobs online
DDN magazine is the place for recruitment for the treatment field. We have a variety of vacancies across the country from a wide selection of treatment providers.
Please visit the jobs pageto view the latest vacancy, or contact ian@cjwellings.com for details of advertising for your next star!
Careers, training and development
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Johnny shares his experience as a homeless recovery coordinator in Lancashire.
I have had almost ten years’ experience in this field. However, following the loss of a role that I loved, I had a cataclysmic relapse. Back in the whirlpool of cocaine and alcohol addiction, I very nearly died.
With the support of my father, I re-engaged with the local drug and alcohol service in February 2020. I then trained to be a volunteer peer mentor, delivering peer-led education to service users and co-facilitating psychosocial interventions (PSI) groups. I recently applied for and have accepted the role of homeless recovery coordinator with the same service.
Most of my recent work has been on Zoom, during the pandemic. I co-facilitate a ‘thrive’ group for six to eight service users, some of whom are just out of rehab/detox. I have done some limited learning in the office, spending time with the medical team and learning from them.
The part of my job that fires me up is the contact with people. Sharing my lived experience to show how life can be after addiction can be fantastic. I enjoy learning from colleagues, working with them in a team which includes my fellow peer mentors. The most rewarding aspect of all of it is being witness to a person’s growth and recovery.
The thing I’d most like to change would be to give greater accessibility to housing, mental health and medical services. We urgently need more funding in these areas, as there’s a crisis that’s reaching epidemic proportions.
If you’re wondering whether to become a recovery worker, I would say ‘just do it!’ You’ll make such a difference to so many lives.
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Tracey McMahon is a substance misuse nurse at Delphi Medical.
Nursing will throw many challenges at you and at times you will question if nursing is for you. But the positives outweigh any negatives and it’s such a rewarding job.
Lena Larsen is a volunteer service user representative at Change Grow Live
‘The best part of my role is watching service users change – from appearing on Zoom all chaotic, in the thick of addiction, to becoming a valued part of the group.’
Charlie Parker is an addiction psychiatry clinical nurse specialist, working in the liver unit.
I now work as a nursing prescriber at an acute hospital, the Queen Elizabeth Hospital Birmingham. I qualified as a mental health nurse in 2005 then worked on an acute psychiatric ward before moving into community drug and alcohol services and did an MSc in the treatment of substance misuse. Six years ago I started working with the liver transplant team as an addiction psychiatry clinical nurse specialist (CNS), primarily seeing patients with alcohol-related liver disease.
How did you get into this role?
I had always been interested in mental health, then when I was training I noticed there was still a lot of stigma and prejudice in terms of drugs and alcohol. My boyfriend at the time was in recovery so I found these attitudes hard to understand. When the substance misuse job came up I leapt at the chance and haven’t looked back since!
Tell us about your day…
I run nurse-led clinics and see patients as part of their liver transplant assessment, working with them and their families to build recovery capital and reduce the risk of relapse. I work both in outpatients and on the liver ward with a multi-disciplinary team of hepatologists, transplant co-ordinators, hepatology CNSs and specialist dieticians.
Which parts of the job do you find most rewarding?
Helping people on their recovery journey and linking them in with peer support and mutual aid – people are often very anxious about this but can get so much from it. Seeing people change their lives, realise their potential and go on to help others is very rewarding.
What would you like to change?
Equity of access to liver transplant – not everyone gets this chance depending where they live. Sadly a postcode lottery does exist; some areas have fantastic services but others much less so. I would also like to see a treatment pathway for people who are abstinent but still want to access support/relapse prevention from statutory services.
What’s your advice to anyone considering a similar career?
We need skilled professionals alongside peer support and mutual aid and those with lived experience, and although the social and political landscape is challenging substance misuse services are needed now more than ever. Alcohol-related liver disease in particular is ever on the increase and we must be ready.
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Chelita De La Haye tells us about her role as a nurse prescriber at Delphi Medical Consultants Ltd, a community drug service in Blackpool, Lancashire. Read Chelita’s story here.
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Stewart Bell tells us about his role as isolation support worker at Phoenix Futures’ Wirral Residential service. Read Stewart’s story here
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Martin Holmes is service manager and registered CQC manager.
‘I am humbled that my past has become my greatest asset in helping others to freedom.’ Read Martin’s story here.
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Muriel Gutu is group clinical lead of the Social Interest Group
‘At Brook Drive there is no ‘them and us’, but ‘we’ – and we’ll continue working towards excellence.’ Read Muriel’s story here
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Leanne Smullen-Bethell is head of house at Phoenix’s National Specialist Family Service, where people can seek treatment for their substance use problems while staying together as a family.
To anyone considering a similar career, I would say: if helping people is your passion, then go for it. A career in addiction services can be the most rewarding job of all. Knowing that you can help someone who is broken to rebuild their life is just amazing. You get to meet lots of really interesting people and have the privilege of hearing their stories and being a part of their recovery journey. What can be better than that?
Neil Ainslie is manager of the Jericho Society, a six-month residential drug project in Derby with aftercare and resettlement.
I was a resident of Jericho house in Greenock in Scotland in 2004. I came down to volunteer in 2006 and am now the project manager. We have 11 volunteers, who are all ex-residents, and four full-time staff; between us we have achieved around 45 years abstinence.
The moment our clients arrive they agree to be completely abstinent from all mind and mood altering chemicals. We have nine residents at any given time and we support them to go through any cold turkey with understanding, empathy, one-on-ones, group therapy, chats, hot baths, identification – or whatever they need really!
We have an insight and first hand experience into every step, from when a resident arrives to when they move out. We have truly walked a mile in their shoes and they know this from day one. We understand their mindset, which people without addiction issues usually can’t quite comprehend.
People with addiction issues generally know this and find it hard to expose their irrational, fearful, compulsive and insane thinking patterns to them, so are shocked when we openly discuss this and have a massive depth and insight which brings hope to their lives – sometimes for the first time in many years. We give them hope – ‘if they can overcome this and break the cycle of addiction, then why can’t I?’
Tell us about your day…
There’s never a dull day. My latest shift was a privilege, as always. We had staff handover as always, where we discuss every resident in depth, and then I allocated the daily tasks to the appropriate staff. One of our newer guys had a family death so I had a chat with him to make sure we can all support him as best we can.
After that I talked to one of our longer residents about the possibility of him writing a letter to his ex-partner with the hope he may at some point reconnect with his seven-year-old son. Then a chat with another resident about him deliberately lying to us about social distancing while he was on a family visit and reminding him of the importance of honesty and trust in relationships and how this was a big part of one of his previous relapses.
See the latest vacancies at DDN Jobs.
Then on to another resident who is from the Asian community, about his fears around the expectations of his family members and how hard he felt it was going to be to bring the principles of recovery back to his home. I then needed to talk to an ex-resident about how to handle a situation (and the family trauma) relating to his cousin who had overdosed and was in a really bad way.
