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Tougher rules to protect children from gambling ads

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DDN
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New standards to protect children from ‘irresponsible’ gambling adverts have been published by the Committee of Advertising Practice (CAP). The new guidelines prohibit online adverts for gambling products being targeted at people ‘likely to be under 18’, along with the use of celebrities, sportspeople or others who are – or appear to be – under 25.

A 2016 report from the Gambling Commission estimated that around 9,000 children in England and Wales were ‘problem gamblers’, with 450,000 gambling every week via fruit machines, scratch cards or other means. Twice as many 11-15 year olds had gambled in the last week than had drunk alcohol, the review found, with three quarters reporting seeing gambling ads on TV.

The new standards, which come into force in April, include a list of unacceptable content that includes licensed characters from films or TV, certain types of animated characters such as cartoon animals, references to youth culture, and use of sportspeople and celebrities ‘likely to be of particular appeal to children’.

‘More freedom for gambling operators to market their products has gone hand-in-hand with huge growth of digital gambling platforms,’ says the report. ‘Online gambling is now readily accessible through smartphones and other internet-connected devices. Developments in social media have given rise to new marketing channels through which operators seek to engage more directly with consumers.’

Games that feature elements of simulated gambling are also not to be used to promote ‘real money’ gambling products, and gambling companies also need to avoid placing their adverts on web pages likely to appeal to under-18s, such as the parts of football club websites aimed at younger supporters. They must also ‘use all the tools available to them’ to prevent targeting young people on social network platforms, including information around browsing behaviour and users’ interests.

‘Playing at the margins of regulatory compliance is a gamble at the best of times, but for gambling advertisers it’s particularly ill-advised, especially when the welfare of children is at stake,’ said CAP director Shahriar Coupal. ‘Our new standards respond to the latest evidence and lessons from ASA rulings, and require that greater care is taken in the placement and content of gambling ads to ensure they are not inadvertently targeted at under 18s.’

Protecting children and young people – gambling guidance here and at www.asa.org.uk

This year’s DDN conference includes a dedicated session on gambling addiction and treatment. Book here

Government announces drugs and violence review

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DDN
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The government has appointed Professor Dame Carol Black to lead a wide-ranging review into ‘the ways in which drugs are fuelling serious violence’. Professor Black previously led the government’s review looking at whether people with drug or alcohol problems should be made to undergo treatment in order to claim benefits (DDN, September 2015, page 4).

Professor Dame Carol Black: bringing ‘a wealth of experience’ to the role

The ‘changing drugs market’ has been identified by the government’s serious violence strategy as a key driver of the recent increase in violent crime, and the new review will look at ‘who drug users are, what they are taking and how often’ to build a comprehensive picture of the issue, the Home Office states. The initial findings will be reported in the summer, followed by a second phase of the review.

‘We know the sale and use of drugs is driving serious violence,’ said the home secretary, Sajid Javid. ‘This review will give us a greater understanding of the drugs market so we can make our action even more targeted. Dame Carol has a wealth of experience and I am confident that she will bring independence, integrity and a strong focus to the review.’

In a radio interview with Professor Black she stated that the Home Office had placed issues of decriminalisation and legalisation outside the scope of the review, however, an approach that Transform chief executive James Nicholls called ‘untenable’.

CZAR GAZING – So how are we doing?

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DDN
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As deputy drug czar for the Blair government, Mike Trace oversaw the expansion of today’s drug and alcohol treatment system. In the second of his series of articles he gives his personal view of the successes and failures of the past 20 years, and the challenges the sector now faces... Read it in DDN Magazine.

Mike Trace is CEO of Forward Trust

In my previous article, I described the policy and financial strategy that the last Labour government used to build the national drug and alcohol treatment system we all now work within. This time, I want to take an unvarnished look at the results achieved over the last 15 years with the billions of pounds of taxpayers’ money that has been expended. Most readers will know that the picture has been mixed.

My personal view is that we have not achieved everything we set out to do because, despite political support and big investment, the system we have created is too often process driven and bureaucratic, and insufficiently human and welcoming. The evidence is stacking up that the key precondition for engagement and behaviour change is human connection (Johann Hari sums it up well), and the services that have most impact are the ones that get this right.

For too many marginalised people, their experience of services is too much form-filling and onward referral, and not enough inspiration and consistent personal support. If we want people to change and grow, we have to give them more reasons to believe that a different life is possible.

So how do we get better at facilitating real change, when the sector is under the pressure of cuts, and our clients’ lives are getting harsher? That is now the challenge we face, which I will address in my next article.

REASONS TO BE CHEERFUL

  • We have one of the most comprehensive publicly funded treatment systems in the world, with a high rate of ‘penetration’ (proportion of the population in need who are in touch with services). This major investment in care and support for some of the most vulnerable people in society is both humane and cost effective.
  • We have been successful in reducing drug-related crime, with Home Office research concluding that our treatment system was a key contributor to the reduction of overall crime rates between 2000 and 2010 (although recent trends seem to indicate that this effect is waning).
  • We have been successful in keeping drug-related HIV infections low. The UK was an early adopter of harm reduction practices such as needle exchanges in the 1980s. As a direct result, HIV transmission rates from injecting drug use have remained among the lowest in the world. (Once again, the scope and quality of harm reduction services has recently been under pressure, which may lead to an upturn in infections).

REASONS FOR CONCERN

  • We have not been able to reduce the scandalous level of drug-related overdose deaths, that remain way above European averages. There has been much discussion around the reasons for this, but the fact remains that one of the key objectives of having a well-funded treatment system was to significantly reduce the misery caused by these premature deaths, and we have not yet succeeded.
  • We have not been good at moving people through the treatment system into positions of independence and wellbeing. Apart from the missed potential for individuals, this has created a ‘system’ problem where capacity demands on services constantly increase as new clients outnumber those who move into recovery.
  • We have not sufficiently overcome the funding and delivery ‘silos’. We all know that drug/alcohol treatment clients have multiple needs, but there are not enough examples of truly integrated planning or care and, conversely, sometimes duplication of services. In particular, substance misuse and mental health services still work to separate methods and objectives, and support for children and family members is still an underfunded afterthought.

Mike Trace is CEO of Forward Trust

Alcohol-related hospital admissions up 15 per cent in ten years

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DDN
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There were 338,000 hospital admissions in 2017-18 where the ‘main cause’ was a result of drinking alcohol, according to the latest figures from NHS Digital, a 15 per cent increase on a decade ago. People over 45 accounted for almost 70 per cent of the admissions, with more than 20 per cent of adults drinking over the government’s recommended 14 units per week.

The figures are based on a measure where alcohol-related diseases, conditions or injuries were the primary reason for admission – using the broader measure of looking at ‘a range of other conditions that could be caused by alcohol’, the numbers rise to 1.2m.

There were 5,800 ‘alcohol-specific’ deaths in 2017, up 6 per cent on the previous year and 16 per cent higher than a decade ago, with alcoholic liver disease accounting for 80 per cent of the deaths.

While those in the higher income brackets were more likely to drink above government guidelines, alcohol-specific death rates were once again highest in the most deprived areas, and – despite the rising rates of hospital admissions and deaths – the number of people in treatment for problematic drinking fell from by 6 per cent between 2016-17 and 2017-18.

‘Once again these figures demonstrate that it is the most vulnerable in our communities who are suffering because cheap alcohol is far too available,’ said chair of the Alcohol Health Alliance, Professor Sir Ian Gilmore. ‘In fact, studies suggest that there tend to be more outlets selling alcohol in poorer areas than in more affluent communities. These figures send a strong message to the government that an evidence-based approach to tackling alcohol harm is long overdue if they are truly committed to tackling health inequalities.’

The government’s forthcoming alcohol strategy ‘must’ include measures to tackle affordability, availability and promotion, he said, and should ‘start by following Scotland’s example’ of introducing a minimum unit price. ‘The measure would save lives amongst poorer groups and at the same time reduce the pressure on our over-stretched public services,’ he said.

Huge increase in ‘county lines’ activity, says NCA

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DDN
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‘County lines’ drug dealing networks are continuing to expand with increasing exploitation of children and vulnerable adults, says a report from the National Crime Agency (NCA). The county lines model involves gangs and criminal networks moving drugs – primarily heroin and crack – into new supply areas such as smaller towns and rural areas, and using dedicated mobile phone lines to take orders.

There are now around 2,000 operative mobile lines compared to 720 in 2017-18, says NCA’s latest County lines drug supply, vulnerability and harm document, with the gangs remaining ‘highly adaptable in their operating methods and practices’. Gangs will offer free drugs in exchange for contact details of potential customers to expand their supply base, says the report, using ‘mass marketing text messages’ to advertise their product.

Children aged 15-17 – both male and female – make up the bulk of vulnerable people involved, recruited via grooming techniques ‘similar to what has been seen in child sexual exploitation and abuse’. Rather than seeing themselves as victims, the young people are often ‘flattered by the attention and gifts they receive’, making them less likely to engage with the police. However, the exploitation methods used include sexual abuse, modern slavery, and the ‘threat of violence and injury to ensure compliance’.

County lines gangs will also ‘capitalise on drug users who allow the use of their property, as well as those who introduce new customers to suppliers in exchange for drugs’, says the document. ‘These drug users may believe the arrangement to be mutually beneficial, but in many cases will be building up a debt to the offending network, which they are expected to pay back through engagement in county lines offending.’

Government, law enforcement, charities and other organisations need to work together to ‘safeguard the vulnerable’, the report stresses, with county lines activity driving a two-thirds increase in the number of minors referred as potential victims of modern slavery between 2016 and 2017 (DDN, April 2018, page 4). One week of coordinated police activity between 21 and 27 January this year saw 600 arrests, says NCA, along with more than 400 vulnerable adults and 600 children ‘engaged for safeguarding purposes’ and seizures of more than 140 weapons including guns, machetes and swords.

Nikki Holland: ‘We need to ensure that those exploited are safeguarded.’

‘We know that criminal networks use high levels of violence, exploitation and abuse to ensure compliance from the vulnerable people they employ to do the day-to-day drug supply activity,’ said NCA’s director of investigations, Nikki Holland. ‘Every organised crime group trafficking drugs is a business which relies on cash flow. County lines is no different. What we will continue to do with our law enforcement partners is disrupt their activity and take away their assets. We also need to ensure that those exploited are safeguarded and understand the consequences of their involvement. This is not something law enforcement can tackle alone – the need to work together to disrupt this activity and safeguard vulnerable victims must be the priority for everyone.’

Report at www.nationalcrimeagency.gov.uk – read the report here

Countdown to hep C eradication

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DDN
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NHS England’s target date to eliminate hepatitis C is now just six years away. DDN hears what progress has been made, and what’s left to achieve, at the LJWG on Substance Use and Hepatitis C annual conference.

Read the full article in DDN Magazine

‘The strategy from NHS England has always been to eradicate hepatitis C,’ NHS clinical lead for hepatitis C, Dr Graham Foster, told December’s Seven years to elimination: the road to 2025 event. ‘We’ve never pulled punches – we just want to get rid of the damn thing for once and for all.’

Reductions in drug prices meant this was now achievable, he said, and the strategy had been to split the country into networks and allocate treatment numbers accordingly. ‘From the get-go we insisted on outreach treatment, and we insisted on using the cheapest drugs. The strategy is to get out there and find and treat, and we’ve been pretty successful. We’re still not testing enough, but the figures are moving up. We are working, we are curing people, the strategy is being successful.’

Testing rates in good drug services stood at around 95 per cent, while in some it was as low as 5 per cent. ‘So the challenge is to move that bottom segment into the top segment’. Treatment in prisons remained poor, meanwhile, and too many needle exchanges still weren’t offering testing. However, death rates were falling, as were waiting lists for liver transplants.

But the main challenge was that ‘too many people with a history of drug use still aren’t getting tested’, he said. ‘We need to look at the good services and follow their lead.’

‘For me it’s about supporting services to be doing this treatment themselves,’ said nurse consultant at King’s College, Janet Catt, adding that peers were fundamental to reaching marginalised populations. ‘A lot of people know they’re positive, but hep C treatment can also help them engage more with drug treatment and build goals for themselves,’ added peer support worker Chris Laker. ‘Word of mouth builds that treatment is accessible and successful. Clients really want this.’

People who inject drugs accounted for 95 per cent of all new diagnoses, consultant hepatologist at Chelsea and Westminster, Dr Suman Verma, told the conference. They were a group that tended to ‘dip in and out’ of treatment, she said, and were often of no fixed abode, with no GP and no NHS number. ‘But they do engage with needle exchanges.’

This is where a recent pilot project offering testing in pharmacies with needle exchange facilities had proved so successful (DDN, June 2018, page 5). The aim had been to develop sustainable, effective point-of-care testing and pathways into treatment, she said, adding that it was important that participating pharmacies had adequate facilities for confidential discussion and were able to refer patients with positive tests to the appropriate pathway.

‘But what do you do if you have no fixed abode?’ The answer was the pharmacies themselves acting as mailing addresses for clients so they wouldn’t miss appointment notifications, she said. In the pilot more than 50 per cent of service users were found to be antibody-positive, and 57 per cent of those tested were unaware that treatment was now interferon-free. ‘Opportunistic HCV testing in NSP community pharmacies can be really effective,’ she stated.

‘We all know that hepatitis C is a huge health inequality issue that affects some of the most marginalised,’ said London Assembly member Susan Hall. ‘So it’s a travesty that it wasn’t part of the mayor’s recent report into health inequalities. It shows what a battle we have on our hands to get people to take notice.’ There was growing momentum from more and more organisations to take action, however, but this would need a ‘huge amount’ of joined-up working across often complex networks.

In terms of the practicalities of operational delivery networks (ODNs) meeting their HCV targets, Dr Katherine Morley of the National Addiction Centre at King’s College shared the results of an evaluation project on identifying obstacles. Among the main themes that emerged were degrees of confusion over who should be meeting Public Health England (PHE) reporting requirements, as well as issues around referrals to secondary care as a result of service user drop out, often related to time lag. Missing data was also a problem, the result of providers having different electronic patient record systems – ‘an endemic problem across the NHS’.

Chair of the British Viral Hepatitis Group, Dr Andy Ustianowski, described the methods used in Greater Manchester’s HCV elimination programme, and the lessons learned. The first step was to ‘get an idea of what you’re dealing with – the numbers’, he said, and also to ‘get rid of preconceptions’. The next step was always to ‘contemplate the simplest model’ and work out how to get people to engage for minimal cost.

‘Work out what needs to be done – what’s absolutely necessary and what’s “nice”,’ he told delegates. ‘The “nice” might need to be sacrificed.’ The programme was treating around 930 people a year, he said, using community pharmacies and reaching out to treat people’s networks. ‘Before we treat them we incentivise them to bring their network up for testing.’

Also useful were interrogation of records, rapid prison diagnosis and treatment, and – just as importantly – knowing when an initiative had reached its logical conclusion and should be stopped. The programme was currently also scoping the possibility of testing in primary care and A&E settings, he added. ‘Anyone who’s got a good idea, I’m happy to shamelessly nick it.’

‘One of the things I feel in retrospect is why is it so difficult?’ said former Hepatitis C Trust chief executive Charles Gore. ‘We have these drugs, they cure people – so why does it seem such a struggle?’ In the 1990s, after his hepatitis C diagnosis, he had only been able to find one support group, he said. ‘Everybody was using heroin, and half of them were nodding out – it didn’t feel very supportive.’ He had set up the Hepatitis C Trust despite having ‘no useful experience’, as there was not a single charity for the condition. ‘It was very much on-the-job learning. But I cared about people with hepatitis C, particularly those who don’t have a voice.’

Although the charity had had to abandon its aim of only employing people with a hep C diagnosis after it proved ‘way too restrictive’, it was still driven by the belief that ‘people with lived experience are incredibly useful’, he said, with the role of peers now central to the hepatitis C response in the UK.

Awareness remained a critical issue, and not just in this country, he stated. ‘The big problem is that not enough people are diagnosed, and I’ve become a big convert to the idea of screening. There’s now screening in drug services and prisons, but we need to do more of it. And with the cost of the drugs coming down, it means you can spend more money on screening and it will still be cost effective.’

There were now discussions about long-acting injectables for the condition, he told delegates – ‘one shot and that’s all. It looks like that might be possible’, while in the past NHS England’s rationing of drugs had been ‘appalling’ (DDN, April 2017, page 20). ‘In my view that was simply because of the assumption that people with hepatitis C were a disadvantaged group, and wouldn’t complain too much.

‘I truly think this is doable, and we’re beginning to see more and more countries saying, “yes, we want to do elimination”,’ he continued. ‘We have a cure for a disease that kills people, and we don’t do it? That’s just insane.’

‘There are lots of things yet to do, there are still some challenges,’ Dr Suman Verma told the conference. ‘But we just have to keep on pushing harder.’

Read DDN’s guide, Hepatitis C and Health 

Speaker pictures by Jon Derricott. To view video footage of the event visit Jon Derricott’s YouTube channel.

 

Becoming visible: homelessness

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DDN
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Homelessness may be a complex issue but we know how to make a difference, heard delegates at a conference that brought together academics and experts by experience. DDN reports.

Read the full article in DDN Magazine

‘Outreach workers would try and contact me, but I couldn’t hear, they couldn’t get through. I was fretful and frightened.’ Kevin Dooley is now a recovery programme consultant, but at a conference on addressing complexity: homelessness and addiction’ he cast his mind back to a time when he was homeless, addicted to drugs and alcohol, and in and out of prison.

‘I would wake up when I was homeless and not know what time it was – I didn’t know the day or the month,’ he said. ‘I would open my eyes and see Boots the chemist through the gloom, and I’d know I could shoplift.’

When Dooley left prison, he ‘was on everything but roller skates’, but had no support, no crisis plan, no therapy, and was homeless. Vulnerable in every way, he found it impossible to ask for help.

‘Vulnerable people are being penalised rather than supported,’ he said. ‘To penetrate this, we need to understand the problem… Why do people get out of their heads every day? To become functional, to find a sense of wellbeing. Homelessness is not an intelligence deficiency. Addiction is not an intelligence deficiency.’