After that was a meeting with my business manager about expanding our service, before a chat to one of my volunteers about how to conduct himself whilst answering the Jericho House phone, as he was a little dismissive to a potential service user’s brother.
What do you find most rewarding?
I love seeing people turn their lives around, reconnecting with their families and going on to be productive members of their communities. I really love to see them helping others the way they were helped!
What would you like to change?
I would like to see more financial help available for places like ours. We are a charity and rely on volunteers to make our great work possible. We generally run at a loss and are experiencing real financial difficulties.
What’s your advice to anyone considering a similar career?
If your heart’s in it, then go for it. If you are going to work with people with addiction issues then it should be taken deadly seriously as addiction is a killer. The rewards are beautiful – but for every good story there are two not so good. Good luck in whatever you do.
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Carol* is a volunteer working with a community drug service in Berkshire.
I volunteer two days a week on a training placement to become a recovery worker. I do a lot of my training on e-learning in the drug service. I assist the substance misuse nurse run her weekly alcohol support group and help service users read material, and I scribe for them when needed. I also assist the recovery workers with things like phoning service users and making appointments. During lockdown I have not been at the service, and have done refresher drug and alcohol training via Zoom.
I also have another voluntary role supporting an inmate with substance misuse issues at HMP Wormwood Scrubs.
What do you find most rewarding?
Helping the service users through their recovery is very rewarding – also, learning via work shadowing the clinical recovery workers and the consultant psychiatrist in the dual diagnosis clinic.
What would you like to change?
I’d like to be able to offer more one-to-one appointments with service users, especially for those who dislike support groups. It would be good to be able to offer more ongoing support as well, especially when service users relapse.
What’s your advice to anyone considering a similar career?
It’s an extremely interesting, challenging and rewarding career.
*Not real name
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Iain Gray is a commissioner who is also in recovery
I’m based in a local authority, at the London Borough of Southwark. My role involves commissioning services, contract monitoring, partnership working and strategic planning. I’m also Tier 4 Panel chair and involved in rough sleeper outreach commissioning. There’s a constant fight for funding. The parts of my job that I find most rewarding involve contact with service users.
What would you like to change?
I would like central government to support us better and provide more secure long-term funding.
Do you have anything to say to anyone considering a similar career?
Don’t do it for the money. Always, always, always stay focused on the clients and their needs. And never give up fighting for them – they are worth it.
Aisling* is a nurse/prescriber working for the HSE in Ireland
I went to train as a nurse at the age of 28 following a relationship breakdown. I needed a new start and moved to London to do my training.
After five years on psychiatric wards, a community position came up that was specifically working with those who are homeless. Working in substance misuse was not always my plan but it seemed to have developed that way.
Tell us about your day…
I’m out in the community visiting homeless people at hostels and B&Bs, and also run two clinics in two main towns where they also call in. I spend a lot of time filling in forms for medical cards (as healthcare is not free in Ireland) and getting the homeless linked into certain services.
I go to two housing meetings every fortnight – they are called the Homeless Action Teams, where they assign the B&B/hostel beds. We work together as professionals advocating for a homeless person.
What do you find most rewarding?
Getting the health care set up is rewarding, as is getting someone a detox/rehab bed. Doing support letters for courts and disability benefits can have worthwhile results and doing dipstick drug tests is satisfying when you can give praise for having done well that week.
What would you change?
The housing part is tough as B&Bs/hostels are always full. The council can be difficult to get this accommodation from, as the staff often pre-judge the homeless person.
What would you say to anyone considering a similar career?
Be ready for many barriers that you have to overcome for this client group.
*Not real name
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Sean Higgins is a recovery worker/champion at the Kairos Community Trust, a residential drug service in South London.
See the latest vacancies at DDN Jobs.
I had over 30 years in active addiction and was lucky to be admitted into treatment via my local drug and alcohol service. When I was one year drug-free and sober I was offered a volunteer position at the same treatment centre. After three months I was put onto the permitted hours work scheme and enrolled onto level 3 health and social care, which I have now completed, and I am just about to start the level 5.
Three years after being admitted into Kairos I now work as a full-time support worker within the same treatment centre and feel I have found a purpose in my life. Giving back what was so freely given to me is a fantastic feeling.
Tell us about your day…
I complete referrals, assessments, care plans, risk assessments and care and risk assessment reviews with clients on a regular basis – we have the capacity to accommodate 24 clients and I have a caseload of six clients, whom I see weekly for one-to-ones. I also facilitate groups and workshops, which make up part of each client’s treatment pathway.
What do you find most rewarding?
Supporting individuals to achieve their full potential.
What would you change?
I would love to see more funding available for the whole substance misuse field.
Do you have anything to say to anyone considering a similar career?
If you are considering a career in this field then I would suggest that you try it out on a voluntary basis first.
Never lose sight of your own recovery – and don’t kid yourself that working in the field is your recovery.
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Charlotte* is a volunteer at a community drug service in the South East.
She volunteers two days a week on a training placement to become a recovery worker and does much of her training on e-learning in the drug service.
Tell us about your day…
I assist the substance misuse nurse to run her weekly alcohol support group and help service users read material and scribe for them when needed. I also assist the recovery workers with helping with service users – telephoning them, making appointments etc. During lockdown I have not been at the service, and have done refresher drug and alcohol training via Zoom.
I also support an inmate with substance misuse issues at HMP Wormwood Scrubs – another voluntary role.
See the latest volunteer opportunities at DDN Jobs.
What do you find most rewarding?
Helping the service users through their recovery is really rewarding. I’m really enjoying learning via work – shadowing the clinical recovery workers and the consultant psychiatrist in the dual diagnosis clinic.
What would you change?
It would be good to be able to offer more one-to-one appointments with service users, especially for those who dislike support groups. It would also make much more sense to offer ongoing support, especially when service users relapse.
What would you say to anyone considering a similar career?
It’s an extremely interesting, challenging and rewarding career.
More than a quarter of people who have ever drunk alcohol think they have been drinking more during lockdown, according to research commissioned by Alcohol Change UK. Almost half said they expected to continue drinking at the same rate as the lockdown eases and pubs reopen, while 17 per cent said they anticipated drinking more.
Richard Piper: ‘We were right to worry’ about the impact of lockdown on people’s drinking.
The figures are based on a survey of more than 2,000 people, around 1,600 of whom were current or former drinkers. Just under 20 per cent of this group said they had been drinking to cope with stress or anxiety, with parents of under-18s more likely to cite this as a reason than non-parents or parents of adult children. Although one in five drinkers had been drinking more often, the number of units consumed on an average drinking day ‘does not seem to have changed significantly’, says the charity, with 13 per cent drinking more units and 12 per cent drinking fewer. Of people who typically drank seven or more units a day, however, 38 per cent said they were now drinking more.
Just under 20 per cent of drinkers said they intended to visit a pub within two weeks of lockdown easing, but 7 per cent had stopped drinking altogether during the lockdown –equating to more than 3m people – with younger people more likely to have cut out alcohol. More than one in three people had also been taking ‘active steps’ to manage their alcohol consumption, including having alcohol-free days or looking for advice online. Traffic to the ‘get help’ section of Alcohol Change UK’s website from March to June was almost 250 per cent higher than during the same period last year, the charity says.
‘From the very start of lockdown, charities and treatment services have warned of the impact on people’s drinking,’ said chief executive Richard Piper. ‘This research shows that we were right to worry. One in five of us has drunk more often than usual over the past three months, and this research suggests that those drinking more often during lockdown are less likely than others to cut back as it eases. But the good news is that one in three of us are acknowledging that drinking is a concern and taking active steps to manage our drinking during lockdown. One in three are also planning to manage our drinking actively as the pubs reopen and lockdown eases, putting in place plans like drink-free days, keeping an eye on the amount of alcohol we buy, and getting support online or from our GPs.’
The second part of Professor Dame Carol Black’s independent review into illegal drug use in England has now been launched, the government has announced. While the initial phase looked at drug supply and demand, the second will study treatment provision, recovery services and prevention.
Prof Carol Black: An opportunity to correct ‘a decade-long erosion’.
The review will look at how drug treatment interacts with housing, employment, mental health and criminal justice services, with the overarching aim of ensuring that vulnerable people get the right support to ‘recover and turn their lives around in the community and in prison’. The final document will contain policy recommendations to government, including around funding, commissioning and how local bodies are held accountable to ‘ensure they are effective’. The review’s first phase concluded that even if more money were made available for drug treatment, there would still be ‘a lot of work to do’ to build up capacity and expertise in the sector (DDN, March, page 4).
The second phase will engage with a ‘wide range of stakeholders’ including service users and people with ‘lived experience of drug addiction’ to build a detailed picture of treatment, recovery and prevention, the government states. Professor Black will be supported by government recovery champion Dr Ed Day (DDN, June 2019, page 8) and former drug policy adviser to president Obama, Dr Keith Humphreys (DDN, June 2012, page 16).
‘In my foreword to part one I said that behind the thorough analysis of the market for illicit drugs that we had just completed lay a very tragic human story – about the effect on individuals, their families, youngsters caught up in the trade, and the economy,’ said Professor Black. ‘We showed a decade-long erosion, under previous governments, in almost every aspect of drug addiction, prevention, treatment and recovery. We now have the opportunity to correct this and build a better world. To do this many stakeholders and government departments must work together as never before.’
‘The findings of Dame Carol’s first review set out the scale of the challenge,’ added health minister Jo Churchill. ‘Now our focus must shift to ensuring the appropriate services are in place to support the treatment and recovery of drug users, as well as preventing drug use in our communities in the first place.’
More than 120 killings of children and young people were carried out in the Philippines between July 2016 and December 2019, according to a report by the Geneva-based World Organisation Against Torture (OMCT) and the Philippine Children’s Legal Rights and Development Center. Just under 40 per cent of the killings were carried out by the police, with the remainder by ‘unknown individuals, often masked or hooded assailants, some of them with direct links to the police’.
The document – which is based on interviews with families, witnesses and local authorities, as well as official documents – states that the children’s ages ranged from just 20 months up to 17. In one case a seven-year-old boy was killed simply because he had witnessed the murder of an adult. The organisations estimate that the total number of extrajudicial killings since the country began its ‘war on drugs’ under president Duterte four years ago is just under 30,000 – with just one police officer convicted – while at least seven children have been killed in the first three months of this year.
The children’s deaths documented in the report were either the result of direct targeting, mistaken identity, ‘collateral damage’ or ‘as proxies when the real targets could not be found’. Almost all of those interviewed for the report asked not to be named, and most did not even file a case for the murder of their children through fear of reprisals. ‘With parents often too afraid to testify, even anonymously, it is likely that the actual numbers of children killed are higher than the 122 documented in the report’, states OMCT.
There has also been a sharp increase in the arrest and detention of children on drug-related charges since Duterte came to power, says the document, leading to the ‘overcrowding of detention centres where abuse, ill-treatment and even torture are rife. This increasingly brutal policy has spilled over during the recent COVID-19 related lockdown, with numerous children arrested for curfew violations, sometimes threatened with being shot and detained in dog cages or inside a coffin’.
The report’s revelations must be a wake-up call for the international community, which has been ‘largely absent as the Philippine government has kept trampling human rights’, said OMCT secretary general Gerald Staberock. ‘Over the past four years we have hardly seen any meaningful reaction to the wanton killing of thousands of people under the pretext of the “war on drugs”, the targeting of the poorest and most marginalised citizens of the Philippines, and the persecution of human rights defenders, many of whom are in prison for their legitimate work. It is the total lack of accountability that feeds the cycle of violence, including the war on children we are witnessing.’
How could they do this to my child? Extrajudicial killings of children during the ‘war on drugs’ in the Philippines at www.omct.org –read the report here
Read DDN’s guide to help for gambling addiction at https://www.drinkanddrugsnews.com/gambling-addiction-guide/
The bodies overseeing gambling are failing to protect people who are vulnerable to gambling harms, says a report from the House of Commons Public Accounts Committee. The Department for Digital, Culture, Media & Sport (DCMS) and the Gambling Commission – which it oversees – have an ‘unacceptably weak understanding’ of the impact of gambling harms and lack measurable targets to reduce them, says the document, which follows a report from a separate parliamentary group calling for a complete overhaul of gambling regulation (read about that here).
The public accounts committee found the pace of change to ensure effective regulation to be ‘slow’ and the penalties imposed on companies that do too little to address problem gambling ‘weak’. ‘Where gambling operators fail to act responsibly, consumers do not have the same rights to redress as in other sectors’ it says. As gambling increasingly moves online DCMS and the Gambling Commission have failed to adequately protect consumers, even when problems such as increased risk of gambling harm during the COVID-19 lockdown have been identified.
The committee is calling for a published league table of gambling operators’ behaviour towards customers, with ‘naming and shaming’ of poor performers and it also wants to see DCMS embark on a review of the Gambling Act within the next three months.
Meg Hillier: Evidence shows a ‘torpid toothless regulator’
‘What has emerged in evidence is a picture of a torpid, toothless regulator that doesn’t seem terribly interested in either the harms it exists to reduce or the means it might use to achieve that,’ said committee chair Meg Hillier. ‘The commission needs a radical overhaul – it must be quicker at responding to problems, update company licence conditions to protect vulnerable consumers and beef up those consumers’ rights to redress when it fails. The issue of gambling harm is not high enough up the government’s agenda.’
The review of the Gambling Act was ‘long overdue’, she added, and an opportunity to see a ‘step change’ in the treatment of problem gambling. ‘The department must not keep dragging its feet – we need to see urgent moves on the badly needed overhaul of the system. Regulatory failure this comprehensive needs a quick pincer movement to expose the miscreants and strengthen those they harm.’
Gambling regulation: problem gambling and protecting vulnerable people at www.parliament.uk. Read it here
People coping with a loved one’s drug use, drinking or gambling have been hard hit by the COVID-19 lockdown, according to a new survey from Adfam.