We needed to attempt a much deeper understanding, which would help to develop more reflective practice, he said. Relationships were important and sometimes all people needed was ‘a good listening to’. But it was essential to become fully informed about the effects of trauma in early life and realise that ‘the problem was there before the drug dealer came, before the first drink’.

‘It’s a growing problem that’s getting worse and that we need to do more to address,’ said conference chair, Prof Tony Moss. Each measure of homelessness had increased across England since 2010 and deaths of homeless people had increased by 24 per cent over five years.

When represented in the media, the problem was caused by drugs, alcohol, Siberian winds – but never by austerity. ‘The question really should be “why is this problem happening in the first place?”,’ he said. ‘It’s important not to perpetuate the myth that people are dying because of drugs and alcohol.’

Lack of compassion

Most deaths attributed to drug poisoning were ‘thoroughly preventable’, said Prof Alex Stevens, of the University of Kent. ‘The problem is not lack of evidence, but lack of compassion. It’s a class attempt to write people off and not think of them as fully human.’

Leading a report for the ACMD on how to reduce deaths in 2016, he had recommended opioid substitution therapy (OST), drug consumption rooms (DCRs), integrated services, and ‘putting naloxone everywhere’. Latest data from PHE showed that only 12 per cent of people were leaving prison with naloxone, when the odds of death from overdose were eight times higher without it.

‘We should be getting people into treatment and keeping them there,’ he said, explaining that people were nearly twice as likely to die when they were out of OST. Treatment should also involve service integration and assertive outreach, linking drug and alcohol treatment to housing, mental health support, HIV and HCV testing, help with employment, relationships, diet and exercise, and smoking cessation.

There were many things that we could do and should be thinking about ‘rather than just getting people on a script’, he said, such as offering vaping pens to replace the ‘crappy roll-ups’ that caused lung disease.

With evidence being ignored on many initiatives that would have a positive impact, Stevens concluded that the main barriers in drug policy were ‘power and morality’; fiscal policies had redistributed wealth upwards and you were nine times more likely to have a drug-related death if you were from one of the poorest communities. We needed to change the narrative, he said, humanising people who use drugs as ‘people worthy of compassion and fully worthy of respect’.

There were many practical things that we could do to improve life for homeless people, the conference heard. In his opening address Prof Tony Moss said, ‘we’re not particularly good at working together’, so the event went on to share a wide range of expertise.

No help for smokers

Dr Lynne Dawkins of London South Bank University (LSBU) explained the strong link between homelessness and tobacco use and looked at opportunities for harm reduction.

Smoking killed around 200 people a day in England and was responsible for more than a quarter of cancer deaths – and with the average pack price almost £10, it was expensive.

‘You’d expect people on the lowest incomes to be the most sensitive to price changes, but that’s not what the evidence shows,’ said Dawkins. ‘Those who smoke can least afford it.’

While there was a slow but steady decline in smoking in the population as a whole, there were widening health inequalities in people who smoked. It was estimated that 77 per cent of homeless people smoked, which could exacerbate the onset of psychosis.

‘The desire to quit is no less in the homeless population, but attempts are often unaided,’ she said. ‘In some cases, smoking cessation is discouraged as it’s felt they can’t deal with it – that it’s “the only pleasure they have”.’

Evidence had shown e-cigarettes to be 95 per cent less harmful to health than smoking, eliminating the tar and the exposure to 4,000 chemicals, including 60 carcinogens. They gave much faster delivery of nicotine than patches, could replace the all-important hand-to-mouth activity, and didn’t feel like a ‘quit attempt’ to many that tried them. So why aren’t we considering e-cigs for the homeless, an extremely nicotine-dependent population, she asked.

Nothing to lose

Another problem that disproportionately affected homeless people was gambling, and Dr Steve Sharman of the University of East London who had looked at whether gambling was a cause or a consequence of homelessness. ‘Most gamblers have problems before becoming homeless, but also a smaller proportion took it up afterwards – so it’s more complex than we thought,’ he said.

He shared case studies which showed the gradual onset of a gambling habit. Dean’s gambling had started when he was 14 and used to go with his father to collect his mother from the bingo hall. Playing on the slot machines while they were waiting became the start of a habit that led to stealing from friends and family, spending all his wages, becoming homeless when his landlady evicted him for not paying the rent, and two suicide attempts.

Tom was abused from a young age and in care at ten, discovering drugs and alcohol as a way of escaping the negativity he was feeling. He and his girlfriend had a baby at 15, when his gambling career started with interactive tv games; before long he was spending their child benefit in the bookmaker’s, committing burglary, street robbery and violent crime to fund the habit, and became homeless after a spell in prison.

Using the information from personal stories, Sharman was developing a series of tools including a resource sheet with immediate tips and safeguarding measures (freely available at www.begambleaware.org). Fewer people were aware of treatment services for gambling than for drug problems, so the challenge was to find those in need of help, particularly if they were ‘lost’ to the system.

Body and mind

One of the other key areas for review was effective treatment for dual diagnosis, where poor mental (and physical) health overlapped with substance misuse – a situation all too common in homeless people. Using qualitative research, Dr Hannah Carver of the University of Stirling had looked at what could be effective for people in this situation.

As well as long-term, tailored treatment that looked at underlying conditions, it was found that peer support and compassionate non-judgemental staff were important to outcomes. The right environment and the right intervention needed to be paired with stability and structure, and opportunities to learn life skills. ‘Services should be facilitative and friendly, treating people “where they’re at”,’ she said.

Care pathways

Across every facet of healthcare there was evidence-based information that could go a long way to improving the lives of people experiencing homelessness. But as Dr Michelle Cornes of King’s College London demonstrated, the theory came to nothing if multi-professional teams did not work as a unit around the person needing help.

‘The picture is very fragmented,’ she said. ‘We often talk of the need to get physical health better before mental health.’ But pathway teams, including nurses, GPs, housing workers, social workers and occupational therapists, needed to be part of the care team – demonstrated in the case of hospital discharge. The recuperation, rehab, resettlement and recovery were all part of intermediate care that ‘has been shown to give enormous benefits’, she said. She introduced Darren and Jo, experts by experience, who explained what happens when the care pathway breaks down.

Jo had been discharged from hospital to the street with a gutter frame to aid her walking. She had no money and a 0.6 mile walk to her usual sleep site. She then had to walk a total of 6.8 miles on her walking frame over the next two days – to the GP surgery, the day centre to see if there was an emergency bed for the night (there wasn’t one with disabled access), back to the sleep site, to the ‘appointed’ chemist to pick up methadone, back to the GP for assessment, back to the chemist, back to the GP, until finally a taxi was arranged to take her to an intermediate care bed in a local hostel.

‘Why are we still discharging to the street?’ asked Cornes. In 2012 a report published by Homeless Link and St Mungo’s suggested that up to 70 per cent of patients who were homeless were being discharged to the street. In response, the Department of Health and Social Care had released a £10m cash boost to improve hospital discharge arrangements, which had funded 52 specialist homeless hospital discharge (HHD) schemes across England. King’s College had been commissioned to evaluate the schemes over three years, with the aim of showing how to deliver safe transfers of care.

The evaluation showed that homeless people were not being treated the same as others in hospital – for example homeless older people were not being given the same delayed discharge as a patient from a stable background waiting for a care home, to make sure there was somewhere they could go. The intermediate care that had been shown to give ‘enormous benefits’ was in very short supply, even though it was shown to be ‘far more cost effective’ in schemes that had it than schemes that didn’t.

Arranging help on the day of discharge could be invaluable in sorting essential logistics – transporting belongings, registering at the drug service to collect methadone, finding a tenancy that was safe and secure with some heating and basic food ready for arrival, and making sure the person was not alone if they were still feeling unwell.

Motivation to drink

When thinking about longer-term support, it was helpful to know more about motivation said Mick McManus of Barking and Dagenham, who introduced a survey on street drinking in East London. ‘What was their background, what motivated them to drink? Answers to these questions would help to mould our integrated service,’ he said.

Dr Allan Tyler of LSBU explained how their 12-month programme – a collaboration between Westminster Drug Project and LSBU, funded by the London Borough of Barking and Dagenham – combined research and outreach to understand patterns and motives.

The experiences that the team recorded were diverse and showed that not all of the people street drinking were homeless. One important conclusion was that the rich nature of people’s experiences meant that they were not going to create ‘types of street drinkers’.

Among the findings were that many wanted to find a way out of their drinking behaviour, but couldn’t find a path. Others felt stigmatised as ‘weak’ or were excluded from programmes because of a violent past and time in prison. One participant, when asked about giving up alcohol said, ‘Why would I do that? To be the healthiest homeless person in Britain?’

The human touch

Throughout the conference academics shared their findings, but they were illuminated throughout by the contributions of people with lived experience – more relevant than ever representing a population considered ‘hidden’.

‘Your past is not a life sentence,’ said Kevin Dooley. ‘Human beings are capable of change and I’ve lived on second chances all my life… These people are valid and have a voice. These are the ones we need to help us move forward. We can go further and dig deeper – people with experience can contribute to the research and the analysis.’

Lucy Holmes, research manager at St Mungo’s also issued a challenge to researchers – to make their work accessible and easy to absorb.

‘We’re not that interested in methodology – we want stuff that helps us do our job,’ she said, and this could be aided with checklists and toolkits, such as the recent kit on naloxone. Through a lively presentation she urged researchers to get in contact with St Mungo’s, to work together.

‘We do a lot of lobbying, influencing work,’ she said. ‘We sit on project groups, talk to commissioners every day, and we want our messages to be research led. If you want to have real-world impact, talk to us. We talk to the public a lot.’

‘Your research today must reach the coalface,’ agreed Dooley, before chair Tony Moss gave his final thoughts. ‘It’s a relationship between complexity and compassion,’ he said. ‘The more you engage, the more complicated it becomes – but that’s important, because otherwise research is technically inaccurate. Good quality research can start to unpick complications.

‘The sooner you realise a person isn’t in a situation because of the decision they made, the more compassionate you become,’ he added. ‘A whole lot of things in life are out of your control.’

Addressing complexity: homelessness and addiction was organised by the Centre for Addictive Behaviours Research and the London Drug & Alcohol Policy Forum, and held at The Guildhall, London.

Street Smart: integrated outreach

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DDN
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The ISEU project is taking street outreach to the next level, says Peter Burleigh.

Read the full article in DDN magazine

Peter Burleigh is an integrated street outreach worker for Turning Point

I’ve been going into hostels, working with homeless people to provide substance misuse support for Turning Point around the Westminster area over five years, but the ISEU project is different. This is outreach on the streets and frontline partnership working in Central London.

ISEU (the Integrated Street Engagement Unit) includes staff from Turning Point, Westminster City Council, the Metropolitan Police, The Connection at St Martins-in-the-Fields (a day centre run by a homelessness charity), The Passage (which operates London’s largest voluntary sector resource centre for homeless and vulnerable people), and the Compass team and street outreach (St Mungo’s outreach services). It’s an innovative project combining integrated health, housing and social care support in order to provide effective routes off the street, with the goal of helping some of the most vulnerable to turn their lives around.

We plan our operations for the upcoming week every Friday, and these can include tent removals, antisocial behaviour enforcement, begging or tackling organised crime. On some days there will be no specific operation and we will go out solely to engage the street homeless and offer social care, medical health and substance misuse support. ISEU recognises that enforcement isn’t the most effective way to support people who are sleeping rough, and that long-term we need to be addressing the wider needs of every individual. In every operation there will be a minimum of two plain-clothed police officers who are trained to work specifically as part of ISEU, a city inspector, myself and other partners, depending on the nature of the operation. On larger operations we can have teams of up to 15 people.

When we approach an individual of interest, unless it is a targeted specific police operation (where there is no need for substance misuse expertise), I often lead in approaching and engaging them into conversation. Nine times out of ten, people are willing to have a chat and are receptive. In some cases we’re faced with challenging clients who are treatment resistant and will refuse support, and this is usually to do with trust. Every situation is different, but being cautious and confident is key.

When we are engaging with someone, it’s important we try to find out the individual’s name, age, whether they are currently in a hostel, whether they have been to a day centre, if they have any medical needs and if they are having any problems with drugs or alcohol. When we have a name we can check this against CHAIN, a multi-agency database recording information about people sleeping rough and the wider street population in London. This enables us to see if the person is seeking any health and social care support from services or charities – if they are not on the database I will give them the details of Connections at St Martins, a day centre where they can register for support services.

Since April 2018 I have engaged with 112 clients, with heroin, cocaine and spice being the most commonly used drugs. Age and gender vary – women often have more complex needs, but can also be more engaged with support. At present I am working with 33 active clients, while 23 have already completed treatment and are waiting for – or are already in – housing. Meanwhile, 18 have dropped out and nine have been referred to Turning Point’s drug and alcohol wellbeing service to address substance misuse.

I visit Passage House every week, a 28-day assessment centre for those who have been sleeping rough in Westminster but are not from the borough. Passage House is designed to provide a safe, flexible and supportive environment, and the service uses a trauma-informed approach. Every client has their own room and a designated lead worker. You must be referred by one of the outreach teams, but Passage House offers a wrap-around service, working with people to help them plan a route off the street that is sustainable in the long term.

One of the main challenges we face is reminding individuals that things can’t just happen overnight. Getting the right support in place for housing, medical needs, employment, benefits and so on takes time and often requires multiple appointments that need to be attended. We are here to support people in the most efficient way possible, but this also requires mutual understanding and dedication. If people show up on time to appointments progress can be made, but when people don’t show up sometimes it means we end up back at square one.

ISEU works really well because every person and organisation brings different skill sets and knowledge, with the same collective aim and commitment to meet it. Prior to ISEU outreach happened in hostels and supported accommodation but the rough sleepers who weren’t already seeking any provision were difficult to reach.

I learnt very early on in my career that I have to be able to enjoy my own life outside of this job and not let it impact my personal life – that being said you can’t do it if you don’t love it, and I have a real passion to help improve people’s lives. I wouldn’t change it for the world.

 

A capital idea

By
DDN
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WDP’s Capital Card scheme has been helping to incentivise and empower service users, the team tells DDN.

Read the full article in DDN Magazine

People who come into drug and alcohol services looking for support and treatment are very often also experiencing profound isolation from their communities. Not only can this be damaging to their recovery, it can also have a negative impact on their general health and wellbeing. Helping service users reconnect with the world is a vital issue for substance misuse services.

With this in mind, WDP has launched a simple earn/spend points system that supports service users to make sustainable and significant changes. Created by WDP’s joint CEO, Manish Nanda, the Capital Card aims to transform the lives of service users and their families by protecting against social isolation and encouraging people towards proactive and positive engagement at their service.

Points are saved on a smartphone app.

Much like a retail loyalty card, Capital Card users earn points as they go. When they begin treatment with WDP they are given their own personal Capital Card, and each time they attend a keywork appointment or take part in a group or recovery-related activity they earn ten Capital Card points. They can then redeem the points they’ve accrued at ‘spend partners’ in their local communities. These recovery-focused opportunities are diverse and growing, and include gym passes, restaurants, cinema tickets and adult learning. These benefits and experiences inspire people to engage with their local communities, as well as bolstering their recovery.

The idea of Capital Card was initially conceived while trying to improve the engagement we had with our prison-releases – an arrangement was made with a local barber to provide free appointments for a haircut and shave on their day of release. This proved popular, as service users often like to have something tangible to incentivise and reward their treatment milestones. Manish Nanda, joint CEO, and who was key in its development, said that ‘by developing more links with other local businesses, service users would have access to opportunities that they may have previously felt excluded from. After all, everyone likes something for free so why shouldn’t our service users get something extra from coming into treatment?’

The card has been designed based on the principles associated with ‘contingency management’, an evidence-based treatment intervention endorsed by the National Institute for Health and Clinical Excellence (NICE) and which suggests that positive behaviour change is strengthened through reinforcement, reward and recognition. It has also been mapped against the ‘five ways to wellbeing’ and all spend rewards are focused on supporting service users to achieve healthier lifestyles. The evidence suggests that even a small improvement in wellbeing can help people to flourish.

Points are awarded in real-time, allowing service users to make the immediate connection between their motivation and the incentives for their positive behaviour. There is also a companion app that acts as an e-card where users can check their points balance and see which spend partners are available in their area.

The Capital Card was shortlisted by the Global Good Awards and the Charity Times Awards, and was also named ‘digital innovation of the year’ at the 2018 Third Sector Awards.

‘Winning the digital innovation category at the Third Sector awards is truly a testament to the cutting-edge technology that we are continuously developing as well as the incredible hard work and passion of our Capital Card team,’ said WDP chair Yasmin Batliwala. ‘It also clearly demonstrates that our service users are at the very heart of all we do.’

After its launch in Hackney in April 2017, the card has been rolled out in the boroughs of Barking and Dagenham, Barnet, Brent, City of London, Harrow, Havering and Redbridge. The scheme will be also be available in the London Borough of Merton and in Cheshire West and Chester from April 2019.

While the scheme and technology are national, the card can easily be adapted locally to meet the needs of each service and its clients. Some services have used it to help meet their KPIs or to incentivise particular groups of service users by setting up ‘bonus’ structures – for example, by providing bonus points to those who complete a full course of BBV vaccinations within six months.

Having such a flexible scheme means that each service can benefit from national spend partner opportunities while also having smaller local independent businesses involved. Most Capital Card spend partners are charitable or corporate social responsibility-minded organisations that want to give something back and reward those trying to help themselves during a difficult period in their lives.

WDP services also run monthly in-house Capital Card pop-up shops, which have donations from local spend partners and community members. These allow service users to ‘purchase’ goods such as clothing, essentials, toiletries and books that they may not otherwise be able to afford in exchange for points. ‘I think the Capital Card pop-up shop is absolutely wonderful,’ said one cardholder. ‘I think it is a very good place to get some toiletries and helps a lot – it’s given me a boost. This morning I was strongly grieving over my daughter and I am feeling good now.’