Families are often overlooked when it comes to discussions of problematic alcohol or drug use. However, half of the respondents to Families in lockdown said the situation had had a negative impact on their own mental health, while 28 per cent said they were experiencing more verbal abuse than usual and 13 per cent admitted to being concerned for their safety. Nearly 5 per cent said they had been experiencing more physical abuse during lockdown.
Almost half also stated that their loved one’s substance use or gambling had increased during the lockdown period, while just under a third reported that the person had either relapsed or their recovery was at risk.
Vivienne Evans: Lockdown is making feelings of isolation even worse
Around 5m people are thought to be dealing with the negative effects of loved one’s alcohol or drug use in the UK, with 85 per cent of respondents to the survey saying the lockdown had made a ‘bad situation worse’. Many of these people will need urgent additional support as lockdown conditions ease, warns the charity.
‘At least one in ten of us are currently affected by a loved one’s drinking, drug taking or gambling problem,’ said Adfam chief executive Vivienne Evans. ‘Our survey shows that this unrecognised and hidden problem has been made worse by the lockdown. When you are already isolated, fearful or in poor mental and physical health, lockdown takes an even bigger toll. Even when restrictions ease, people will need help and support to recover. Now more than ever, we need a national conversation about how we can help people to cope with the life-long impacts of a loved one’s alcohol, drug or gambling problem.’
Meanwhile, UNODC’s latest World drug report has highlighted the increased prices and reduced purity of many drugs as a result of COVID-19 lockdown measures. The economic fallout from the pandemic is also likely to disproportionately affect the poorest and make them more vulnerable to problem drug use, it warns.
If governments react in the same way they did in the aftermath of the 2008 financial crisis, then reduced budgets for drug treatment could mean severe impact on vital areas like naloxone provision and prevention measures.
‘Vulnerable and marginalised groups, youth, women and the poor pay the price for the world drug problem,’ said UNODC executive director Ghada Waly. ‘The COVID-19 crisis and economic downturn threaten to compound drug dangers further still, when our health and social systems have been brought to the brink and our societies are struggling to cope. We need all governments to show greater solidarity and provide support, to developing countries most of all, to tackle illicit drug trafficking and offer evidence-based services for drug use disorders and related diseases.’
New funding from the Treasury will provide ‘interim support’ for 15,000 vulnerable people placed in temporary accommodation during the COVID-19 pandemic, the government has announced. The £105m package will be used to help rough sleepers secure their own tenancies and provide short-term housing in the meantime, it says.
The £105m is made up of £85m of new funding and £20m from ‘refocusing’ existing homelessness and rough sleeping budgets. The money will provide help with deposits and secure ‘thousands of alternative rooms already available’ – such as student accommodation – and is part of the government’s commitment to ‘end rough sleeping for good’. Partnership working between government, local authorities, charities and the hospitality sector has seen thousands of people temporarily housed in hotels during the outbreak (DDN, May, page 5).
A further £16m is being made available to help people in emergency accommodation access substance misuse support – money already announced but brought forward because of the pandemic.
Robert Jenrick: ‘An unprecidented commitment’ to ending rough sleeping.
‘In recent months, I have seen a huge effort across the country to keep almost 15,000 vulnerable people off the streets,’ said housing secretary Robert Jenrick. ‘This has been vital to ensure their safety during the peak of the pandemic and has changed the lives of thousands for the better. The additional funding announced today will allow us to continue to support these individuals – giving them access to the accommodation and support they need now while we continue with plans to deliver thousands of long-term homes in the coming months. Together, this takes the funding provided by government for vulnerable rough sleepers and those at risk of becoming homeless to over half a billion this year – an unprecedented commitment as we move towards ending rough sleeping for good.’
Dame Louise Casey: ‘There can be no going back to the streets.’
‘I am clear that there can now be no going back to the streets as people begin to move on from the emergency accommodation that has been put in place,’ added chair of the COVID-19 rough sleeping taskforce, Dame Louise Casey. ‘The government is committed to ending rough sleeping by the the end of this parliament, and has taken unprecedented steps to protect thousands of vulnerable rough sleepers and those at risk of becoming homeless.’
‘This a great news but support in England is patchy with councils often uncertain who they should be helping,’ stated homelessness charity Crisis. ‘We need emergency legislation to ensure that every local council can provide housing support to everyone experiencing homelessness.’
Service user involvement is about making sure people can influence decisions that will affect them. To influence, people need the opportunity to speak and be heard. The voice of people using services provides valuable feedback and we need to make sure we always acknowledge and consider it.
By Chris Barnes, National Service User Involvement Coordinator at Change Grow Live.
Through my role as service user involvement coordinator, I have continually been impressed by the way people adapt and work collaboratively to overcome adversity and achieve incredible things.
Coronavirus has impacted on every aspect of our lives, including the way we deliver our services. Back in March, as changes to our ways of working started happening, we quickly noticed that our approach to hearing the voices of people who use our services needed to change.
It is critical that we continue to listen to the people who use our services.
If you are getting support from us, we have heard you. We now want to know more about your experiences. Please click here to share your story and your experience through our survey.
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.
The All Party Parliamentary Group (APPG) for Gambling Related Harm has called for a ban on all gambling advertising as well as a complete overhaul of the UK’s system of gambling regulation. ‘The Gambling Commission is not fit for purpose,’ it states.
APPG chair Carolyn Harris
The recommendations are among more than 30 set out in the APPG’s final report into online gambling-related harms, following a year-long enquiry. The group, which comprises more than 50 MPs, is also calling for a ban on all ‘VIP’ schemes and inducements – a ‘cynical tool to incentivise problem gamblers’ – and for the stake limits for online slot machine style games to be capped at £2, ‘given the potential to cause harm’. The APPG has previously called for a £2 stake limit in its interim report (DDN, November 2019, page 5).
The group’s final report is based more than ten evidence sessions, as well as submissions from a wide range of stakeholders. Other recommendations include a new Gambling Act to reflect the realities of the digital age, as well as affordability limits to be set and imposed by the Gambling Commission. According to the commission, there almost 400,000 problem gamblers in the UK, with at least 1.8m more considered ‘at risk’. A recent report from GambleAware found that just under half of people with a gambling disorder had never accessed support (DDN, June, page 5).
The COVID-19 pandemic has underlined the need for greater protection for people who can ‘gamble with ease from home, at any time of day and at any level, via a mobile phone’, says the APPG, which also refutes claims that it is prohibitionist or anti-gambling. ‘This is to debase what is an important discussion to protect vulnerable people and children and prevent online gambling harm,’ it says.
The DDN guide on gambling addiction helps identify problems and the available treatment options.
‘This multi-million pound industry has destroyed people’s lives,’ said APPG chair Carolyn Harris. ‘They resist change at every turn and claim to be reforming themselves but put forward limited changes. Their primary motive is profit. During the COVID pandemic they said they would end TV and radio advertising (DDN, May, page 4) but just ended up replacing ads with ads – that none of us want to see. They have shown time and again that they will not effectively self-regulate. We cannot ignore this any longer. Urgent change is needed to stop this industry riding roughshod over people’s lives.’