Service user involvement is central to the Capital Card enterprise. Service users have enthusiastically supported the production and evolution of the card from the begin­ning and provide regular feedback on what’s working well and what needs improve­ment, as well as the type of spend partners and incentives that they want to see.

Service users have been involved in planning and running the project.

There have also been spend opportunities organised for more isolated service users so that they can attend group activities with their peers. One good example is locally organised Nando’s outings. These have had excellent feedback, with service users describing how they allow them to socialise, avoid isolation and feel safe in an accepting environment, while enjoying a meal that they wouldn’t otherwise be able to afford.

‘One of the key reasons for Havering Council awarding the adult drugs treatment service to WDP was its commitment and drive to innovate in the sector,’ said senior commissioning manager at the London Borough of Havering, Daren Mulley. The Capital Card is not only local authority-endorsed but was also singled out in a positive Care Quality Commission (CQC) report for WDP’s Harrow service in 2018, where it was described as an area of ‘outstanding practice’ for service users. The next step is now looking at the card’s impact in more detail. With more than 12 months of data from its Hackney Recovery Service, WDP is working with London South Bank University (LSBU) to analyse and publish the statistical impact.

‘We compared treatment completion rates in Hackney over a two-year period, before and after the introduction of the Capital Card,’ said professor of addictive behaviour science at LSBU, Antony Moss. ‘Once we controlled for some differences between these two time periods in terms of client demographics – age, sex, and primary substance – our analysis showed that the Capital Card was associated with a 50 per cent increased likelihood of clients successfully completing treatment. These results are very encouraging and justify further evaluation of the Capital Card in a definitive trial.’

‘Our belief that recovery cannot be achieved behind just the four walls of a treatment agency has really fuelled this simple yet powerful home-grown innovation,’ said Arun Dhandayudham, joint CEO. ‘The early findings from the LSBU analysis are incredibly encouraging, and combined with service user feedback, strengthens our belief that those who have access to the Capital Card can achieve improved recovery outcomes as well as reconnecting with their local community.’

www.capitalcard.org.uk

If you are interested in setting up the Capital Card in your area, contact Holly Price, capital card manager on holly.price@wdp.org.uk or 07557 393 980.

 

DDN February 2019

By
DDN
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‘We need to challenge the narrative on homelessness’

The rising rate of homelessness in this country is a scandal that shames our society. Furthermore, we are passive to the theory that through wrong choices, drugs and alcohol, those on the streets nominate their fate as they become consigned to an invisible underclass that will die a third of a lifetime sooner than they should.

We need, as Alex Stevens says (page 16), to challenge the narrative and acknowledge the moral bankruptcy involved. Crucially, we must do more to bring evidence to daily practice through simple, cost- effective harm reduction, early interventions, and the confidence to reach out and create strong peer networks. Turning our backs on this situation and leaving it to others is not an option – we have the knowledge and the networks to disseminate better practice and ensure that people like Jo (who brought her experience to the recent conference on homelessness) do not fall through the gaps.

An important part of the story is the case studies provided by experts by experience/patients/service users. Their feedback is our gain in improving services, and they should be equal partners in consultation. Our cover story combines service user involvement with innovation and shows what can be achieved as an exciting idea takes hold.

This month we’re looking forward to seeing you at our annual conference, where we’ll be hosting a debate on the future shape of service user involvement. Let’s embrace the opportunity to create a national network that has a clear and informed voice and strikes at the heart of where it’s most needed.

Claire Brown, editor

Conference details and booking at www.drinkanddrugsnews.com

Keep in touch @DDNmagazine. Your letters are welcome – email the editor

Read the virtual magazine or download the PDF

Reading the signals

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DDN
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Gay men can find it very difficult to seek help when ‘chemsex’ becomes addictive. Leon Knoops explored the issue at Hit Hot Topics.

Read the full article in DDN

Chemsex is the name for combining drugs with sex. Gay men use drugs twice as much as straight men and a part of the dating app culture is to order drugs and find sex parties.

The list of substances being used has grown and a new trend is smoking crack during sex. The crystal meth in circulation is the strongest available on the European drugs market and it’s taken by slamming – injecting drugs before or during sex.

In 2014 I started to interview people who had experience and found that a lot of guys had issues – abscesses, blue spots, sharing needles, and many were experiencing mental health issues and sleeping problems.

Many were finding they were unable to have sex without drugs, and more and more men were losing control. Some were losing their houses and belongings, and even contemplating suicide.

It’s not done to talk to your friends about this because of the stigma, and there’s not enough information or expertise. So at Mainline we set up chemsex meetings and training for professionals, including STI nurses and consultants. There wasn’t enough cooperation initially, so we set up a roundtable that meets twice a year to discuss Interventions around chemsex.

The way to connect with those who need help is to use slang and be curious. Don’t have judgement but show support – there can be many underlying issues such as loneliness. Let’s work together to improve the situation.

‘I felt the connection and couldn’t stop’

I had a great job, working for an airline in Holland. I had a lovely partner, my husband. I earned a lot of money and had several apartments.

But something went wrong – there were cracks in our relationship. I decided to end it and fled to an apartment in Sitges. At 53, I felt overdue on the gay scene, but it was easy to install the dating apps. I met a guy in Barcelona – a man smoking a pipe. He gave it me to try and I thought it was part of the game.

The effects hit my body and before I knew I had had sex for four days and three nights. I thought holy shit, what is this? And I loved it. But I was worried it would cost me my job – we were not allowed to fly with any substances in our bodies. I had to fly to Toronto, so I thought I’d see if they have the same there – and they did. It was the beginning of my world tour.

I felt the connection and I started smoking crystal meth. Then I was offered injecting and didn’t at first – but when I started slamming, the rush I felt was incredible. I wanted more sex, more guys, I wanted it to go on forever.

But as I came down I had severe depression. My weight went down. I was looking for information, but all I could find was American sites with all those pics of crystal meth users, and I thought ‘that’s not me’.

So I kept going and met other guys, and I enjoyed the connection. When my mother died, I was partying in Toronto. I was raped and I thought that was part of it. I couldn’t go to the police and tell them I’d been taking crystal meth. A lot of people tried to help me, but I didn’t want to help myself because I was so into the connection with those guys.

But I was pulled over in Amsterdam and found with drugs. I found myself in jail.

I went to 12-step groups and to addiction counselling. What I was looking for was for people to listen to me, know what I was going through and not judge me. People were judging me because I was part of the gay chemsex scene.

My mission now at Mainline is to find people and help them. I won’t judge them – I already judged myself.

Leon Knoops and Sjef Pelsser are members of the Mainline chemsex team, based in the Netherlands with projects at home and abroad. Their website is a valuable resource at https://english.mainline.nl

Photography by nigelbrunsdon.com

So, how are we doing?

By
DDN
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As deputy drug czar for the Blair government, Mike Trace oversaw the expansion of today’s drug and alcohol treatment system. In the second of his series of articles, he gives his personal view of the successes and failures of the past 20 years, and the challenges the sector now faces.

Read the full article in DDN Magazine

Mike Trace is CEO of Forward Trust

In my previous article, I described the policy and financial strategy that the last Labour government used to build the national drug and alcohol treatment system we all now work within. This time, I want to take an unvarnished look at the results achieved over the last 15 years with the billions of pounds of taxpayers’ money that has been expended. Most readers will know that the picture has been mixed.

My personal view is that we have not achieved everything we set out to do because, despite political support and big investment, the system we have created is too often process driven and bureaucratic, and insufficiently human and welcoming. The evidence is stacking up that the key precondition for engagement and behaviour change is human connection (Johann Hari sums it up well), and the services that have most impact are the ones that get this right.

For too many marginalised people, their experience of services is too much form-filling and onward referral, and not enough inspiration and consistent personal support. If we want people to change and grow, we have to give them more reasons to believe that a different life is possible.

So how do we get better at facilitating real change, when the sector is under the pressure of cuts, and our clients’ lives are getting harsher? That is now the challenge we face, which I will address in my next article.

Reasons to be cheerful

We have one of the most comprehensive publicly funded treatment systems in the world, with a high rate of ‘penetration’ (proportion of the population in need who are in touch with services). This major investment in care and support for some of the most vulnerable people in society is both humane and cost effective.

We have been successful in reducing drug-related crime, with Home Office research concluding that our treatment system was a key contributor to the reduction of overall crime rates between 2000 and 2010 (although recent trends seem to indicate that this effect is waning).

We have been successful in keeping drug-related HIV infections low.

The UK was an early adopter of harm reduction practices such as needle exchanges in the 1980s. As a direct result, HIV transmission rates from injecting drug use have remained among the lowest in the world. (Once again, the scope and quality of harm reduction services has recently been under pressure, which may lead to an upturn in infections).

Reasons for concern

We have not been able to reduce the scandalous level of drug-related overdose deaths, that remain way above European averages. There has been much discussion around the reasons for this, but the fact remains that one of the key objectives of having a well-funded treatment system was to significantly reduce the misery caused by these premature deaths, and we have not yet succeeded.

We have not been good at moving people through the treatment system into positions of independence and wellbeing. Apart from the missed potential for individuals, this has created a ‘system’ problem where capacity demands on services constantly increase as new clients outnumber those who move into recovery.

We have not sufficiently overcome the funding and delivery ‘silos’. We all know that drug/alcohol treatment clients have multiple needs, but there are not enough examples of truly integrated planning or care and, conversely, sometimes duplication of services. In particular, substance misuse and mental health services still work to separate methods and objectives, and support for children and family members is still an underfunded afterthought.

 

 

DDN Conference 2019 Programme

By
DDN
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Keep on Moving, the DDN service user involvement conference – Motorcycle Museum, Birmingham, Thursday 21 February 2019

9-10am, Registration

10-11.15, Food for thought

10-10.10 – Welcome from the chair.

10.10-10.30 – Lord Victor Adebowale introduces the theme ‘keep on moving’ and its significance to service user involvement.

10.30-10.50 – Rosanna O’Connor explains how PHE are moving on hepatitis C strategy.

10.50-11.10 – Mat Southwell makes the case for putting people who use drugs back at the heart of the response to drug user health and rights.

11.10-11.20 – Question time

———

11.20 -11.50, Tea and coffee break

———

11.50-1pm, The big conversation

‘Where are we going with SU involvement? What is it? Why do we need it? Can we construct a national network that is relevant for today’s needs?’

This is an invitation for everyone to join in the debate. Our panel will give their thoughts and we want your views, with the aim of kick-starting a new, viable and sustainable initiative.

Chaired by Carole Sharma, with expertise from Release, Collective Voice and SMMGP

Panel:

  • Mark Pryke, CGL
  • Radha Allen, B3
  • Tim Sampey, Build on Belief
  • Peter Yarwood, Red Rose Recovery
  • Jon Roberts, Dear Albert

———

1-2.15pm – lunch and exhibition

———

2.15-4pm, Insights

2.15-2.30 – My Lightbulb Moment – The Recovery Street Film Festival

2.30-2.50 – Naloxone: a personal story. Kevin Jaffray shares his moving experience of this life-saving intervention.

2.50-3.10 – Turning the tables. Owen Baily gives invaluable insight into gambling addiction and treatment.

3.10-3.40 – An open heart. Jacquie Johnston shares her unforgettable journey of personal growth and connection through her experiences of life’s ups and downs, including addiction. An unmissable finale that will leave you inspired.

3.40-4pm – Reflections and conference close

Refreshments will be served at 3.45pm and drinks will be available in a takeaway cup for your journey!

———

 

December 2018

By
DDN
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‘How difficult, when stigma adds to the pain’

It’s harder than usual at this time of year for any of us who have lost loved ones or who are struggling to support them through illness. How much more difficult must it be when stigma adds to the pain and heartbreak? Katie’s decision to share her story (page 6) is a courageous one that will help to tackle prejudice on many levels. Storytelling is particularly helpful in the context of family support, as John Taylor discovered when he suggested the idea to his clients at the DAWS Family and Friends service. He found that many had even stopped talking to people closest to them and were working through their trauma alone. Tapping into this form of peer support can offer a valuable source of strength that deserves our encouragement.

As the year comes to a close, conference season has been in full swing and we have reports from HIT Hot Topics (page 12) and the GPs’ conference (page 16). Our write-up of the LJWG’s event on hepatitis C will be in our next issue. The themes may be recurring but there are many new ideas, fresh inspiration and invigorating debates. At HIT there was an interesting discussion about the ‘othering’ of people in society and an invitation to re-examine preconceptions.

And in this spirit of contemplation, we reflect back on another year of cuts and chaos, where we have felt powerless to halt the rise of drug and alcohol-related deaths. But we are also reminded of some important things that make a difference – strong harm reduction, good commissioning, and a commitment to learning from each other.

I hope you enjoy a safe and peaceful festive season and we’ll be back for the February issue. Keep in touch with us over the break – and don’t forget to secure your ticket to the DDN conference on 21 February!

Claire Brown, editor

Read the latest issue as a E-magazine or download the PDF

Migrants will not be charged for most drug and alcohol services, government clarifies

By
DDN
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Updated government guidance on implementing health charging regulations for overseas visitors has clarified the position on drug and alcohol services. These can be considered the equivalent of primary medical services, says the revised Department of Health and Social Care document, which means that they are exempt from any charges to foreign nationals.

The guidance states that pharmacotherapy and behavioural support – which covers most drug and alcohol treatment – can be regarded as primary medical services. ‘It is important to note that some services provided in the community will be “equivalent” to primary medical services and so do not attract a charge for any overseas visitor,’ says the updated document. ‘Examples are services provided by school nurses and health visitors and many drug and alcohol treatment services.’ Previous versions had been unclear on which services were considered equivalent. Inpatient care, however – which includes residential rehab – is not considered a primary medical service and will therefore not be available without charge.

‘This is a significant positive change in government guidance which Blenheim welcomes,’ said Blenheim CEO John Jolly. ‘Along with other organisations in the sector Blenheim has been seeking urgent clarification of the position of foreign nationals for some time. The change will enable drug and alcohol services to provide treatment to anyone who needs it, irrespective of who they are and where they come from. The changes also remove the uncertainty for EU nationals in treatment as we approach Brexit. Making equal access to treatment and the opportunity for change possible is so important to us at Blenheim where we advocate that the opportunity to change is a right, not a privilege.’

Guidance on implementing the overseas visitor charging regulations here

Finding a voice

By
DDN
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Katie’s experience of stigma made her determined to help herself and others – the beginning of Adfam’s #StigmaMakesMeFeel campaign. She shares her story, with DDN.

Katie’s family have suffered from the stigma surrounding her brother’s drug addiction.

My older brother has been addicted to class A drugs for the past 17 years. I was 12 years old when he began using drugs, and my younger brother was just ten. Needless to say, his addiction has affected my family in every way possible, but perhaps the worst part was how other people treated us – all because of the stigma surrounding drug addiction.

The stigma was ridiculous – nobody wakes up in the morning and says ‘I think I’ll become an addict today’. Yet why does it prevent so many people from speaking out?

Is it because they’re worried that people will judge? Of course. Is it because people are worried that others will think they’re an addict? Perhaps. Does it mean anyone has failed? Absolutely not. Does wider society realise the anguish that comes with having somebody who is addicted in the family? No. These are questions that I have been asking for 17 years now.  

The first time I experienced stigma was when I was 13 years old. The day before we had had a horrible ‘post-high comedown’ drama with my brother. He was incredibly violent and the police were called – and of course being in a small village, that meant that our neighbours watched the drama unfold.

While I was looking at the magazines in the village post office, treating myself to an escape for the afternoon, I overheard three fellow villagers saying, ‘I don’t want a family like that in the village, I don’t want my children growing up surrounded by drug addicts.’

I calmly walked around the corner and corrected their perception, making it quite clear that my family were not a ‘bunch of addicts’, but incredibly hard­working and respectable people who were going through tremendous pain and heartbreak supporting someone with an addiction, and that they should be ashamed of themselves for being so naïve. I didn’t get an apology, but was met with rather embarrassed looks and silence. After that day I never returned to the shop.

That’s why Adfam is so important to me. Stigma has had a huge impact on me – it silenced me for 16 years, and those who know me, know I am not easily silenced!

All the years of not being able to speak openly about something that has several times come close to destroying my family and me was released, and I am incredibly grateful to Adfam for giving me the confidence to speak out against stigma. I hope this campaign will not only bring people together, but go some way for us, as a group, to have a voice and influence policy.

Through #StigmaMakesMeFeel we are determined to help others and get our voices heard.

Gaining momentum

Adfam has embraced the opportunity to talk openly about stigma, says Robert Stebbings.

Robert Stebbings – Adfam Policy and Communications Officer.

Stigma has been a prominent theme for us at Adfam and something that we frequently encounter in our varied work supporting families affected by alcohol or drug use.

One family member spoke to us about how stigma is ‘like being labelled with a big invisible sign that I can’t see but others can’.

This isn’t good enough. Families should feel able to talk about their experiences openly and live their lives without fear of judgement from others. Often stigma isn’t malicious or deliberate; it’s due to people misunderstanding the issue and what families are going through. That’s why we have launched #StigmaMakesMeFeel – a campaign that gets stigma out in the open and tackles it face on.

We’re aiming for 1,000 photos of people with our campaign boards writing their own personal messages of how stigma makes them feel and how it’s impacted on their lives.

By talking about this issue openly and honestly, we believe we can make a huge impact and change the way people think about substance use and the families affected.

Since our launch earlier this year the response has been fantastic, with people across the country sending us a range of powerful and inspiring photos and messages.

How does stigma make you feel? You can get involved in our campaign to raise awareness of stigma experienced by families affected by drugs and alcohol through three simple steps:

  1. Download and print off our campaign board (pdf)
  2. Write your own message on how stigma makes you feel
  3. Take your photo and tweet it using the hashtag #StigmaMakesMeFeel (or email it to us at admin@adfam.org.uk)

Strength in narratives

Helping families and friends to tell their stories has been an effective way to offer support, says John Taylor.