Report from the Gambling Related Harm All Party Parliamentary Group: online gambling harm inquiry, final report at www.grh-appg.com
In the first part of his two part series ‘Doctor Wars’ Bill Nelles describes how the running battles between substance misuse clinicians in the ’70s and ’80s helped to shape today’s treatment landscape.
Bill Nelles is an advocate and activist, now in Canada. He founded The (Methadone) Alliance in the UK
What to do about opiate use and users has been discussed, argued, and shouted about for more than a century now to relatively little positive change. It’s like the opening song in The Sound of Music – ‘how do you solve a problem like Maria?’ Only no one ever does solve the problem of Maria (although I think it has something to do with finding love and, of course, climbing every mountain – a familiar metaphor for any users).
The same seems true for opiate users. We dutifully sing the songs asking for help, but too often leave disappointed. There are still hundreds and even thousands of opiate-dependent users in the UK and around the world who want and deserve a safe supply of that medicine under medical oversight, and finally some are getting it. And I use the word oversight for a reason. It should mean ensuring services are providing empathic access to a safe supply with all the social support, trauma therapies and help with housing that we know are essential to settling down to a life of quality without the poisons on our streets. Having all these is what saved me for nearly 40 years. All were necessary for me and there should be widespread shame at the lack of this joined-up care today.
It wasn’t until the late ’60s that serious prohibition started in the UK – largely because young people, not elderly users and dependent doctors, were now using heroin and getting it from doctors famous for their unusual prescribing locales like coffee bars and street corners. Some changes were understandable as the system was anarchic and largely unregulated.
But the ‘classic’ NHS clinics born around 1969 all had differing attitudes with little agreement on what to do within the teams formed to run them. Thus the era of the ‘doctor wars’ broke out – psychiatry came to dominate treatment in the UK, leading to psychotherapy becoming the approach, and in London high quality Chinese heroin replaced the state gear. So people voted with their veins.
This was in direct contrast to Dr Vincent Dole and Marie Nyswander’s approach in New York that saw opiate use as a physically mediated condition that was treatable but not curable, and not always responsive to psychotherapy. Opiate receptors were identified soon afterwards, and real research started uncovering just what was going on.
But the UK’s NHS drug dependency units were taken over by psychiatrists, not medical doctors. With some notable exceptions, their goals were abstinence through withdrawal and therapy. All these psychiatrists who held the new licences needed to prescribe heroin hardly used them, with a few notable exceptions. People were moved onto oral methadone or nothing if your particular clinician wouldn’t prescribe, or you only had access to a non-medical community drug team – tea and sympathy (of little use) if you were ‘lucky’, but confrontation if you weren’t.
The fights at the monthly meetings held at the Home Office Drugs Branch during the ’70s to mid ’80s brought together psychiatrists who hated prescribing, some of the private doctors who could still prescribe some opiates and opioids (but not heroin or cocaine), and the very few doctors who did still prescribe injectables to the few. They were often vicious and sometimes very personal – some moderating influence came from the presence and later letters and testimony of dear Bing Spear, head of the Home Office Drugs Branch the until the early ’70s. He was replaced by a warrior who did his best to shut down even oral methadone.
By 1983 even getting methadone for more than a short period became very rare in the NHS clinics and unheard of in Scotland. One of the heads of the Royal College of Psychiatrists held that ‘no one needs more than 40mg of methadone a day’ – which was a big reason so many people had such poor outcomes and used on top. Most were expected to and that’s why their methadone was kept so low. There were no objective medical tests or practices used in the UK to ensure patients had adequate doses to minimise fluctuation of methadone levels.
Prescribing anything opiate-like through the NHS to those dependent had almost completely stopped by 1983. But events were about to take an unprecedented shift, and that changed how everything would be done. I’ll explore this further in the next edition.
Sales of alcohol from supermarkets and off-licences in Scotland fell between 4 and 5 per cent in the year after minimum unit pricing (MUP) was introduced, compared to England and Wales.
The analysis, from Public Health Scotland in partnership with the University of Glasgow, was controlled for seasonal fluctuations, underlying trends such as household income and other factors, the researchers say, meaning it is ‘reasonable to conclude that the reductions in volume of alcohol sold were due to the introduction of MUP’.
The biggest relative net reductions were seen in the products whose price increased most after the introduction of MUP, such as high-strength cider, with smaller reductions recorded for beer and spirits. MUP was introduced in Scotland in May 2018, following a lengthy legal battle with the drinks industry. Public Health Scotland says it will publish a three-year analysis of post-MUP sales in 2022.
‘The methods used in this study allow us to be much more confident that the reduction we have seen in per adult off-trade sales is as a result of the introduction of MUP, rather than some other factor,’ said professor of medical statistics at the University of Glasgow’s Institute of Health and Wellbeing, Jim Lewsey. ‘Incorporating data from England and Wales into our analysis controls for any changes in sales in a neighbouring region where the legislation was not introduced. We’ve also been able to adjust for other factors, such as household income, sales of alcohol through pubs and clubs and of other drink types.’
However the reductions were partly offset by off-trade sales of wine, fortified wine and ready-to-drink beverages, which the analysis ‘found to have increased in the year post-MUP’, said public health intelligence principal at Public Health Scotland, Lucie Giles.
Alison Douglas, chief executive of Alcohol Focus Scotland.
‘It’s very encouraging to see further evidence that minimum unit pricing for alcohol seems to be changing our drinking habits for the better,’ added chief executive of Alcohol Focus Scotland, Alison Douglas.‘A reduction of between 4 and 5 per cent in off-sales in the 12 months following the introduction of MUP is really significant. It is also clear that it is the high-strength, low-cost drinks, favoured by heavier drinkers, which we are drinking less of. This gives real cause for optimism that MUP is having the intended effect and that it will improve – and save – many people’s lives.’
It was important not to become complacent, however, as Scotland was still drinking enough for every adult to exceed the CMO guidelines by a third every week, she said. ‘For some of us the pressure of lockdown and social distancing may mean we are drinking more.’
Delphi Medical are a leading provider of drug and alcohol addiction treatment in the UK
Delphi Medical have an outstanding reputation as one of the leading providers of recovery-focused drug and alcohol treatment in the UK. The team offers excellent care on a pathway that supports and facilitates patients engaging in genuine recovery.
Delphi Medical’s services include:
Rethink detox – a private community-based alcohol detox service based in Lancaster.
Pavilion– a residential drug and alcohol detox treatment centre on the outskirts of Lancaster.
Drug & Alcohol Services in Prisons – providing confidential help and support, and a range of life-saving clinical and psychosocial programmes.
Delphi Medical provide flexible solutions to recovery by working with individuals to better understand the traumas linked to their addiction.