John Taylor is DAWS family and carers lead. The Drug and Alcohol Wellbeing Service (DAWS) is run by Blenheim and Turning Point.

I was reading a recovery stories book, full of inspirational stories of how service users found recovery from substance misuse. With that in mind, I thought ‘what about the people around them – their families and friends? Do they not need some form of recovery and for their stories to be told?’

I started to ask my clients at the Daws Families and Friends service if they would be willing to tell their stories about how they found their own recovery with a ‘loved one’ in addiction, and the response I got was both positive and quite remarkable. Many said they would like to tell their story to help someone else to feel less alone.

 

Most felt when they came into the service that they were all alone in dealing with their loved one’s addic­tion and that they couldn’t tell anyone about what was happening in their life because they feel so much guilt and shame – hence it becoming a ‘family illness’.

They stopped talking to people closest to them because they felt sick of talking about the same old stuff or they had received advice that wasn’t useful to them, such as ‘kick them out’ and ‘don’t have them in your life’. They felt that those around them didn’t understand about addiction and were quick to judge, adding to a sense of shame.

This is exactly why groups can work so well for ‘affected others’ just as they can support people tackling their own addiction. You can be with people who are just like you, get identification and lose the feelings of judgement and shame. It takes away the isolation that can come with addiction and make people unwell.

The result of this project to share experiences, the DAWS Families and Friends Recovery Stories book, is about these forgotten victims of addiction – people who rarely have a voice and who are often supporting loved ones to access treatment and find recovery from substance misuse.

Read the Recovery Stories book here.

My clients who attend DAWS have loved ones who might be in treatment or might not; they might be in their lives or they might not. Whatever the circumstance, if someone has been affected by another’s substance misuse, they are welcome. In some cases their loved one has passed away as a result of addiction and they are left with the trauma. More than ever, they need support to help them process the loss that they are going through and they often experience a debilitating sense of guilt.

At DAWS we help them to explore how they are processing their thoughts and feelings. Our 12-week rolling programme covers setting boundaries, self-care, healthy relationships, looking at anger, building up resilience and social networks. The first half of the programme is a process group, where we work with whatever is brought up by clients.

The strength and courage that the families and friends show on a daily basis amazes me, and this shines through the book. These are stories of how people are watching their loved ones on a destructive path and unfortunately often end up on the path with them.

It’s so very important to remember how substance misuse affects so many others around that one person. Figures from Adfam state that for every person in active addiction, eight people around them are likely to be affected. This highlights the problem we have and also shows how important it is for these people to get support and have their voices heard.

Alcohol focus for new NHS plan

By
DDN
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Alcohol care teams will offer support to alcohol-dependent patients in more hospitals, as part of the new NHS long-term plan. The teams will be rolled out in hospitals with the highest number of alcohol-related admissions to provide support to patients and their families, with the service to be made available in the ‘25 per cent worst affected parts of the country’.

‘Drinking to excess can destroy families, with the NHS too often left to pick up the pieces,’ said NHS England chief executive Simon Stevens.

Alcohol care teams in hospitals in Bolton, Salford, Nottingham, Liverpool, Portsmouth and London have already led to a reduction in A&E attendances and readmissions, says the NHS, while ambulance call outs have also ‘significantly reduced’. The new teams will work in as many as 50 settings across the country, delivering alcohol checks and providing rapid access to  counselling, medically assisted help to give up alcohol and ‘support to stay off of it’. Although hospital-based, the teams will work with local community services to ‘ensure all needs, including any other health needs, are met’.

Alcohol-related hospital admissions have increased by 17 per cent over the course of a decade, to 337,000 in 2016-17. NHS England estimates the annual cost of alcohol-related harm at £3.5bn.

The initiative is part of a major focus on prevention in the new NHS plan, alongside support for patients who smoke and action on obesity and diabetes. Partners of pregnant women will also be encouraged to stop smoking to ‘give new mums the best chance of not smoking again’.

‘Drinking to excess can destroy families, with the NHS too often left to pick up the pieces,’ said NHS England chief executive Simon Stevens. ‘Alcohol and tobacco addiction remain two of the biggest causes of ill health and early death, and the right support can save lives. The NHS long-term plan delivers a sea change in care for a range of major conditions like cancer, mental ill health and heart disease, as well as stepping up to do more on preventing ill health in the first place by giving patients the support they need to take greater control of their own health and stay fitter longer.’

The focus on managing alcohol-related ill health was ‘very welcome’, said Royal College of Physicians president Andrew Goddard. ‘It is an increasing problem in our hospitals where many patients first come to the attention of the NHS. We mustn’t forget prevention though and further measures to reduce harmful drinking are much needed.’

www.longtermplan.nhs.uk

Harm reduction worldwide has ‘stalled’, warns HRI

By
DDN
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The number of countries providing harm reduction initiatives has stalled in the last two years, according to Harm Reduction International’s (HRI) Global state of harm reduction 2018 report.

Despite injecting drug use being present in almost 180 countries, the number providing needle and syringe programmes (NSP) has fallen from 90 in 2016 to 86.

Policy changes have meant that NSP services have ceased to exist in Bulgaria, Laos and the Philippines, where ‘punitive drug policies result in people who use drugs experiencing harsh criminalisation’, the report states.

Although the number of drug consumption rooms worldwide has risen from 90 to 117 and OST provision has increased slightly from 80 to 86 countries, the latter is still ‘well short of what is required for an effective public health response’, says HRI.

The ‘worrying increase’ in opioid-related overdose deaths in North America has been met with a public health response that ‘broadly encompasses the principles of harm reduction’, says the report, albeit to ‘differing extents’ in the US and Canada. The emergence of fentanyl in Europe, meanwhile, should ‘instil greater urgency in preventing drug-related deaths’ and adds weight to the ‘already strong arguments for increasing the availability of naloxone and DCRs’.

There are an estimated 15.6m people worldwide who inject drugs, with more than half living with hepatitis C and almost one in five living with HIV. Harm reduction in prisons remains ‘in a worse state than in the community’, the report adds, with just ten countries operating prison-based NSP and 54 OST. This is despite the fact that since 2000 the world prison population has grown  20 per cent faster than the general population, and ‘up to 90 per cent of people who inject drugs may be incarcerated at some point in their lives’.

Funding for harm reduction in low- and middle-income countries is just 13 per cent of ‘what is needed annually for an effective HIV response among people who inject drugs’, says HRI. ‘The prohibition of drugs, combined with the lack of capacity and effective health care coverage, means that life-saving and cost-effective harm reduction services are disregarded by health authorities in low- and middle-income countries where the burden of the drug-related health issues is the greatest,’ said chair of the Global Commission on Drug Policy and former Swiss president, Ruth Dreifuss.

‘The lack of progress in implementing harm reduction measures is a major concern and stunting progress in global health,’ said public health and social policy lead at HRI, Katie Stone. ‘Harm reduction is cost effective and proven to promote healthier societies. It is disgraceful that governments continue to ignore the evidence in favour of demonising people who use drugs. This is a crisis in need of urgent response.’

Read the report at www.hri.global

Homeless deaths up by a quarter over five years

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DDN
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There were almost 600 deaths of homeless people in England and Wales in 2017, according to ONS figures, an increase of 24 per cent over the last five years. Men accounted for 84 per cent of the deaths.

Homeless men accounted for 84 per cent of the deaths.

More than 30 per cent of all the deaths were as a result of drug poisoning, says ONS, an increase of 51 per cent over the same period. Opiates were involved in more than three quarters of the drug poisoning deaths, while a third also mentioned alcohol on the death certificate. Drug poisoning, liver disease and suicide accounted for more than half of all deaths, with the mean age of death 44 for men and 42 for women, compared to 76 and 81 for the general population.

The highest death rates – both as a total and as a proportion of the population – were in London and the North West. The records identified were ‘mainly people sleeping rough, or using emergency accommodation such as homeless shelters and direct access hostels, at or around the time of death’, says ONS.

‘Every year hundreds of people die while homeless,’ said the agency’s head of health and life events, Ben Humberstone. ‘These are some of the most vulnerable members of our society so it was vital that we produced estimates of sufficient quality to properly shine a light on this critical issue. Our findings show a pattern of deaths among homeless people that is strikingly different from the general population. More than half were related to drug poisoning, suicide, or alcohol, causes that made up only 3 per cent of overall deaths last year.’

Ben Humberstone, Head of Health Analysis and Life Events at the ONS.

Separate research commissioned by Crisis estimates that there are currently 12,300 people sleeping rough on the street and almost 12,000 sleeping in tents, cars or on public transport. The numbers are more than double the government’s official figures, which are based on local authority estimates or street counts on a given night.

‘The ONS report is further confirmation of what we have long known and feared – that the number of people dying while homeless is nothing short of a national scandal,’ said chief executive of St Mungo’s, Howard Sinclair. ‘These numbers are shocking. People are not just stuck sleeping on the streets, they are dying on the streets. Worse still many of these deaths are premature and entirely preventable. The statistics do not do justice to the individuals who have died. Their stories must be told and lessons learned. We want the government to deliver on its commitment to ensure a formal review when someone dies while rough sleeping.’

Deaths of homeless people in England and Wales: 2013 to 2017, at www.ons.gov.uk

Rough sleeping figures at www.crisis.org.uk

Driving Change

By
DDN
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The theme of this year’s Hit Hot Topics conference was ‘The Road Ahead’. As each speaker began to explore the theme, it became obvious that we needed to talk about the obstacles in our way.

Drug law enforcement was bound to be at the top of the agenda for a conference that cares passionately about harm reduction. While drug use was ‘ubiquitous, right across the population’, drug law enforce­ment was ‘a tool for social control’, said Niamh Eastwood, executive director at Release. Furthermore, it had before a weapon against the poorest and most vulnerable, designed to ‘push people out there’.

‘We have to call out the “othering” of people in society,’ she said. ‘We have to end criminal sanctions for people in possession of drugs’ and instead look at helping them back up into housing and stability.

Writer and researcher Imani Robinson asked us to think about the world we were born into. ‘We’re taught to give our trust and to normalise particular things. We believe what is told to us about drugs,’ she said. ‘Think about a time when you felt safe. Did anyone think about police, prisons and surveillance? Yet this is the narrative – that we need these things to feel safe. We normalise these ideas.’

The narrative had become contaminated with racism – not just structural racism, but internal racism, where you are ‘born into a world that tells you are better’ – ‘a whole system of power and privilege’.

‘You can’t talk about drug policy reform without talking about racial justice because they are the same,’ she said, and there was much to do on every level. ‘Myths are used to tell children they’re going to die if they take drugs. We act as if this is real, and that punishment is the best approach to deal with harm and violence.’

To make any progress we needed to take ‘a level of stepping back and realising who we are’.

Neil Woods, chairman of the Law Enforcement Action Partnership (LEAP UK) brought particular experience to the argument for urgent drug law reform. As a former undercover drugs detective sergeant, he had come across corruption driven by the drugs black market ‘a great deal’ within the police force – of which the public knew little.

Neil Woods, chair of LEAP UK.

The only way to change the shape of this market was to accept the need for a radically different approach.

‘At the beginning of the 1960s there was no organised crime related to drugs,’ he said. ‘If people had a problem they got help, and there was no association with theft. We’ve gone from the prescription pad to the hand grenade.’

A high proportion of drug crime was driven by people who used heroin – ‘so the logic of using heroin-assisted treatment is that you take half of the market from organised crime, just like that.’ County lines were mainly about the heroin market, ‘so if you prescribe heroin you take away half of the market that drives child exploitation,’ he said.

Woods believed we needed to be bold in our actions, adding ‘history will judge society in the same way as we judge slavery or the treatment of homosexuality.’

‘Prohibition lies need to be exposed and challenged,’ said researcher and activist Julian Buchanan, who built the case for a human rights approach.

‘There’s never been a global drug problem, but a global drug policy problem,’ which needed to be confronted, he said. Our attitudes and prejudices were built on a ‘social construct’. ‘Drug free’ didn’t exist because ‘we all use drugs’. Alcohol, tobacco, caffeine and sugar had ‘become the components of every social event’ and as state-approved substances, were ‘untouchable’. The idea of banning drugs was based on ‘propaganda and racism’.

‘Prohibition likes to blame drugs for cartels and gangs but they are only the inevitable outcomes,’ he said. Prohibition targeted the poor, the indigenous, people of colour. It undermined public health, encouraged hostility and stigma, increased crime, facilitated lucrative markets and overcrowded prisons. It was an ideologically driven system of oppression, he said.

But when we were calling for legalisation, we needed to be clear about the model we were talking about. ‘We must be united in our push to decriminalise all drugs – a simple step that could be enacted quickly, with little cost. This would enable us to explore full legalisation,’ he said. ‘All drugs should be made available at pharmacies and off-licences, and then through cafes, bars, restaurants and major events. It sounds like uncharted territory, but it isn’t. Alcohol is a state-approved psychoactive drug.’

‘We can do a better job of living with drugs,’ he added, and changing the law would lead to ‘wiser and better-informed choices’.

The distinction between decriminalisation and legalisation was demonstrated by Jay Levy, policy and advocacy officer at INPUD, who described the situation in Portugal, 17 years after decriminalisation. INPUD had held a consultation with the drug user community in Porto, and had found that there had been ‘demonstrable improvements in public health’, including a ‘considerable’ drop in drug-related deaths and a decrease in the prevalence of HIV.

‘The lens has shifted from criminalisation to health,’ he said, but the decriminalisation was only partial, with limits set. Drugs in Portugal were still not legalised, so drugs were still bought and sold on the black market, with their strength and ingredients unknown. So while Portugal was ‘distinctly safer’ for people who use drugs, with ‘less violence, harm from police and stress with dealers’, the situation was ‘complex and nuanced’. Police could still stop and search, and there was still a mandate to confiscate drugs – even if it was just one dose for personal use, which wasn’t a crime, but ‘really problematic for people with little money’.

So while incarceration had given way to dissuasion, this different narrative was not benign. There was a new kind of stigma in focusing on drug use as a health issue. Before people who used drugs were criminals; now they were ‘sick and unhealthy, needing some type of intervention and deviant in some way’.

So while a change in the law was ‘an important first step’, it was ‘not a magic bullet and shouldn’t be the end point in our advocacy,’ he said. ‘People like uncomplicated narratives, but people take drugs for lots of reasons.’

Creating the right kind of narrative was central to Fiona Gilbertson’s work at Recovering Justice. As co-founder, she had spent time lobbying politicians and trying to bring people together to talk about policy reform. Much of the time she had been ‘trying to engage with prejudice’ to bring about change, and had realised that the best tool was the voice of personal experience.

Challenging stigma through the Support, Don’t Punish campaign.

‘I’m tired of people not listening to each other,’ she said. We needed to create spaces so people could make choices without being ‘consigned to criminalisation’. ‘Having conversations will be key – about freedom from oppression and stigma, a movement for peace,’ she said. ‘Recovery is a vibrant social movement – not about the absence of drugs, but about the presence of community. How we engage with it is up to everyone in this room.

Tackling public opinion

How can we help to challenge outdated narratives?

Joshua Haddow is a filmmaker and journalist who has worked on the BBC series, Drug Map of Britain. Engaging with the people filmed for the series had helped him to understand their lives and made him think carefully about how to convey the truth of each person’s situation.

Film maker Joshua Haddow.

‘When you report on anything you have to make a decision – including whose story to tell in the first place,’ he said. ‘Humanising people who use drugs, and therefore their experiences, is the opportunity you have when you turn the camera on.

But there was a great deal of vulnerability and journalists ran the risk of stereotyping, he said. Drugs in the media were ‘either scandal or hush hush’, but we needed to go beyond the end point of an article being ‘she was on drugs’.

The best a journalist could do was to say, ‘this is what I found’. And the value of personal stories was immeasurable in bringing truth and insight to the report, he said, adding ‘if a reporter calls you, it could be a chance to change someone’s life.’

Working as communications officer with Open Society Foundations had given Alissa Sadler many opportunities to explore effective ways to connect with difference audiences about harm reduction.

She offered a simple framework called GAME, to help a more strategic approach to communications.

G was for goal – what are we trying to do, where are we trying to get to, and what needs to happen next? ‘It should be like a tube map, with stops along the way.’

A was for audience – who are we trying to get to, who do we need to talk to to get to the next stage? ‘Profile them, meet them where they’re at, bring them along.’

M was for messaging – what do we need to say to people? ‘Hit the heart with the story, the head with the data, then take the hand to move them along.’

E was for evaluation: something to think about before you roll out communications. ‘You need to constantly evaluate what you do, and if it’s not working, change it.’

Pictures by Nigel Brunsdon www.nigelbrunsdon.com

 

 

Final destination?

By
DDN
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‘The road to recovery – political destination or patient journey?’ was the theme of this year’s RCGP and SMMGP primary care conference. DDN reports.

‘None of us need reminding about shrinking budgets and decommissioned services,’ said clinical lead for alcohol and drug misuse at NHS Nottingham, Dr Stephen Willott. Issues like the rising cost of buprenorphine were making matters worse, he said, and ‘while we’re told there’s an extra £20bn coming for health, my worry is that it won’t come anywhere near local councils and drug and alcohol services’. Many people, however, were doing the best they could for a vulnerable group. ‘We need to help people to find softer landings. Sure, if we had more money we could do more.’

Clinical lead for alcohol and drug misuse at NHS Nottingham, Dr Stephen Willott.

There were some grounds for cautious optimism, however. While the latest drug-related death figures were still the highest ever there was ‘at least a flattening of the increase’, he said. ‘We need to make sure that people are seen in a timely manner, that there are no forced exits before someone is ready, and no unnecessary hurdles. We need more roads to recovery and we need to be able to help a wider range of people.’

In terms of drug harms there remained serious questions about why certain drugs were illegal, said Professor David Nutt of Imperial College. ‘The main reason why drugs are illegal is because that’s what the media and politicians want.’ One paradox of working in the field was that drug harms did not correlate with their control, he argued. ‘By far the worst harm comes from alcohol, and it’s legal. The Misuse of Drugs Act is supposed to be evidence-based, but it’s not.’

In terms of OST, treatment optimisation was crucial, SMMGP clinical director Dr Steve Brinksman told delegates. ‘We have to ask ourselves why more people are dying, and people in OST are at much reduced risk. We need to properly understand lapses – people will generally blame themselves, but we need to start thinking about measuring craving as well as withdrawal when we talk about dose optimisation. We shouldn’t make people who are comfortable and doing well in their lives feel ashamed that they’re having evidence-based treatment. I’ll support anyone who wants to work towards abstinence, but I will not force people to come off treatment.’

SMMGP clinical director Dr Steve Brinksman.

Public Health England (PHE) was working on an OST good practice programme, its alcohol and drug treatment and recovery lead Pete Burkinshaw told the conference. ‘We’re doing this for all the right reasons and, at the moment, it’s a blissfully politics-free zone. It’s building on what’s gone before but asking what we can do better.

‘People talk about the jewel in the crown of the UK treatment system being the very low HIV prevalence, and I agree with that, but there’s also the 60 per cent treatment penetration. Internationally that’s very good – but it could be better. We need to hold the centre and focus on what’s important in the current operating context, and what constitutes quality treatment. That’s more important than ever.’

Resources were hugely constrained, he acknowledged, and there were challenges such as increasing levels of crack use and falling numbers in alcohol treatment. ‘The system needs to respond to all those things, but the people taking up most of the capacity are still opiate users.’ The programme’s initial topics would include prescribing practice, psychological and social interventions and the segmentation of the treatment population, he said, through the filters of service user experience and implementation barriers. ‘Let’s look at what are the absolute must-dos, and take it up from there.’

When it came to policy and practice, we were ‘at a turning point’, said professor of addiction medicine at Edinburgh University, Roy Robertson. ‘We’ve got new drugs, patterns of drug use we haven’t seen before, demographic change.’ In terms of the high rates of drug-related deaths, policy was ‘a bit tricky’, he stated. ‘Things like time-limited treatment and trying to get people off methadone are damaging, and the UK government has no intention of allowing consumption rooms.’ People who use drugs had also been ‘framed’, he stated – characterised as reckless, indulgent, violent and responsible for crime.

‘The upshot of that is that we have a marginalised treatment population. There is neglect, reluctance and a lack of innovation.’ Studies of drug-related deaths could, however, lead to advances in care, he said. ‘It shines a light on the range of morbidities this client group is suffering from.’

The new Scottish drug strategy (see news, page 4) also had ‘some good things in it’, he added. ‘It endorses things like human rights, take-home naloxone, lived-experience advocacy and it takes a swipe at the UK stance on consumption rooms.’ However, while it was evidence-based that evidence was ‘highly selective’, he argued. ‘There’s stress on the “recovery journey” but, to my mind, at the expense of the NHS.’

While Scotland’s take-home naloxone programme was well-received and discussed internationally it was still not possible to see a ‘causal effect’ in preventing drug-related deaths, he said. ‘But it has clearly had an impact in that super-high risk period of the first few weeks after release from prison, so there is clear evidence that it can work.’ On the issue of consumption rooms, ‘we really do have to make some progress on this’, he stressed. ‘The international evidence is there, and they’re part of a whole spectrum of treatment. You wouldn’t have a hospital without an A&E or intensive care unit.’

Deaths involving ‘festival and party drugs’ were increasing alongside those involving opiates, director of The Loop, Fiona Measham, told the conference, with purity levels for ecstasy at their highest ever level. Her organisation had been carrying out festival testing for the last three summers, and there was ‘an opportunistic element’ to festival drug use with people tending to take more drugs than they normally would.

Director of The Loop, Fiona Measham.

‘There’s polysubstance use, and a significant group of older people who only ever take drugs at festivals and may be unaware of the higher purity levels.’ One in 20 MDMA samples from this summer were actually n-ethylpentylone, a very long-lasting cathinone, she added, with festival dealers twice as likely to be selling contaminants and substances of concern. ‘They can sell anything and get lost in the crowd.

‘We’re not encouraging or condoning drug use, but we give harm reduction advice – 90 per cent of our service users have never spoken about drug use to a healthcare professional so we’re reaching people at the very beginning of their drug-taking careers. We can monitor trends in local drug markets and remove high risk substances from circulation.

The Loop had also been involved in setting up testing in consumption rooms in Copenhagen and Vancouver, and would soon be operating in Bristol and Durham city centres. ‘This is something that should be available to all drug-using communities.’

The human cost behind the statistics, however, was brought home powerfully by author and journalist Poorna Bell, who told the conference how her husband Rob had taken his own life in 2015. ‘He struggled with chronic depression and addiction. They tore at him to the point where he couldn’t see anything getting any better.’

She’d known nothing about addiction, she said. ‘My mind reeled with the horror that it had been heroin. We have this incorrect hierarchy of substances, and heroin seemed the worst of the worst. I stayed with him and helped with his recovery but ironically I felt I couldn’t tell my family and friends, which shows the isolation faced by people and their loved ones. The resources for someone whose loved one is an addict are abysmal.’

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Comment: In it together

The GPs’ conference showed the power of a united front for better treatment, says Lee Collingham.

Service user activist and advocate, Lee Collingham.

After a decade of attending the RCGP conference, I was in London for this year’s event. I’ve learnt that to get the most from the programme, it’s handy to go through the running order for the two days and see if there’s anything or anybody that I must see. Otherwise you spend your time nipping from session to session and not particularly learning anything new.

With this in mind, I identified sessions which matched my own personal goals. These included reducing drug-related deaths, the testing of substances to eliminate contaminants, and inclusivity for those working in or using the treatment. Whether the goal is abstinence or the approach is focused on harm reduction, I believe it is important for us to work in partnership and together, rather than being a foghorn alone.

One of the sessions that caught my eye was by Professor Roy Robertson from Edinburgh University who spoke about the recently released Scottish drug treatment strategy. Although not entirely relevant for England or Wales, it does however give us good indicators of what is and isn’t working and what the overall aim is. It was unclear whether the provision of naloxone in the community had made any difference to drug-related deaths; however it had been a success with those leaving prison. He made welcome suggestions that treatment should be person centred and lead with a multidisciplinary approach.

Of personal interest to me was finally meeting Fiona Measham, who discussed the growing success of The Loop in giving festival guests and nightclub users the opportunity of having the drugs they’d purchased tested. The team was shocked to find the increase in strength of MDMA, some with over 90 per cent purity, and they also found a number drugs being missold as other things. The initiative had been a success, not just with service users who were having second thoughts about what they were taking, but also the police and organisers. They planned to do at least 18 events in 2019 and were looking at working with more nightclubs.

Other than the moving tributes given to both Rob Bell and Beryl Poole, two of the many we have lost, the final highlight for me was attending a presentation on the future face of recovery from Annemarie Ward of Favor UK. She highlighted the challenges and problems service user groups and organisations often face when it comes to raising funds – particularly if we’re fighting against each other, rather than together, for the same resources. All too often, she pointed out, it’s left to a team of motivated individuals and volunteers to ensure the success of such projects, and I could identify with that.

 

 

Beyond the gate

By
DDN
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Prisons have a unique opportunity to introduce a life-saving naloxone strategy, so is the message getting through? DDN reports.

Read the full article in DDN Magazine

Naloxone saves lives, and for people leaving prison it can be a vital component in their survival kit. We know that the first few weeks following release carry a much higher risk of dying from a drug-related overdose, as tolerance is low while the availability of drugs in social situations returns.

Despite the strong link with unacceptably high drug-related death figures, there has been an absence of clear strategy and accountability. Both Public Health England and the government have recommended that local areas need to have naloxone provision in place, but when John Jolly reviewed the situation in July (DDN, July/August, page 14), he found that it was rare for any of Blenheim’s service users to have been provided with naloxone on release from prison.

John Jolly, Blenheim CDP.

Jolly investigated further and found that of the 36 prisons in England and Wales claiming to give out naloxone on release, many were failing to give out kits, citing ‘operational difficulties’

Since Jolly’s research, the government has responded to parliamentary questions from Grahame Morris MP, stating that new data on prisons issuing naloxone is being collected and is ‘expected to be published in January 2019’. Apart from that, any progress depends entirely on regional interest, with a continued lack of engagement on the issue from NHS England, according to Jolly.

‘There is no national oversight and accountability for providing take-home naloxone to people released from custody,’ says Zoe Carre from Release, adding ‘It is therefore crucial that every prison strategy includes take-home naloxone programmes.’ Many unnecessary deaths could be prevented if all prisons adopted the strategy, but ‘while some prisons are leading the way, sadly others are still not making this life-saving medication available,’ she adds.

In Scotland, where a naloxone programme was made an important part of public health policy in 2011, there has been effort to adapt to the challenges of making it a part of prison culture. Naloxone kits are given to people at risk of overdose, or likely to witness overdose, on release from all 15 prisons in the country.

‘This is a crucial component of the programme due to the increased risk or overdose for individuals within the first four weeks of release,’ says Kirsten Horsburgh, strategy coordinator for drug death prevention at the Scottish Drugs Forum (SDF). The results speak for themselves: ‘The percentage of opioid-related deaths within four weeks of prison release is substantially lower now that it was pre-implementation of the programme,’ she says.

Kirsten Horsburgh, strategy coordinator for drug death prevention at The SDF.

The programme depends on a clear strategy in place to be effective, she stresses, and that includes key stakeholders being fully engaged in the process. ‘The majority of the obstacles faced in a prison setting are operational and should be addressed with clear communication, training and guidance.’

In a paper published in the Australian journal, Drugs and Alcohol Review, Horsburgh and co-author Andrew McAuley gave a detailed account of the challenges involved in implementation. These included availability of staff (for escorting prisoners as well as co-facilitating sessions), and problems around a group format for training sessions – the subject under discussion had the potential to be emotive for those involved, as ‘the majority of people who use drugs will have had personal experience of overdose or experienced the loss of friends and loved ones’.

Bringing in peer education had helped, giving the choice of a one-to-one training session delivered by peers themselves as well as the option of a group session. This had also achieved collaborative working between prisoners and staff.

The other area highlighted for attention had been staff training throughout the prison. Once a prisoner had been trained, nursing staff needed to label a naloxone kit and deliver it to the reception area for prison officers to add it to prisoners’ valuable property, ready for them to collect on release. It was vital that prison officers knew what this medication was, so there was no disruption to a streamlined process of release.

The authors concluded that the naloxone programme had been an ‘important milestone’ in drug policy in Scotland and that prisoners on release were ‘reaping the benefits in terms of reduced opioid-related mortality’.

Karen Blatherwick, nurse manager at Turning Point’s substance misuse services at HMP Leicester, underlines the risks during the first two weeks after release, particularly for those who inject.

‘We encourage service users to carry the naloxone kits at all times, so if they are found with signs of overdose a friend or family member can use the naloxone on them,’ she says. ‘We also train service users to use the naloxone and encourage them to use it on other people if necessary.’

The need for a clear strategy seems to be working its way into the infrastructure of some of the larger providers of prison healthcare, including Care UK Health in Justice.

‘A number of the prison healthcare services we manage give training in naloxone use to prisoners close to their release dates,’ says their national medical director, Dr Sarah Bromley.

She calls the training sessions ‘critically important to saving lives’ as they also teach participants to recognise symptoms and respond to people who are experiencing an overdose, supporting them until the emergency services arrive.

‘These group sessions are set to increase nationwide as more NHSE commiss­ioners ask us to incorporate the training and dispensing into broader community strategies,’ she says, adding that the commissioners’ understanding and buy-in has been crucial: ‘We believe that commissioners recognise that prison healthcare is in a unique position to teach and reinforce messages on preventing overdose deaths at a time when prisoners are more stable than at other points in their journey.’

Elsewhere there are also signs that naloxone has a firm footing in prison healthcare. Inclusion, part of South Staffordshire and Shropshire NHS Foundation Trust, were early adopters and pioneers of naloxone strategy, including in their prison-based services. ‘We have been issuing naloxone with Birmingham and Solihull Mental Health Trust at HMP Birmingham since 2005,’ says head of Inclusion, Danny Hames.

Head of Inclusion, Danny Hames.

When Change, Grow, Live embraced naloxone strategy, they made it ‘an objective to ensure that those integrating back into society from the prisons with which we work are provided with take-home naloxone kits, as well as guaranteeing that they receive advice, information and support around access to local community services,’ says CGL executive director, Mike Pattinson. ‘We have been taking this approach in our prison-based services for some time and shall continue to do so as part of our overall harm reduction plan.’

For Forward Trust, whose substance misuse work spans 18 prisons, ‘a more organised and structured approach to promoting naloxone’, began at HMP Lewes. By having a designated ‘naloxone lead’ in the team, they make sure each new service user is added to the naloxone waiting list, regardless of whether their release date has been set. They also make sure clients who are ready for release are booked in for an appointment in the two weeks before they leave.

They believe the scheme is working well because of the staff and client training, good organisational skills, and efforts to improve communication – between Forward team members and with other departments in the prison. Keeping a database of staff members who have completed their training helps them to analyse progress.

‘Sometimes clients refuse the naloxone or training when we first offer it, but change their minds later on,’ says Forward’s Amy Williams. They are offered more chances to engage including, crucially, when they are close to their release date, which ‘lets them know that even if they don’t think they will need it, it could be used to save the life of someone else. This ensures that we are not only helping them on their recovery journeys in prison, but out into the community too.’

WDP’s substance misuse team have also come across the issue of prisoners refusing naloxone, during their work at HMP Woodhill. As part of each prisoner’s release plan they are offered training, harm reduction advice, and a kit on release.

‘Some inmates who are on a stable dose of methadone, or who have recently detoxed, may decline the offer of a kit, saying that they feel that they have achieved stability or detox in the prison and have no intention of using drugs or associating with their drug-using former associates,’ says WDP’s Kate Bonner. ‘But they are reminded that prison is a false environment and that while they may be perfectly capable of managing their own lives, they have no control over who they might meet on the street or who might come to their home.’

From those who have come to realise the value of naloxone as they prepare to leave prison, there is gratitude. Whether all prisons will extend this safety net to their inmates in the new year remains to be seen.

This article has been produced with support from Martindale, which has not influenced the content in any way.

At the cutting edge

By
DDN
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DDN looks back at a year that saw cuts continue to bite, deaths continue to rise, ‘county lines’ become headline news – and a G7 country legalise cannabis.

Read it in DDN Magazine

JANUARY

A predictably downbeat start to 2018 as, after years of shrinking budgets, the latest State of the sector docu­ment warns that the field’s ability to absorb cuts through efficiency savings and service redesign has been ‘exhausted’. The report uncovered ‘worrying signs that potentially serious damage’ has been done, says Adfam chief executive Vivienne Evans. Meanwhile, Release warns that levels of naloxone provision by local authorities are ‘chronically inadequate’ and PHE announces its review of the ‘growing problem’ of prescription drug dependency. On a more positive note, the NHS states that its hepatitis C strategy could see England become the first country to eliminate the virus.

FEBRUARY

Get Connected, DDN’s eleventh annual service user conference, sees another vibrant day of debate and networking in Birmingham. In a measure of how far the event – and user involvement – has come, SUIT’s Sonny Dhadley tells delegates that ‘I can remember coming to a DDN conference for the first time about a decade ago, not long out of detox – I didn’t understand that this world existed. But if you’re championing something you believe in, you’ll do anything to make it happen. There’s so much energy and potential in every one of us.’

MARCH

MPs warn that ‘significantly greater’ numbers of people will need to be tested, diagnosed and treated if the NHS is to meet its hep C elimination target, and the National Crime Agency reveals that it is seeing a dramatic increase in modern slavery cases as a result of county lines activity, with referrals of minors up by two thirds between 2016 and 2017.

 

 

APRIL

The government announces that its serious violence strategy will include a £3.6m county lines coordination centre, citing the drug trade as an ‘important driver’ of rising incidences of knife and gun crime. Meanwhile, in what is seen as a landmark move, the Royal College of Physicians (RCP) issues a statement backing drug decriminalisation. ‘The RCP strongly supports the view that drug addiction must be considered a health issue first and foremost’ it says, adding that it had been ‘alarmed’ by rising rates of drug-related deaths.

 

MAY

In what could help show the way forward in eliminating hep C, a report from the London Joint Working Group (LJWG) reveals that a four-month community testing pilot project in pharmacies with needle exchange facilities has seen 50 per cent of people testing positive. Significantly, almost 60 per cent of participants were also unaware that the virus could now be treated with oral tablets rather than interferon. Meanwhile, minimum pricing finally comes into force in Scotland after years of legal wrangles and last month’s 12-step article by Alex Boyt, ‘All or nothing’, fills the DDN letters pages with reactions ranging from ‘brilliant’ to ‘reading this has ruined my day’.

 

JUNE

EMCDDA’s annual European drug report identifies the UK as among the biggest consumers in a ‘buoyant’ cocaine market, with purity levels at their highest for a decade, while Kevin Flemen wonders in DDN if the recent growth in crack use indicates a move towards social acceptability. ‘I’m probably more anxious about crack this time around than I have ever been working in the field,’ he writes. ‘I hope I’m wrong.’

 

 

JULY

In what is becoming a depressing annual event, Scotland again records its highest ever number of drug-related deaths. The ‘sheer toll’ of deaths represents a ‘staggering weight carried by families and communities and the wider Scottish nation’, says Scottish Drugs Forum CEO David Liddell. Drugs are also behind the ‘huge increase’ in violence across the prison estate over the last five years, says the annual report from the chief inspector of prisons. Meanwhile the government is urged to overhaul drinks marketing legislation as campaigners warn that social media is creating ‘unprecedented alcohol marketing opportunities’.

 

AUGUST

Following last month’s Scottish statistics, ONS figures again show record drug deaths for England and Wales. A cautious note of optimism is struck by the fact that, while previous increases had been ‘statistically significant’, rates since 2015 are only increasing slightly and remain ‘broadly stable’. Fentanyl-related deaths continue to rise, however, and deaths related to cocaine have now increased for six years in a row.