As part of their service delivery, Delphi Medical recognise that they have a wider role in changing cultures and social support. The service works with multiple partners and communities to make real improvements. As part of The Calico Group and Syncora, Delphi Medical are in a unique position to provide bespoke services that fit the most complex needs.
With passion and excellence, Delphi Medical make a difference to people’s lives by providing innovative and specialist addiction services that lead the way from dependence to freedom.
The Nursing Team are on duty 24 hours a day to support patients and monitor any changes in physical health during detox.
Delphi Pavilion Detox
The Pavilion is a residential drug and alcohol detox treatment centre on the outskirts of Lancaster, run by Delphi Medical. As part of a not-for-profit organisation, we endeavour to make detox and addiction treatment as affordable as possible.
The Pavilion team – made up of doctors, independent prescribers, therapist, nurses, support workers and volunteers – prides itself on delivering care to the highest standard with a focus on supporting patients into recovery.
The Pavilion is accessible to patients aged 18 years and over, delivering personalised and structured detoxification programmes, personally tailored to each individual.
Health, wellbeing, and personal empowerment are at the forefront of every programme, delivered in individual and group settings by trained medical and therapeutic professionals, with all services reflecting best practice, meeting CQC standards.
A combination of clinical and therapeutic services are delivered to safely support patients’ detox, whilst also addressing the contributing factors that have led to their dependence.
Detox is the first step into abstinence from drugs or alcohol, and can be a daunting decision for patients. The Pavilion provides a safe and effective in-patient detox from both drugs and alcohol, through medically assisted withdrawal.
Single and multiple detoxification services are available for the following substances:
COVID-19 has proven to be an incredibly challenging time for the addiction rehabilitation sector, with community services having to limit face-to-face meetings where possible and lockdown forcing residential units to rethink their admissions process or close altogether. However, Kenward Trust, a residential alcohol and drug rehabilitation centre based in Yalding, Kent, are proud to say they are still open and taking admissions.
The Trust, situated in 15 acres of stunning Kent countryside has a variety of services to provide support to those affected by addiction, homelessness and crime. The core service of Kenward Trust is their residential rehabilitation programme which provides support to those affected by alcohol and drug addiction from for to 24 weeks. They also have Kenward Lodge based on their site in Yalding, which provides supported accommodation to those who are struggling to access drug and alcohol treatment due to not having accommodation, whether this be because they are street homeless or living in unsuitable housing.
Increased demand
‘We are currently facing a significant increase in demand for our residential services during lockdown, so have managed to repurpose some of our accommodation to allow two isolation areas for new arrivals to the project,’ said Penny Williams, CEO of Kenward Trust. ‘We have ensured that during isolation, any residents can still partake of the programme through remote connection, so they are benefitting from all the time they have with us. I am incredibly proud of our team for keeping COVID-19 off our site and for ensuring that we can safely help those who really need it and that this is being recognised by our referrers.’
Kenward Trust are currently recruiting for a Residential Resettlement Manager (closing date 19.6.20) Click here to find out more
The Trust has Move On accommodation across Kent and East Sussex, which are quickly filling up due to the increase in demand. Residents live independently in the Move On accommodation but have support from a dedicated Kenward staff team member to help them reintegrate back into the community whilst sustaining their recovery. The typical length of stay is up to two years while they find longer term accommodation and employment or volunteering opportunities.
Kenward Trust CEO, Penny Williams
‘Due to this increase in demand we are looking at finding more Move On accommodation within the Maidstone area, so it is closer to our Yalding base,’ explained Penny Williams. ‘We are currently getting in contact with the council and surrounding housing associations to see how we can start this process, however if anyone could provide support with this please do get in touch. We are passionate about helping as many vulnerable members of society that we can, so any support would be greatly appreciated.’
Statutory funding
While demand for the Trust’s services is increasing, the statutory funding for residential rehabilitation is continuing to decline. Additionally, as a charity which relies on donations and grants to help fund the services, we are in a challenging time with lockdown. Therefore, to help provide support to those who either cannot afford the residential treatment privately or cannot take the four to 24 weeks needed off work, the Trust is launching a Day Treatment Service. This service can be run remotely during lockdown with confidential counselling via Zoom, but will also feature Evening and Weekend groups when lockdown is over.
To find out more about the services Kenward Trust provides, or to find out how you can support their life changing work visit kenwardtrust.org.uk or give them a ring on 01622 814187.
Peer distribution of naloxone is the best way to get the opioid overdose reversal drug where it’s needed.
by Nye Jones, We Are With You
Andy struts through Redcar town centre, his bright blue naloxone hoody protecting him from the fierce north sea breeze. He bellows hello to a woman across the street and fist bumps a guy he knows from his childhood. Then he sees a man he recognises from picking up his methadone script and it’s all systems go. Andy asks if he’s heard of naloxone. He hasn’t. He asks if he’d like to learn how to save a life. He would. The two sit together on a bench outside Sports Direct. In just eight minutes Andy expertly takes him through how to respond if someone has taken an opiate overdose. With a slap on the back, he hands the man a naloxone pack to keep and waves him on his way.
Read more DDN articles on naloxone.
It seems like he’s been doing this for years, but just three months before the programme started Andy knew very little about naloxone — “I’d never seen a pack before, I never had a clue.” Drug related deaths are at record levels in the UK, with the north east recording the highest rate of deaths in England. Now, Andy is part of a team of peers proactively taking naloxone out into the community in the coastal area of Redcar and Cleveland.
‘Active and resilient’ organised crime groups have been successfully adapting their drug trafficking routes, transportation models and concealment methods during the COVID-19 pandemic, according to a report from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and Europol. While the pandemic has led to local shortages, higher prices and reduced purity of some drugs, crime groups are continuing to thrive and make ‘huge profits’, it says.
Disruption of the drug supply chain has been seen ‘mostly at the distribution level’, the document states, as lockdown and social distancing measures have made street deals more difficult. While dealers and customers are increasingly turning to encrypted communication apps, social media platforms and the dark web to buy and sell substances, the ‘continued commercial transportation of goods across Europe’ has enabled the ongoing movement of bulk quantities of drugs between countries.
Trafficking via maritime shipping remains at pre-pandemic levels, say the agencies, although there has been ‘marked disruption’ in smuggling via passenger planes, echoing the findings of a recent UNODC report (DDN, June, page 4). Violent incidents related to drug trafficking have also continued during the pandemic, the document says.
Alexis Goosdeel: We are likely to see ‘greater volatility’ in the drug trade.
‘The economic effect of the crisis is likely to make some in our communities more vulnerable to both drug problems and drug market involvement,’ said EMCDDA Director Alexis Goosdeel. ‘Furthermore, the growth of online dealing and encrypted communication will place greater strains on law enforcement. In the post-pandemic period we are likely to see greater volatility, competition and violence associated with the drug trade. By anticipating these developments now, we will be better prepared to respond quickly and effectively to the new challenges we are likely to face.’
Improving our understanding of benzodiazepines would save many lives, says Kevin Flemen.