 

SEPTEMBER

As a WHO report states that one in 20 global deaths are now caused by alcohol, PHE launches its ‘Drink Free Days’ campaign in collaboration with Drinkaware as a ‘clear to follow, positive and achievable’ way for middle-aged drinkers to reduce their health risk. Partnering with the industry-funded body, however, leads to concern from some in the treatment sector and the resignation of PHE’s alcohol leadership board co-chair Sir Ian Gilmore.

 

 

OCTOBER

Canada becomes the second, and largest, country to legalise the recreational use of cannabis, with justice minister Jody Wilson-Raybould stating that this ‘progressive public policy’ would help keep cannabis ‘out of the hands of youth and profits out of the pockets of criminals’.

 

 

 

NOVEMBER

Scotland pledges a ‘person-centred, health approach’ in its new drug strategy, Rights, respect and recovery. Meanwhile, the impact of price increases associated with ongoing buprenorphine supply problems continues to be felt, compounded, as PHE’s Pete Burkinshaw tells DDN, by ‘the financial pressures local authorities and services are currently under. We will continue to do everything we possibly can.’

 

 

DECEMBER

As the year comes to close preparations are well underway to bring people together for DDN’s 2019 conference, Keep on Moving. See you on 21 February!

 

An equal partnership

By
DDN
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Meaningful service user involvement is about give and take, says Mark Pryke.

Read the full article in DDN Magazine

Mark Pryke is national service user lead at Change, Grow, Live (CGL).

My role is to help increase opportunities and choices for service users. The more options we can offer people in terms of their treatment and structured activities, the more likely they are to choose one.

We want to avoid things being done to people, so the development of services should be an organic process – it’s all about collaboration. I enjoy hearing about service users who have stood up and said, ‘you need to hear this’. It’s important to be receptive when a service user wants to say something and needs an answer.

 

 

People sometimes misinterpret service user involvement (SUI), believing it to mean that service users can have anything they want. In practice, because of regulations, safeguarding and resources, we can’t always respond to every request as service users would like – but what we can do is give honest and frank reasons why we can’t take an idea forward. This helps people to understand the reasons why they don’t always get what they ask for.

I help people to share stories about what their challenges were and how they got round them. This can be incredibly motivating to tell and hear. I also attend communities and partner meetings – sharing the SUI approach and the ways it can be used to create positive change.

We need to make sure that the service user involvement feedback loop works effectively. Service users participate in surveys and changes, but often they don’t hear what’s happened to their input or the outcomes and results. This devalues the system. So when we have an outcome, we need to share it.

Be part of the biggest Service User Involvement Forum, at the 2019 DDN Conference!

Anyone can be a service user rep and often they are ex users of the service. Reps support a more flowing and honest conversation as a staff presence may influence service user responses. You are more likely to share your story with someone like you. The regional SU councils come together to discuss and share resources, and the network helps people to talk to others in a safe and supported way.

Our services attract people from many different backgrounds, enabling us to access a massive bank of information – people with a wealth of knowledge and experience to whom we can ask questions and vice versa, and whose experience and creativity can help other people overcome their challenges. Service users get fulfilment from giving back and knowing they, and their opinions, are valued too.

Their feedback can also influence practice. Last year we became aware that service users were having difficulty getting their medication if they moved away for a few weeks or went on holiday – their prescription needed to go with them. Service users would come in say, ‘I’m going on holiday on Monday and I need my prescription sorted,’ and wouldn’t be happy that we’d need more time.

To help resolve this we developed a ‘Going away on holiday’ poster to make it clear we needed four weeks to make arrangements for them to continue their treatment. We consulted on the poster with regional services and our national service user committee and the feedback helped us develop a clear visual and catchy strapline that tackled the problem effectively.

We’ve also redesigned our waiting areas, adding toys for people who need to bring along their kids and bike racks so people can cycle. Suggestions come through at a local level and then managers decide what’s most appropriate for their service.

We should be asking questions in the places where service users go. We need to reach out using methods that are engaging, and improve our digital offer. People don’t want to give their time without seeing the benefits or receiving some other type of incentive. It’s got be reciprocal.

Meetings should be structured so service users can talk about what’s affecting them and not have the agenda set for them. The agenda needs to emerge as part of the natural conversation so that they feel like they own that meeting.

Service user feedback can make a difference straightaway. For instance, in Gateshead we asked service users why they might have missed their appointments. One of the many people who had to travel right across the city to get to the service said, ‘It’s going to cost me a tenner to get the bus and it might not even turn up, so I have to get a taxi and on my way to the bus stop I’ve got to walk past the dealer or the off licence. So realistically where’s that tenner’s going go?’ Staff realised the Tesco superstore next to the service had a community bus that did a regular circuit, so they made sure service users were given appointment times that coincided with the bus timetable. Everybody wins.

We try and tailor services to meet service users’ needs but these often change and we’re learning all the time that we need to facilitate options and choices. There are still many cohorts of service users who we’d like to hear from, such as individuals who access our street outreach services. We can’t shirk the challenge. Instead we can work towards this in little steps, so it’s meaningful.

 

 

 

CZAR GAZING – The golden years

By
DDN
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As deputy drug czar for the Blair government, Mike Trace oversaw the expansion of today’s drug and alcohol treatment system. In the first of a new series, he gives his personal view of the successes and failures of the past 20 years, and the challenges the sector now faces. Read it in DDN Magazine.

Mike Trace is CEO of Forward Trust

It is hard to imagine these days, but from 1997 into the early 2000s, we had a government that saw drug policy as a top-level priority, that accepted the argument that treatment was the most cost-effective response and was willing to spend money on a nationwide system aimed at reducing the crime, health and social problems associated with problem drug use.

I had the privilege of working for the wonderful Mo Mowlam at that time, a period where we increased spending on drug treatment from around £200m to over £800m per year (it reached over £1bn by 2005). We sent this money to local drug action teams (DATs) with pretty tight guidelines on the range of services to commission, and set up the National Treatment Agency (NTA), to oversee spending and delivery.

With the benefit of hindsight, there are many things we could have done better, but the basic intention was sound – to offer a national system of care and treatment to marginalised people struggling with drug problems, with the aim of reducing drug-related crime, deaths and infections. We also hoped that this policy would help some of the most marginalised and stigmatised people in society to turn their lives around.

We wanted local partnerships to develop drug treatment systems (replacing a patchwork of unconnected services), consisting of a ‘menu’ of services that delivered four functions – supportive outreach and immediate care to encourage users in to contact with services; consistent case management and one-to-one advice; substitute prescribing for those dependent on heroin; and a range of options to motivate and facilitate recovery. We also developed specific procedures to channel users into treatment from the criminal justice system (arrest referral, drug treatment and testing orders, prison programmes).

The vision was of a well-funded national framework of health and social support to a marginalised and stigmatised group, to help them stay alive and healthy, and make positive changes to often harsh lives.

We know that, in the last ten years, the national political commitment to this strategy has dissipated, the NTA has closed down, the responsibility for sustaining it has been passed to local authorities, and the amount of funding available has gone down by at least a quarter.

In this series, I want to ask the big questions – how much of our original vision has survived, did it achieve its objectives, how well has the sector managed the downturn to protect what matters, and how can we tackle the challenges we face now?

Read Mike’s other articles here.

 

 

 

The right to challenge

By
DDN
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Know your ground when contesting CQC inspection reports and ratings, says Samantha Cox. Read it in DDN.

Samantha Cox is a solicitor at Ridouts, a law firm specialising in health and social care law.

CQC now has the power to rate independent standalone substance misuse services and is currently rolling out its first wave of comprehensive inspections to establish a ratings baseline for future inspections. This is the first time such services are being rated by CQC. Adverse ratings can have a negative impact on the financial and operational viability of provider services and it is therefore vital that CQC get it right.

Providers are afforded the opportunity to challenge the content and ratings of an inspection report through official routes set out in CQC guidance. This includes the factual accuracy and rating review processes, which are set out in more detail below. Other potential routes of challenge include complaints to CQC and judicial review.

Factual accuracy challenges

It is important for providers to challenge factual inaccuracies and misleading comments presented in draft inspection reports, to ensure an accurate picture is communicated with the public. If errors are not challenged, these will be deemed to be correct and any perceived areas of non-compliance with the regulations can lead to the requirement for the production of action plans or, in more serious cases, use of CQC enforcement action.

Providers should therefore ensure they read their draft report thoroughly and, where relevant, ensure challenges are raised with CQC through its formal factual accuracy comments (FAC) process.

Once a draft inspection report has been received, providers have ten working days to submit any FACs to CQC. CQC provides a FAC table for providers to populate with relevant comments.

Providers should be aware that as well as challenging the accuracy of statements, they can also challenge judgements (including alleged regulatory breaches) and ratings through the FAC process, particularly if factual errors have been relied on to inform judgements. Where possible, providers should be supplying evidence to support their assertions.

FACs will be considered before the report is finalised and published on CQC’s website. CQC will respond to the provider with a written response to any FACs, and the final inspection report is usually published within a couple of days of communication of its findings.

However, there is no clear consistency in when reports are published, and we have seen instances where publication has taken place on the same day the FAC response was sent to the provider and before the provider has had the opportunity to review the response. Ridouts has previously taken issue with this process as CQC’s rush to publish reports can have an adverse impact on providers who are considering further legal challenge, for example through judicial review.

Rating review process

The second, and final, official route of challenge to inspection findings is CQC’s rating review process. This can only be requested after publication of the final inspection report. Therefore, the report will already be in the public domain before a challenge has been considered. Consequently, for providers who want to avoid misleading ratings being published in the first place, the FAC process is crucial.

CQC requires providers to inform them of their intention to submit a rating review request within five working days from the date of publication of the report. Providers must submit their full, detailed request for a review of ratings within 15 working days of publication of the report.

The rating review process is very limited in its remit. It does not re-consider any factual disagreements or disputes over CQC’s judgements. CQC is clear that the only grounds for requesting a rating review is that they have failed to follow their processes for making ratings decisions (ie the application of the ratings characteristics to CQC’s findings as displayed in the final report). This process can be difficult to demonstrate and published CQC figures on the success of rating review challenges show that the vast majority of such challenges fail.

Staying ahead

To avoid the potential adverse impact of having an incorrect inspection report placed in the public domain, providers should ensure they read their draft inspection reports thoroughly and raise any challenges within CQC’s set FAC timeframe. This will ensure that any disagreements with evidence and judgements are on the record. Even if the FAC process does not produce the desired result, this could assist with any future arguments as to CQC’s judgements and potential enforcement action. Following the receipt of an FAC response, providers should consider whether they wish to pursue submitting a rating review request, depending on the facts of the case.

At Ridouts we are experienced in supporting clients with challenges to draft inspection reports, and empower them to challenge CQC when a report is not truly reflective of their service.

Samantha Cox is a solicitor at Ridouts, a specialist law firm that has a core expertise in health and social care law, www.ridout-law.com

The news, and the skews, in the national media.

By
DDN
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Read all about it in DDN Magazine

In the UK, alcohol is a national treasure. While advocates against the status quo should continue to unroll startling health data to the public, we have another task that is equally im­portant: dismantling the glorification of alcohol. Regulating the messages on billboards and products and, more perniciously, on card racks and in gift shops. The messages on t-shirts, candles, coasters, and fridge magnets; everywhere you look. The endorsement and enabling of binge drinking sells, because so many of us do it.

Catherine Gray, Lancet, 1 November

The adverse effects of excessive alcohol are legion. The Alcohol Health Alliance, a group of more than 50 medical organisations, says 23,000 deaths a year are linked to alcohol… The unpalatable truth is that the NHS itself militates against individual responsibility because its core assumption of healthcare entitlement is a one-way street. People will only alter their risky behaviour if they have to contribute to the cost of treating the consequences. That means replacing the NHS with some kind of European-style social insurance system, with higher premiums for self-destructive lifestyles.

Melanie Phillips, Times, 6 November

Tracey Crouch, the sports minister, earned widespread admiration this week for her principled resignation over gambling machines. She wants a law to cut the maximum stake from £100 every 20 seconds to £2, and was furious when Philip Hammond in the Budget announced it would be delayed until October next year. I haven’t seen a single good reason for the delay… In the welter of negativity about politics, it is easy to forget that many politicians have principles, and that some of them are even prepared to stand by them. My view is that most politicians are more idealistic and sincere than most people think. Thank you to Tracey Crouch for reminding us of that.

John Rentoul, Independent, 4 November

Gambling is a simple but socially wasteful business where the amount of money made by the industry varies according to the losses made by the punters. And when it becomes addictive – as it often does – there are higher healthcare, welfare and criminal justice bills to be paid. The government will never eradicate problem gambling but it can take steps to minimise it.

Larry Elliott, Guardian, 8 November

Thanks to the ‘county lines’ business model of the gangs, huge quantities of coke are now flooding Britain’s market towns and villages, bringing bloodshed in their wake. As the wave of violence sweeps the UK, those who snort this drug cannot maintain their moral blindspot.

Clare Foges, Sun, 7 November

 

Drugs, Alcohol and Justice Cross-Party Parliamentary Group.

By
DDN
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Good commissioning goes beyond purchasing, hears DDN.

A robust discussion on commissioning was the focus of the year’s final meeting of the Drugs, Alcohol and Justice Cross-Party Parliamentary Group.

WDP chair Yasmin Batliwala.

‘The focus has been on austerity and shrinking funding, but the demand for our services has certainly not decreased,’ said WDP chair Yasmin Batliwala, who gave a provider’s perspective. Doing more with less meant that providers had to be innovative and ‘think outside the box’. In turn, commissioners ‘must give providers the best chance of success’ by addressing inconsistency and subjectivity in tenders, she said.

Commissioning varied enormously from area to area, and a commissioning ombudsman (as proposed in the recent Charter for Change) would help to encourage standardisation, including minimum-term contracts, and ‘eliminate questionable decision-making’.

All too frequently immediate cost savings were not taking into account longer-term investment, such as provision for youth services and healthy-living interventions. ‘Since the NTA went, we assumed more wellbeing would be added to contracts, but this hasn’t been the case,’ she said.

Mark Gilman had worked in the sector for 35 years before setting up the Expert Faculty of Commissioning with colleagues, as ‘we were concerned we were losing the memory of commissioning and wanted to keep a repository of expert knowledge’. The faculty already works with around half of local authorities that commission drug services and aims to promote best practice.

Mark Gilman, Discovering Health.

‘Too often commissioning falls to purchasing, but it’s a design job,’ he said. ‘It’s about having the vision to say, “What’s the problem, who’s in pain, and what should we do about it?”’

The most important thing was to get those who were not in treatment into treatment – ‘and you get this if you give them a free opioid. Until sanity breaks in the war on drugs, give them OST… they want to get, as quickly as possible, a drug that keeps them alive.’ The rise in polydrug use and the increase in drug-related deaths intensified the need for commissioners to understand this.

Anthony Bullock, drug and alcohol commissioner from Staffordshire, had been working with the faculty to share good practice. Among his recommendations were to make sure the narrative was much clearer: ‘There are so many nuances to addiction and recovery – what is it we want to achieve?’ Alongside this, we needed to shift the mindset ‘from funding to investing’ and ‘be able to demonstrate the value of what we do’.

 

Treatment meant different things to different people and it was important to recognise that different elements were needed, including peer support. ‘Our job as commissioners is to collaborate and coordinate,’ he said. ‘We need to support services to work together and have support around them.’

In the discussion that followed, Pete Burkinshaw, PHE’s alcohol and drug treatment and recovery lead, commented that it was important not to generalise in associating bad practice with all commissioning, and that we needed to be ‘careful, nuanced and precise.’

 

Post-its from practice

By
DDN
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Now tell me yours…

Different lives require different approaches to treatment, says Dr Steve Brinksman. Read it in DDN.

Steve Brinksman is a GP in Birmingham and clinical lead for SMMGP and RCGP.

I had the privilege of speaking at the annual RCGP/SMMGP conference at the end of November. I have been attending these for 20 years now and the knowledge I have gained, alongside the peer support, has been invaluable in my career working with people who run into problems with their alcohol and/or other drug use.

I was talking about treatment optimisation. By that I don’t mean just increasing the dose of OST prescribed, but also increasing the psychosocial interventions and making sure that all aspects of treatment are in place long enough for people to make sustainable change.

There has been – to my mind – a climate change over the past decade or so where increasing pressure is being applied to get people out of services and signed off as ‘treatment complete’. This prevailing paradigm has the knock-on effect that anyone who is taking OST in the longer term almost feels they should be ashamed of it.

We should not feel guilty for providing good quality evidence-based treatment that protects and supports people and gives them the space to establish and manage their own recovery.

Jake came to see me at the surgery for a review. He had started in treatment three years ago and his buprenorphine had been titrated up to 16mg at which point he had stopped using heroin completely. His relationship with the mother of his two sons had improved and he had started a college course with a view to becoming an electrician.

About nine months after starting OST his recovery worker suggested he try reducing his dose. He managed to cut down to 10mg daily – but at that point he started using heroin again. His dose was titrated back up and he again stopped using heroin. Six months later he tried reducing again and the same thing happened.

By the time he came to see me he had made four attempts at reducing and he felt he was failing in treatment. He was guilt-ridden that he lacked willpower, because as he couldn’t cope with the craving, he had to use heroin when his dose reduced.

He seemed slightly surprised when I suggested to him that not only do we put his dose back up but that we leave it at that for an extended period of time. Six months on, he is well and happy and feeling confident in treatment. He has started work in a warehouse, sees his sons regularly and has them overnight every other week. He hasn’t used heroin since our last appointment.

He does say he would like to come off his OST at some point in the future but feels that time isn’t now. We will discuss this whenever we meet and I will always encourage him. However, it will be up to him to make the decision when – or if – he wants to undertake this.

Aneurin Bevan, one of the founders of the NHS, once said: ‘This is my truth, now tell me yours.’ I feel this encapsulates beautifully the different approaches to how we all live our lives and I think it adapts to our field. So to paraphrase, ‘This is my recovery, now tell me yours.’