Non-medical use of benzodiazepines creates big challenges for treatment services. There need to be significant changes in how we respond if we are to reduce dependency and fatalities related to this family of drugs.
The extent of non-prescribed benzo use is poorly understood. The Crime Survey for England and Wales (CSEW) reports a drop in use, but anecdotal information from drug services, including young people’s services, suggests the opposite is true.
The CSEW data is highly suspect in relation to benzos, and this may be because it misses key using populations. Questions to identify benzo use need to be carefully framed too – would young people taking ‘Xans’ automatically know that this is alprazolam, a benzodiazepine? If not, standard screening questions such as ‘have you used benzodiazepines in the past six months?’ are liable to under-count actual use.
Further, not all our benzo-type drugs will show up on urine screens, possibly because the stronger ones produce effect at very low doses – producing lower levels of metabolites below the detection threshold. And some of the drugs, such as etizolam, are thienodiazepines not benzodiazepines, so won’t produce metabolites that show up on a standard screen.
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Young people
Young people’s benzo use appears to have increased. Some of this is recreational, influenced by popular culture, including a new generation of rappers whose image and lyrics have popularised Xanax. For others, use may be self-medicating for trauma, anxiety or other negative mental health conditions.
The trap here is the slow access that too many young people encounter when seeking help from child and adolescent mental health services (CAMHS). Long waiting lists or failure to meet the threshold to access services mean young people may be waiting months for access to CAMHS, if they can access the service at all.
In the meantime, some will find benzos and start to self-medicate. When and if the young person does access mental health services there is a good chance – in classic ‘dual diagnosis ping pong’ – that they will be told they have a primary presenting drug problem and therefore should be referred to a drug service. In turn, when they present to the drug service they may well find a paucity of treatment options to assist with their benzo dependency.
The benzo backlash
The increase in the use of Xanax may have started among young people, but the wider pattern of non-prescribed benzo use has been an ongoing issue and has morphed over time. Initial benzo dependency was largely driven by massive over-prescribing and long-term prescribing, something that has been addressed but remains an issue.
The path to hell is, however, paved with good intentions. The ongoing guidance to GPs to carefully consider the need for benzo prescribing and review existing patients has certainly reduced the extent of benzos being prescribed in the UK. But without measures to address the underlying reasons why people feel they need tranquillisers, people ended up seeking these drugs first from online pharmacies, then via the NPS market off the dark web and, ultimately, off the streets. This has allowed people to build up tolerance to novel benzos at far higher doses than they would have obtained on the NHS. These same patients, when presenting to GPs for treatment, may encounter the same reluctance to prescribe benzos that pushed them to the street market in the first place.
Prescribing trap
The NICE BNF guidance on benzos for the treatment of anxiety allows for doses up to 30mg a day. For someone who has a significant street-acquired strong benzo habit, the BNF upper limit may be well below that person’s current dose. The dose equivalence for someone using four 2mg alprazolam a day (8mg x 20) would be 160mg diazepam – more than five times the BNF upper limit for treating anxiety.
Where services do have a benzo-prescribing pathway it typically requires a person to reduce themselves off their own illicit benzos to a level where drug services or GPs could take over prescribing. This approach effectively directs a person to continue purchasing off the illicit market, with all the risks that this entails. It is the equivalent of having an arbitrary maximum dose of 30ml methadone and saying to heroin users they should reduce themselves off street heroin until they get to this level.
This situation also assumes that the person has continued access to illicit benzos that they can taper off. If a person has been purchasing off a dark web site which is then shut down, they could be left without any access to drugs, withdrawing off a high dose with no access to legal substitutes. This brings with it huge risks, including psychosis and life-threatening convulsions.
Ashton Manual
Many professionals and people seeking help online will find the Ashton Manual, a guide to benzo reduction and withdrawal by Professor C Heather Ashton. A helpful resource for many, the manual and related resources create two key challenges. First, for some people, reading the manual could reinforce fear and anxiety of withdrawal symptoms. There is a risk that people will anticipate and expect symptoms and could therefore experience a wider range of symptoms and with greater severity.
Second, the withdrawal schedules suggested by Ashton typically reflect people reducing off NHS-prescribed dose ranges. Where people have built up dependency on stronger novel benzos, and built up high tolerance on street drugs, following the sort of slow tapers proposed by Ashton could take one to two years or longer to complete. While on the one hand very slow tapers as described by Ashton minimise risks of unpleasant or dangerous symptoms, they can prove prohibitively and unnecessarily slow for people who have been using at high doses. Minute dose reductions can lead to people fixating on each reduction, and losing motivation over a protracted reduction programme.
Unknown tablets
Efforts to accurately substitute prescribe for illicitly acquired benzo habits are further confounded by our uncertainty as to the specific drug and specific dose that the person is actually taking.
A significant amount of the tablets sold as Xanax could contain one or more other compounds. Alprazolam may or may not be present – weaker or stronger benzos could be present, and these could be shorter or longer acting than alprazolam. Dose may be higher or lower than the claimed strength, and there may be other psychoactive compounds present such as quetiapine.
While drug testing websites such as WEDINOS are invaluable in highlighting trends in pill composition they are less helpful when considering tapers and withdrawal protocols – even if pills held by the client are submitted for analysis. The analysis doesn’t show the amount of each psychoactive compound in a pill, and without testing several pills from a batch, no certainty can be derived from testing a single pill.
This uncertainty about drug, dose and strength makes it impossible to accurately assess:
what level of substitute prescribing is required
how fast or slow a taper should be applied – some novel benzos have a very long duration of effect (100-200 hours) and so slower tapers may be required.
In lieu of accurate and rapid pill testing, the only practical way of substitute prescribing and tapering is to prescribe symptomatically, increasing dose and slowing withdrawal where there are clinical indicators of unmanageable withdrawal symptoms combined with careful assessment of the patient’s self-reported symptoms.
Escaping the trap
Services need to urgently develop new pathways and treatment protocols for people using benzodiazepines outside of clinical and prescribed settings. These need to include:
screening tools to assess for patterns and nature of
benzo use
research into the extent of non-prescribed benzo use
in the UK
protocols to test clients’ pills for content and potency
appropriate levels of substitute prescribing with tapers
rapid access for children experiencing anxiety to CAMHS to reduce self-medicating with benzos
staff training and training for GPs about addressing the use of prescribed benzos without driving people towards illicit markets.
www.kfx.org.uk workshops have moved online during the current lockdown.
The new national substance misuse commissioner forum will play a vital role in responding to future challenges, say Chris Lee and Prof Jim McManus.
Even through these unprecedented times, councils are absolutely committed to ensuring that people seeking help with substance misuse get the right treatment and support, as part of their public health and other wider responsibilities. This includes helping vulnerable people being given another chance to find work, rebuild relationships, improve their physical and mental health and find safe and secure accommodation.
Chris Lee is a public health specialist at Lancashire County Council
But more must be done. Only a fifth of dependent drinkers are currently accessing treatment, while the success rates of drug services vary five-fold from place to place. What’s more, new threats are emerging all the time – one only needs to look at the drug-related death statistics to see that. We must not be complacent. Councils know more needs to be done in close collaboration with local partners to ensure everyone gets the support they need wherever possible.