Steve Brinksman is a GP in Birmingham, clinical lead for SMMGP and RCGP regional lead in substance misuse for the West Midlands

‘Health approach’ for new Scots drugs strategy

By
DDN
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Scotland’s new drugs strategy will take a ‘health approach’ and address wider problems such as housing, mental health, family support and employment, the Scottish Government has announced. Rights, respect and recovery also aims to ensure that services ‘treat people as individuals’.

The document replaces the 2008 strategy The road to recovery, and follows the new Preventing harm alcohol framework which was published earlier this month. The Scottish Government will produce an action plan for the strategy early next year, it states. This year saw Scotland once again record its highest ever number of drug-related deaths, at 934 (DDN, July/August, page 4), with its fatality rate the highest of any EU country.

Joe Fitzpatrick: Improving support is one of the hardest issues we face.

The strategy, which also covers alcohol, takes a ‘human rights-based, person-centred’ approach, with a focus on those who are most at risk. Families will receive proper support and ‘be closely involved in their loved ones’ treatment’, while people who use drugs will also be diverted from the criminal justice system ‘where appropriate’. The strategy also places an emphasis on education and early intervention for young people and those at risk of developing problems.

Stigma remains a significant issue, it says, and ‘needs to be challenged across the sector and society’, with integration of services also requiring improvement. While the Scottish Government remains supportive of consumption rooms ‘in response to clear evidence of need’, allowing them would require legislation from Westminster. ‘The Scottish Government will continue to press the UK Government to make the necessary changes in the law, or if they are not willing to do so, to devolve the powers in this area so that the Scottish Parliament has an opportunity to implement this life-saving strategy in full,’ the document states.

‘Improving how we support people harmed by drugs and alcohol is one of the hardest and most complex problems we face,’ said public health minister Joe FitzPatrick. ‘But I am clear that the ill health and deaths caused by substance misuse are avoidable and we must do everything we can to prevent them. This means treating people and all their complex needs, not just the addiction, and tackling the inequalities and traumas behind substance misuse.’

David Liddell: This strategy could help to respond to a public health crisis.

The strategy would be supported with an ‘additional £20m a year on top of our considerable existing investment in drug and alcohol treatment and prevention’, he stated. ‘We want to see innovative, evidence-based approaches, regardless of whether these make people uncomfortable. This money mustn’t just produce more of the same.’

The focus on reducing ‘preventable overdose deaths’ was welcomed by the Scottish Drugs Forum (SDF). Deaths had ‘doubled over the period of the last strategy’, said SDF CEO David Liddell, and the new document contained key elements that could help to respond to what amounted to a ‘public health crisis’, such as faster access to opioid replacement therapy and cutting the numbers of people ‘forced out, or allowed to otherwise drop out’ of treatment. ‘Only time will tell whether this is effective but the indicators of success or failure will be clear and stark, and thousands of Scots’ lives depend on it,’ he said.

Strategy document at www.gov.scot

form test i am a

By
DDN
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The power of connection

By
DDN
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A sensitive approach can be a lifeline to women whose lives revolve around drugs and sex work, as DDN reports.

Read the full article in November 2018 DDN

‘Without these guys I probably would be dead now.’ These are the words of a woman who accessed the SWOP drop-in at a stage in her life when she thought nothing would ever change.

The Sex Worker Outreach Project (SWOP) was set up by the Nelson Trust specifically to help women who had become involved in street-based sex work to fund their addiction. The specialist programme grew from a knowledge base of working with some of the most disadvantaged, marginalised and stigmatised women in the community, and the realisation that intervention could be extremely successful in changing the lives of people who would not otherwise come into contact with services.

‘It can take a long time to gain a woman’s trust,’ says SWOP co-ordinator Katie Lewis. ‘Sometimes they have been through services many times before and their needs may not have been addressed appropriately.’ These needs can be extremely complex. Many of the women SWOP comes into contact with have experienced abuse, trauma and sexual exploitation before adulthood. For some, engaging in ‘transactional sex’ has become a practical way of affording accommodation and drugs. Many have families – and many have come to accept that living with a controlling and abusive partner is the norm.

Unsurprisingly, women in this situation are highly unlikely to walk through the door of a daytime service – not just because the hours don’t suit them, but also because of the stigma they have experienced. So SWOP goes out onto the streets to try to engage women who are likely to be at risk, offering hot food and drinks, clothes, toiletries and the all-important emotional support.

‘We offer kindness and give women the safe space to be listened to.’

‘We work extremely hard to engage women from a non-judgemental and trauma-informed approach,’ says Lewis. ‘We offer kindness and give women the safe space to be listened to.’ Offering support also involves encouraging the women to engage with other specialist support services, she explains, ‘and if it takes ten to 12 attempts for a woman to engage, we will continue to offer this support until she is ready to accept the help.’

Developing local partnerships has been central to the project’s effectiveness and SWOP works with police and probation, social care, child protection, housing and substance use treatment services, among many others. As SWOP co-ordinator, Lewis supports case workers to navigate complex conditions and chairs a monthly multi-agency forum, where all the partner agencies come together to discuss safeguarding and risks for the women, sharing information on how best to support them.

It’s a sensitive process that needs to be mindful of clients’ confidentiality, but Lewis is careful to protect the ‘trusting and respectful relationships’ they have built up. ‘If they were to disclose any safeguarding or risk information, we would have an honest conversation about when information needs to be shared,’ she says.

While it can take many attempts to engage with the women, through out-of-hours services, there is much to offer them in the safe spaces of the van in Swindon and Wiltshire or the drop-in centre at Gloucester. Both environments offer a place of respite and safety, and over food and hot drinks they have the opportunity to talk about the support they need.

Some need protection from clients and stalkers; others need help with abusive relationships at home. Many need help with finding safer accommodation for themselves and their children, and there is often the need for help at different stages of the criminal justice system – from attending court to ‘through the gate’ support when leaving prison.

At each stage SWOP encourages feedback, which helps the team adapt and grow their services. ‘We’re always consulting our women on how they want their services, and this may mean changing times of delivering outreach or providing more underwear,’ says Lewis. ‘We listen to our women and give them a voice.’

Improving the women’s health is a driving force of SWOP’s work and the approach is grounded in harm reduction. The network of partner agencies enables swift referral to treat sexually transmitted diseases, infections and HIV, and working with sexual health and homeless health teams helps with access to testing and healthcare. There are often mental health issues to address, particularly where distress has led to suicidal thoughts.

Tackling clients’ addiction can be a gradual step-by-step process that needs support from different partner projects and agencies. SWOP has developed three specialist interventions for sex workers, each of them based on giving women a safe space to explore their feelings about sex work while providing emotional and practical support.

At the harm minimisation end of the scale, the Pegasus Programme works through assertive outreach or prison inreach, night drop-ins and intensive key work with women who are actively sex working. The Griffin Programme offers drug and alcohol treatment at an abstinence-based residential treatment centre to women who are no longer actively sex working; while the Phoenix Programme gives aftercare to women who have been in recovery for over three years, but who still need support. All three programmes use shared experience and the concept of connectedness to reframe past trauma and explore the concept of choice for the future.

The work is challenging in many different ways, particularly when it can take many attempts to make the first successful connection, but Lewis says it’s the women they help that keep the team motivated. ‘We work with some of the strongest women I have met, who face adversity and prejudice daily,’ she says. ‘They empower us to continue to support them to exit sex working – and when we see an outcome of supporting one of our women to rehab, we know our model works.’  

Partnership of trust: Rachel’s story

After a year of Rachel’s engagement with her key worker and partner agencies, she was able to exit sex work and is now in recovery.

Rachel (not her real name) was street sex working most nights to fund her addiction when she was encouraged to engage with SWOP by other women who had accessed the service. She was very anxious about getting involved, but she was experiencing housing problems and had been a victim of domestic abuse.

Because of her anxiety and feeling ‘very closed up’ she would sporadically engage by accessing evening drop-in services only. She mentioned she wanted to exit sex working and quit drugs, so SWOP offered her support and encouragement to leave sex work and access treatment for her addiction.

After building a trusting and safe relationship with her key worker, Rachel was supported to access a script through the drug and alcohol service and reduced the frequency of her drug use and sex working. She was also now accessing the Nelson Trust Women’s Centre in the daytime, where she attended the Pegasus intervention.

Following regular intensive key worker sessions, Rachel hadn’t taken drugs for three months and hadn’t sex worked in more than four months. This enabled her to focus on her housing situation and pay off all her rent arrears by accessing benefits and learning to budget. SWOP supported her to access safe housing through a local housing provider.

After a year of Rachel’s engagement with her key worker and partner agencies, she was able to exit sex work and is now in recovery. She has resettled into recovery accommodation for women only and finds she is ‘at peace’ there. She has found the courage to reconnect with her mum – something she longed for.

There have been many ups and downs but her relationship with her key worker helped her keep her strength and determination. Rachel’s hope for her future is that she will be able to peer mentor women who want to exit sex work.

It’s time to get tested, urges PHE

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DDN
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Public Health England (PHE) and NHS England have launched a nationwide exercise to identify and treat people who have previously been diagnosed with hepatitis C. While almost 25,000 people in England have accessed new and ‘potentially curative’ treatments over the last three years, ‘tens of thousands’ of people who were diagnosed in the past may not have done so, says PHE.

Read the DDN special on Hep C treatment and testing

The agencies are urging anyone who may have been at risk of contracting the virus – ‘especially if they have injected drugs, even if only once’ – to get tested. The last three years has seen 95 per cent of people who completed treatment cured of the infection, says Hepatitis C treatment monitoring in England, with 70 per cent of those treated reporting injecting drugs as their ‘likely risk’ for acquiring the virus.

‘Hepatitis C is a serious infection and therefore we are delighted to see that at least nine in ten people who have completed treatment in England have now been cured,’ said PHE clinical scientist Dr Helen Harris. ‘This is fantastic news, and a step towards eliminating hepatitis as a major public health threat by 2030, as knowing the numbers accessing treatment is vital to tackling this infection. We will however continue in our endeavours to find and treat everyone who is living with hepatitis C. If you have been at risk of contracting hepatitis C, particularly through injecting drugs, even if you injected only once or in the past, then I urge you to get tested to see if you would benefit from these new, effective treatments.’

‘This is an extraordinary opportunity to eliminate hepatitis C in the near future’ – Hep C Trust CEO Rachel Halford.

There was ‘an extraordinary opportunity to eliminate hepatitis C in the near future if we can ensure all those living with the virus are treated with simple, curative treatments’, added Hepatitis C Trust chief executive Rachel Halford. ‘We know that many people who were previously diagnosed were never treated, and might be unaware that new treatments are now available. This re-engagement exercise will help ensure everything possible is being done to find, treat, and cure those infected and move towards elimination by 2030.’

Hepatitis C remains the most common blood-borne infection among people who inject drugs, says PHE’s updated Shooting Up: infections among people who inject drugs in the UK report, with ‘significant levels of transmission among this group’. While levels of needle and syringe sharing have fallen it remains a problem, the report says, with one in six reporting sharing of needles and syringes in the last month.

Reports at www.gov.uk

 

Scots look to ban TV alcohol ads before 9pm

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DDN
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The Scottish Government’s new alcohol strategy includes a range of plans to tighten marketing regulations. The Scots will ‘press the UK Government to protect children and young people from exposure to alcohol marketing on television before the 9pm watershed and in cinemas – or else devolve the powers so the Scottish Parliament can act,’ states Alcohol framework 2018: preventing harm.

Plans would ban alcohol TV advertising during the day when young people might be watching.

Alcohol misuse now costs Scotland £3.6bn per year, the equivalent of £900 per adult, says the document, which also includes proposals to consult on alcohol marketing in public spaces and online.

The 50p minimum unit price will also be reviewed after 1 May 2020, it says, while alcohol producers will  be urged to include health information on labels.

The framework also states that while the government will work with the drinks industry on projects that ‘can impact meaningfully on reducing alcohol harms’ it will not do so on health policy development, health education or health messaging campaigns – Public Health England’s recent partnership with industry-funded body Drinkaware proved highly controversial (DDN, October, page 5).

Scotland is leading the way in introducing innovative solutions to public health challenges, said Public Health Minister Joe FitzPatrick

‘Our new alcohol framework sets out our next steps on tackling alcohol-related harm,’ said public health minister Joe FitzPatrick. ‘We need to keep challenging our relationship with alcohol to save lives. These new measures build on the progress of our 2009 framework which has made an impact by tackling higher-risk drinking, but we want to go further. Scotland’s action is bold and it is brave and, as demonstrated by our world-leading minimum unit pricing policy, we are leading the way in introducing innovative solutions to public health challenges.’

‘There is strong support from the Scottish public to limit marketing of alcohol products and the evidence is clear that exposure to marketing drives consumption by children and young people,’ said chief executive of Alcohol Focus Scotland, Alison Douglas. ‘We believe plans to consult on alcohol marketing restrictions are a positive step towards protecting the vulnerable and challenging alcohol’s prominent role in our society. Likewise, we are pleased to see that the Scottish Government are committed to improving alcohol labelling. It is clearly unacceptable that more information is required on a pint of milk than a bottle of wine and the industry continues to show a complete disregard for our right to know what is in our drinks and what the risks associated with alcohol consumption are.’

Meanwhile a new report from Manchester Metropolitan University and Aquarius urges health and social care practitioners and substance use professionals to ‘rethink the needs of older people with drinking problems’. Increasing numbers of older people are drinking to ‘harmful or mildly dependent levels’ says Older people and alcohol: a practice guide for health and social care.  

‘Older people seeking treatment for alcohol use are often in poor health and have a range of complex social, health and other care needs associated with their substance use,’ said professor of adult social care at Manchester Metropolitan University, Sarah Galvani. ‘Evidence suggests that the complex health and social care needs of older people with problem alcohol use requires a different approach.’

Alcohol framework at www.gov.scot

Report at www2.mmu.ac.uk

North South Charity Merger

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DDN
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Health and social care charity Humankind and London-based alcohol and drug charity Blenheim CDP have announced they are intending to merge in April 2019 to form a national organisation which takes a different approach to addressing health and social inequalities.

Paul Townsley, CEO of Humankind: ‘Together, we would continue to deliver the best of services for our service users, funders and partners.’

The organisation, which will be named Humankind and employ over 1,100 staff, will build upon their commitment to pursue their vision for people of all ages to be safe, building ambitions for the future and reaching towards their full potential.

Paul Townsley, CEO of Humankind said today: ‘As two separate organisations, we have worked successfully across both the North and South of England for the last 50 years; we believe it is now time to come together to create one organisation that takes a new approach to addressing health and social inequalities. Together, we would continue to deliver the best of services for our service users, funders and partners, including housing, supported living, employment training and education, young people and family, clinical and substance misuse services.’

John Jolly, CEO Blenheim CDP: ‘Current stakeholders of both organisations can continue to expect the same high standard of delivery.’

John Jolly, CEO of Blenheim CDP, said: ’Blenheim CDP and Humankind have long valued innovation in service design and delivery, and we are both committed to taking this work forward, including extending our digital offers. We also have ambitious plans to capitalise on the opportunity our merger will bring to develop campaigns and influence national policy, recognising the changing nature of the social and political climate.

‘When the merger goes ahead, the current stakeholders of both organisations can continue to expect the same high standard of delivery, and Blenheim CDP services will keep their name and branding. Our decision to merge has resulted from our shared desire to pursue our objectives, increase our impact and to grow the services we offer.’

 

Clear steer on alcohol

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DDN
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Launching the Alcohol Charter, key figures from the sector called for a definitive alcohol strategy based on evidence, as DDN reports.

Read the full article in November DDN Magazine.

Alcohol takes ‘huge toll on crime and health’ – Sir Ian Gilmore, The alcohol Health Alliance.

The government should take immediate action to reduce alcohol-related harm through an evidence-based strategy, according to a new alcohol charter (see news, page 5).

Launching the charter at a well-attended meeting in Westminster, Sir Ian Gilmore said we must lead internationally on alcohol strategy. The ‘penny hadn’t dropped’ as far as alcohol was concerned, he believed, with government pursuing a strategy that wasn’t evidence based, around licensing, marketing and treatment.

‘Treatment is the part we should be most ashamed of,’ he said. We needed to look at comorbidities, the rise in mental health issues, and at social responsibility – the ‘innocent bystanders’ affected by alcohol problems. Without tangible counter measures, alcohol-related health issues were set to cost the NHS £17bn in the next five years.

The charter gave a ‘clear footprint for government to follow’ and would address the ‘huge toll on crime and health’, said Gilmore. ‘I am delighted that the charter commits to giving the public information and evidence-based guidelines on units,’ he added. ‘Until we get government-funded campaigns the public will stay in the dark. There’s more information on a bottle of milk than a bottle of wine.’

Next to speak, Dr James Nicholls of Alcohol Research UK and Alcohol Concern said that treatment services were being ‘hammered’, with two-thirds of local authorities having cut treatment budgets – a situation that was ‘absolutely unsustainable’.

Cuts in funding hit the poorest hardest – James Nichols, Alcohol Change UK.

‘These swingeing cuts are hitting the most deprived communities,’ he said. One of the main risks of budget cuts was the effect on assertive outreach: there had been a 19 per cent fall in presentations for alcohol-only treatment, but not the same fall in the levels of need. Working with these people cost more but gave the greatest savings to the NHS.

‘People turn up at A&E again and again. There’s a human cost and an economic cost,’ he said. The charter proposed a 1 per cent ‘treatment levy’ through increasing alcohol duties – a move that would provide £100m extra investment and pay for 24-hour teams in hospitals.

Jennifer Keen from the Institute of Alcohol Studies said that with drinking rates doubling since the 1950s and 1m hospital admission a year, it was ‘imperative’ that we addressed these issues. One theme ran through the charter – the affordability of alcohol, which drove consumption and harm. But she emphasised that resolving the issue was about more than increasing duty. The tax system wasn’t fit for purpose, with beer and spirits taxed differently to wine and cider and incentive for manufacturers to make their products stronger.