Covid-19
The COVID-19 emergency comes after a lengthy period of financial and policy upheaval for the drug and alcohol sector. For example, those of us in local government have long argued that reductions to councils’ public health grant – used to fund drug and alcohol prevention and treatment services – is a false economy that will only compound acute pressures for criminal justice, NHS and social care services further down the line.
The Local Government Association (LGA) and the Association of Directors of Public Health (ADPH) have jointly agreed to support the establishment of a national forum for substance misuse commissioners in England. While there are strong regional support networks across England, coordinated by Public Health England regional teams, the purpose of this new forum is to provide a strategic national space in which to bring together those with commissioning responsibility in local government, and enable a representative commissioner voice.
Prof Jim McManus is director of public health at Hertfordshire County Council
With many people currently finding new ways to work, this development will be a timely opportunity adding structure and support around the alcohol and drug agenda in England. It will provide a dedicated space to address the issues and concerns of those commissioning substance misuse related services and the opportunity to share ideas and experience or even just support colleagues.
‘The new national network comes at an important time,’ said director of public health at Hertfordshire County Council, Prof Jim McManus. ‘Bringing commissioners together to learn and share good practice is core to the improvement ethos of local government known as sector-led improvement, and will seek to bring some structured support to an area which has been neglected in recent years. Part of this will be ensuring we develop the best possible services and best commissioning practices. This is just one plank of ensuring we have a response to drug and alcohol issues and the need of our populations. But it is an important plank.’
With physical meetings unlikely to happen for the foreseeable future, the intention is to initially develop an online forum to bring people together and use Knowledge Hub as a central platform – it’s hoped we can physically bring people together at a future date!
Key objectives
To support the development of good practice and effective commissioning approaches
To enable commissioners to share information, intelligence, challenges, ideas, and to support problem-solving
To represent commissioner views on relevant current and emerging policy and strategy
To influence legislation and policy at a local, regional and national level
To enable national representation of substance misuse commissioners in relation to other sector organisations.
While planning is at an early stage, we would welcome expressions of interest to join this emerging forum. If you have any ideas to support this development or wish to register interest in joining, please contact: enyal.lani@adph.org.uk
INNOVATIVE DEVELOPMENTS and impressive collaboration have characterised our sector’s response to the crisis (page 8).
But what we also need to keep up with are the changes in the drugs market and regional trends that could tip the drug-related deaths crisis into further catastrophe. One of the trends identified by Release’s new drug monitoring network is increased use of benzodiazepines, so our cover story looks at how we can respond to this by developing urgent new pathways and treatment protocols. It’s essential that we remain proactive and responsive at the same time as making so many other adjustments to routine.
Commissioners have been thinking along the same lines and there’s an invitation to join a new national forum on page 11. As we’re all particularly concerned about diminishing resources and the threat of services being decommissioned, it’s the right time to create a space for clear strategy and a representative commissioner voice.
Collective Voice are working hard for the treatment sector and invite your involvement in rising to important challenges (p14). When we emerge from this crisis let’s not forget the many gains we’ve discovered from working more closely together.
Christmas is just around the corner and it’s a really magical time here at the family service. We have a big Christmas lunch with presents and lots of food and activities. We decorate the house and everyone really gets involved. We really try to create opportunities for families to make memories.
England’s addiction services are not equipped to deal with the ‘soaring numbers’ of people drinking at high risk levels during the pandemic, warns the Royal College of Psychiatrists (RCPsych). Treatment services should be given ‘a multi-million pound funding boost’ in the upcoming spending review to reverse years of harmful cuts, it states.
City Lit will be offering WDP service users access to an array of online and face-to-face courses across a wide range of subject areas, in exchange for their hard-won Capital Card points.
As Roberts stresses, each part of the initiative has been a learning curve, so supporting the hotels to house their guests safely has been paramount. ‘We’ve been working with local hotels to provide education and training to minimise risks relating to alcohol withdrawal, naloxone training and how to use e-cigarettes,’ he says.
‘It’s been challenging and chaotic, but the fact we’ve been able to come together and have city-wide input has been very useful,’ says Roberts. ‘The government has agreed to try to end homelessness by the end of parliament in 2024 and the work we’ve done will hopefully help that.’
equivalent to just over 19 per cent of the in-need population to 16 per cent (see chart). The drop was within margins of uncertainty, but was consistent each year from 2013-14. With a presumed substantial pool of unmet need, even if there had been no fall in the proportion of the in-need population being treated, a diminishing caseload would still have been of concern.
needed to actualise the government’s recovery agenda, providers were now concerned about being able to maintain the basics of safety and quality.
‘In the mornings I’ll often take a walk around the grounds, just to admire the scenery and breathe in the country air,’ says Nick. ‘I’ve really enjoyed the guided nature walks around the nature trail, where I have been able to take part in wildlife surveys, to identify a range of species. I’ve been given responsibility to look after the greenhouses, which I really appreciate as it’s my way of giving back and contributing to the day-to-day running of Bosence. I’ve learnt so much.’
‘The best part of my role is watching service users change – from appearing on Zoom all chaotic, in the thick of addiction, to becoming a valued part of the group.’
I now work as a nursing prescriber at an acute hospital, the Queen Elizabeth Hospital Birmingham. 
I’m based in a local authority, at the London Borough of Southwark. My role involves commissioning services, contract monitoring, partnership working and strategic planning. I’m also Tier 4 Panel chair and involved in rough sleeper outreach commissioning. There’s a constant fight for funding. The parts of my job that I find most rewarding involve contact with service users.
I went to train as a nurse at the age of 28 following a relationship breakdown. I needed a new start and moved to London to do my training.
New funding from the Treasury will provide ‘interim support’ for 15,000 vulnerable people placed in temporary accommodation during the COVID-19 pandemic, the government has announced. The £105m package will be used to help rough sleepers secure their own tenancies and provide short-term housing in the meantime, it says.
Through my role as service user involvement coordinator, I have continually been impressed by the way people adapt and work collaboratively to overcome adversity and achieve incredible things.
We are proud to work in partnership with many of the leading charities and treatment providers in the sector.
The analysis, from Public Health Scotland in partnership with the University of Glasgow, was controlled for seasonal fluctuations, underlying trends such as household income and other factors, the researchers say, meaning it is ‘reasonable to conclude that the reductions in volume of alcohol sold were due to the introduction of MUP’. 
The Trust, situated in 15 acres of stunning Kent countryside has a variety of services to provide support to those affected by addiction, homelessness and crime. The core service of Kenward Trust is their residential rehabilitation programme which provides support to those affected by alcohol and drug addiction from for to 24 weeks. They also have Kenward Lodge based on their site in Yalding, which provides supported accommodation to those who are struggling to access drug and alcohol treatment due to not having accommodation, whether this be because they are street homeless or living in unsuitable housing. 