‘The government has said they won’t include minimum unit pricing in their strategy, but we hope this charter will encourage them to think again,’ she said.

Fiona Bruce, chair of the APPG on Alcohol Harm admitted there was ‘no single silver bullet’ and ‘a variety of solutions to tackle this epidemic’. It was encouraging to see that young people were drinking less, but a lot more needed to be done, particularly for the older generations.

‘There is something for everyone in this charter,’ she said. ‘Working together, we are beginning to strike up a national conversation so many of us want to have.’ DDN

Charter available at www.blenheimcdp.org.uk/news/alcohol-charter

—————

Call to action

‘Alcohol harm is avoidable. This charter provides the government with practical, workable measures to include in the upcoming alcohol strategy, including the treatment levy, that will reduce alcohol harm and improve people’s lives across the country.’

Richard Piper, Alcohol Research UK

‘The government needs to ensure that the upcoming alcohol strategy includes evidence-based policies which work to reduce alcohol harm and tackle the increased availability of super-cheap alcohol. The best way to do that is by introducing minimum unit pricing in England – which we already have in Scotland and will soon have in Wales – and increasing alcohol duty.’

Sir Ian Gilmore, Alcohol Health Alliance

‘This charter brings together voices from the entire alcohol policy field: the medical community, treatment providers, social care professionals, leading researchers, criminal justice advocates, and experts by experience… It sets out a clear course of action for the government and I urge them to include these policies in the alcohol strategy.’

Jennifer Keen, Institute for Alcohol Studies

‘We need to invest money in specialist services for people with an alcohol dependency. At the moment only one in five people who desperately need treatment can get it. That’s not good enough. It heaps pressure on our health services, but most importantly, it means we’re only reaching a fraction of those who need our help.’

Karen Tyrell, Addaction

‘The charter provides clear direction for the government in dealing with this important and problematic issue. As everyone knows, the cost to the individual and society as a whole is significant. This is a call to action!’

Yasmin Batliwala, WDP

‘There will be 1.2m alcohol-linked cancer cases in the next ten years and alcohol is set to cost the NHS £17bn in the next five years. We urgently need a new alcohol strategy to lead the way internationally in reducing the damage to society. This charter sets out how it can be done with a realistic evidenced based, yet pioneering set of demands that we urge government to adopt.’

John Jolly, Blenheim

 

All change for alcohol charities

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DDN
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A new alcohol charity has been launched following the merger of Alcohol Concern with Alcohol Research UK (DDN, April 2017, page 5). Alcohol Change UK’s mission will be to ‘significantly reduce serious alcohol harm in the UK’, it states, with an aim of creating ‘five key changes’ of improved knowledge, improved drinking behaviours, shifted cultural norms, better policies and regulation, and more and better support and treatment.

‘This is a truly exciting time to be launching our new merged charity,’ said chair of trustees Professor Alan Maryon-Davis.

The new organisation will build on the ‘legacy of Alcohol Concern’s campaigning work’ such as Dry January and Alcohol Awareness Week, it says, along with Alcohol Research UK’s ‘deep insight and knowledge’ from its years of research.

‘This is a truly exciting time to be launching our new merged charity,’ said chair of trustees Professor Alan Maryon-Davis. ‘There is growing recognition that society’s relationship with alcohol needs to change and that more and better support is needed for people whose lives are blighted by drink. Research is key – we need to understand more about the complexities that link drinking and harm. So too is advocacy for evidence-based policy and effective practice. And, as ever, increased public awareness and healthier behaviours are fundamental. All these elements need to work in synergy rather than piecemeal.’

‘Too often, we in the UK remain blind to the sheer scale of serious alcohol harm taking place across our communities,’ added CEO Dr Richard Piper. ‘This harm is massive, but it is not inevitable and it’s not acceptable. Alcohol Change UK’s name, identity and deeply held values reflect this fundamental belief.’

www.alcoholconcern.org.uk

Government reverses controversial FOBT delay

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DDN
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The government has abandoned its plans to delay the reduction in the maximum stake allowed on fixed odds betting terminals (FOBTs).

Association of British Bookmakers claim that the maximum stake reduction would lead to the closure of more than 4,000 shops.

The announcement that it was cutting the maximum stake it was possible gamble on the controversial machines from £100 to £2 was made earlier this year (DDN, June, page 5), following a lengthy campaign from MPs and charities (DDN, September 2014, page 6). However, November’s budget saw chancellor Philip Hammond state that the reduction would not come into force until October 2019, angering many MPs and prompting the resignation of sports minister Tracey Crouch. The reduction will now be brought forward to next April.

It is estimated that the machines – often called the ‘crack cocaine of gambling’ – can account for around half of betting shop takings, with the Association of British Bookmakers stating that the maximum stake reduction would lead to the closure of more than 4,000 shops. Crouch’s resignation letter cited ‘commitments made by others to those with registered interests’ as the reason for the delay.

Tracey Crouch MP said she was pleased the government had reversed its position and ‘common sense has prevailed’.

‘The government was right to agree that the maximum stake should be reduced from £100 to £2,’ Ms Crouch wrote in the Times. ‘But it was hugely disappointing that the implementation was delayed to October next year instead of April, as most had expected it. That is why I resigned two weeks ago. I simply could not defend any delay knowing that two people every working day were estimated to take their own lives because of gambling problems. I’ve held the hands of too many addicts who have contemplated suicide, or the families left behind because loved ones saw no other way out, for me to be able to justify or even explain the delay.’

The decision to abandon the delay would ‘affect many lives for the better and reduce harm on our high streets’, she added. ‘There are many more gambling issues that need to be dealt with including online harm, advertising and the poor standards of treatment for addicts, but on this issue alone I am glad common sense has prevailed.’

Tracey Crouch comment at www.thetimes.co.uk/edition/news/i-don-t-feel-vindication-just-relief-cf7pnq8vr (paywall)

Home Office stands firm on Glasgow consumption room

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DDN
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The government has reiterated its opposition to the opening of a drugs consumption room (DCR) in Glasgow, following a letter to home secretary Sajid Javid from the Drugs, Alcohol & Justice Cross-Party Parliamentary Group.

A drug consumption facility in Germany.

The letter sets out the case for a DCR in the light of record drug deaths in Scotland (DDN, July/August, page 4) and high rates of HIV in Glasgow among people who use drugs. It also cites the effectiveness of similar facilities in almost 70 cities worldwide in reducing equipment sharing and drug-related deaths. Although the Glasgow City Joint Integration Board approved the development of a business case more than two years ago (DDN, November 2016, page 4) and the local health board has sourced potential sites (DDN, July/August 2017, page 4), legal obstacles remain. While Scottish MSPs have backed the plan, Westminster has stated that it is firmly opposed.

The cross-party group’s letter says that the opening of a DCR is an ‘urgent priority’ and that the government’s position to date has ‘been simply to insist on the unlawfulness of DCRs under the Misuse of Drugs Act 1971. We strongly believe a more open-minded and innovative approach is urgently needed to save lives and prevent the spread of blood-borne viruses such as HIV’. The letter urges the home secretary to adopt a similar position to that regarding festival drug testing, where local police and crime commissioners and health authorities are largely able to ‘develop their own positions without direction from Westminster’.

In November’s DDN Nick Goldstein questions if consumption rooms should be a priority in the current climate.

The response from crime minister Victoria Atkins, however, states that ‘our position on DCRs has been clear for some time: we have no plans to introduce them’. Consumption rooms do not form part of the drug strategy’s approach of ‘preventing drug use in our communities’, it says, and the government is ‘not prepared to sanction or condone activity that promotes the illicit drug trade and the harm that trade causes to individuals and communities’. Although DCRs were being operated in other countries ‘there remain legal and ethical issues for agencies involved’, it adds.

Should consumption rooms be a priority the current climate? Read Nick Goldstein’s article on page 10 of November’s DDN

The Right Fix?

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DDN
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We need to talk about safe injecting sites, says Nick Goldstein.

Safe injecting sites, drug consumption rooms, safe injecting facilities, fix rooms or the rather more grandiose medically supervised injecting centres are just some of the many labels applied to legally sanctioned medically supervised drug consumption sites – places where drug users can inject their drugs safely

Read the full article in DDN Magazine

The laudable purpose of these sites is to reduce BBVs and overdose, while also reducing the nuisance caused by drug users injecting in public. They also offer users a route into a variety of mainstream services they otherwise might not have come in contact with.

Sounds super great, right? So, why do I always feel so uneasy when the subject comes up? I have to say, part of the unease comes from the reaction to anyone questioning the virtue of safe injecting sites – a reaction which ranges from scorn to outright hostility. Consequently an orthodoxy is being created around the subject, and in my experience unquestioned orthodoxies tend to lead to poor policy – and there’s more than enough of that out there already!

My unease, however, goes beyond a personal dislike of the virtue signalling and group-think that cloud the issue. There are several concrete reasons for concern regarding the costs that come with the safe injecting sites – costs that really need addressing and analysing.

Firstly, there will inevitably be a cost in community relations. Nothing exists in a vacuum – especially not property prices which, given the amount of stigma around IV drug use, will inevitably drop at the first mention of a safe injecting site in the neighbourhood. While it’s tempting to mock this sort of ignorance-based nimbyism, it would be wiser to realise that anything that further erodes the troubled relationship between drug users and wider society should be treated carefully.

Then there’s the inevitable political cost. By this I mean that admitting an area needs a safe injecting site is equivalent to admitting that a laundry list of policies – including housing, mental health, welfare and addiction polices – have all failed miserably, and politicians don’t like admitting and taking ownership of that kind of collection of failures. Persuading them otherwise takes a concerted effort – effort that could have been used to persuade them to adopt other, less glamorous, but more productive policies. Far too often substance misuse is an afterthought for politicians. Can the bandwidth they do devote to the subject be better used?

Then there’s the bottom-line cost. Money is an ugly subject, but sadly it’s always relevant – especially in an age of austerity and government indifference.

Before we go any further I keep hearing comments like ‘safe injecting sites can be cheap – you just need a tent and some works’. Guys, that’s not a safe injecting site. That’s a shooting gallery in a tent! Unfortunately the things that differentiate between a shooting gallery and a safe injecting site tend to be expensive and range from the cost of premises to the most important of all – the cost of suitable staff. Done right, a safe injecting site is not a cheap option.

In Germany consumption rooms provide information about therapy, clean syringes and cheap meals.

Importantly, it also needs pointing out that while offering a valuable service to the drug users who use them, the majority of drug users won’t use a safe injecting site. Not even a majority of IV drug users will use them – including me. I won’t use a safe injecting site because I’m fortunate enough to have a home. Even if I were homeless I wouldn’t travel far, pay for public transport, or spend time travelling to use a safe injecting site, and I’m far from alone in this. In fact while preparing to write this article I asked several current and past IV drug users what they thought of safe injecting sites. To a man/woman they replied they were a wonderful idea, but when asked if they’d use them personally they universally replied ‘NO’.  

Safe injecting sites’ clientele will tend to be chaotic, homeless users with complex problems, and that’s a small subset of not just drug users, but also a small subset of IV drug users – a very vulnerable, very visible subset, yet still a subset. So, the question is, is it acceptable to furnish the signifi­cant cost of a site that will only be used by a small percentage of drug users from a budget aimed at a much wider community of drug users?

I must admit that one of my pet peeves is that drug treatment is rarely designed for the primary purpose of helping drug users. Instead it tends to be designed to protect wider society from drug users by reducing crime, reducing the spread of BBVs in society and even by attempting to make drug users more economically productive. Safe injecting sites fit firmly into this peeve because it’s easy to see the benefit for local merchants and residents, but it’s a lot harder to discern much of a benefit to the majority of IV drug users.

At my most cynical I feel there’s something disturbing about an approach that can easily be seen as saying ‘come in for half an hour, have a shot so you don’t scare the public and then fuck off back to your cardboard box’. I’m sorry, but there are far more effective ways of helping a larger percentage of IV users – like the far more prosaic re-evaluation and design of housing, welfare, mental health and drug treatment services in the area for a start.

In October 2018 a safe injecting site shouldn’t be a priority in England. However, in other parts of the world they’re a viable policy option. In America the opioid epidemic and open air drug markets (which cause users to congregate in one place) make safe injecting sites viable. In Europe and Australia they’re the fruit of better funding and treatment philosophy, but in England the situation is different. This is not to say things won’t change – it would take a brave person to bet that the gradual arrival of fentanyl and other research chemical opioids won’t completely change the equation and push safe injecting sites up the agenda, but in the here and now we have other more pressing needs.

If, or rather when, the situation in England changes, then safe injecting sites may well become a viable treatment option, and when that time comes there’s much that can be done to mitigate the costs involved. We can accept that the sites should be temporary and serve as an emergency measure while the fundamental issues underlying their need are fixed. Temporary sites would also do much to allay local community concerns regarding their impact. A temporary safe injecting site also opens the door to using pre-fabricated buildings or converted buses, which would help to reduce the financial cost. So, there are options that can be taken to help make safe injecting sites viable in the future – IF they become needed.  

As it is today, safe injecting sites aren’t an exciting panacea to all drug users’ problems. They are in fact a luxury in an age of austerity and all the virtue signalling and group-think in the world won’t change that.

Nick Goldstein is a service user

Your opinions are welcome. Please comment below or email the editor

 

 

 

Treatment crisis

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DDN
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Action is needed now to stop the spiralling costs of buprenorphine, says Roz Gittins.

Read the full article in DDN Magazine

We want to offer high quality, safe, cost-effective services to as many people as we can – that’s why we all go to work in the morning. That’s our passion and our goal. Over the past few months, the spiralling costs of buprenorphine are threatening the vital work of all of us in this sector and more importantly the treatment plans of thousands of clients.

Roz Gittins
Roz Gittins: Director of pharmacy at Addaction

Currently, clients are given the choice to decide whether to use medications, mostly methadone or buprenorphine, as part of their treatment for opioid dependency. They make their own decision about their future, based on their own personal needs. They are empowered to steer their own recovery.

And let’s not forget, there can be a considerable difference in the effects and patient experience between the two medications. Buprenorphine may be associated with a reduced risk of overdose compared to methadone because it partially blocks other opioids. So if an individual takes heroin on top, they won’t experience the usual effects associated with it, and are usually put off doing so.  

Buprenorphine can also make people more clear-headed than methadone so may be preferred by some people who are working. Often parents also prefer it because the risks from unintended ingestion are far lower because buprenorphine tablets don’t work if they are swallowed (they should be dissolved under the tongue).

Just six months ago, the cost of buprenorphine was about £15 for a month’s supply. Now it’s closer to £130. In one of our services, the prescribing bill for buprenorphine shot up from nearly £3,000 to over £21,000 in just two months.

While we’re continuing to support clients prescribed buprenorphine, the long-term sustainability of this will be put in jeopardy if prices remain this high. In normal practice the option of switching from buprenorphine over to methadone would only be considered if clinically appropriate and if the client makes an informed choice to make the change.

Transferring someone for cost or supply reasons could generate significant anxiety and have a serious impact on the trust between the client and the provider, which in turn could damage their future engagement.

Changing to methadone may also destabilise clients or make them feel that they have been ‘put’ on treatment where they have previously ‘failed’.  At a time when drug-related deaths are higher than ever before do we really want service providers and commissioners to be forced into that position?

The importance of a client’s confidence in their treatment cannot be underestimated. Yet because the cost of this medication increased by more than 700 per cent for some of our services, we have worried clients and frustrated staff, who while knowing the life-saving benefits of buprenorphine are being forced to think about the costs.

It’s estimated there are around 30,000 people in England using buprenorphine as part of their recovery plans. That’s 30,000 parents, brothers, sisters, sons, daughters and friends, who are already doing the best they can with their recovery, experiencing extra anxiety.

It’s not in our control. It’s not sustainable. It’s not OK.

At Addaction, we’re calling for the government to do more. More should be done to monitor the price and supply of this crucial drug within the UK and we want to see adequate contingency mechanisms in place to ensure sudden shortages and price increases do not happen or are quickly dealt with.

Paying the price

The rising cost of buprenorphine has caused serious concern in the treatment field. DDN looks at the issues behind it.

The generic drug market can be a volatile one, with companies ceasing supply or switching production of drugs at little notice and with consequent shortages in supply. While government pricing control mechanisms to manage these shortages rarely affect the treatment field – as it prescribes far fewer drugs than wider health services – in the case of buprenorphine the impact has undoubtedly been felt.

The drugs recommended by NICE and the Drug misuse and dependence ‘orange book’ guidelines as maintenance for people with opioid problems are methadone and buprenorphine. However, as Addaction’s article opposite states, while the latter is the preferred option for many clients, a shortage has led to the price of generic buprenorphine sublingual tablets rising sharply in recent months. This has hit parts of the treatment sector – already struggling with shrinking budgets – hard.

Drug pricing mechanisms can seem complicated and opaque. The UK pharmaceutical sector is strictly regulated, with prices agreed via the Department of Health and Social Care (DHSC). NCSO (No Cheaper Stock Obtainable) is a special concessionary pricing status negotiated by the Pharmaceutical Services Negotiating Committee (PSNC), enabling a set number of drugs above the drug tariff price to be reimbursed at a higher level than that price. The tariff is produced every month by NHS Prescription Services on behalf of DHSC, and then supplied to pharmacists and other bodies.

In May, Public Health England (PHE) wrote to directors of public health in response to concerns from some pharmacists and treatment providers about the availability of generic 2mg buprenorphine tablets. The letter explained that while branded buprenorphine is more expensive than the generic product used by many services, pharmacists are paid a standard price as set out in the tariff for ‘whichever product they dispense against a prescription for generic buprenorphine’, adding that the reimbursement price can change according to market conditions. While the NHS is used to managing these fluctuations and temporary concessionary prices, as PHE’s letter pointed out the limited range of medicines used in drug treatment means less scope to do that.

A further briefing in September stated that the agency recognised the ‘severe financial problems’; that continuing supply issues and raised prices were causing, and in late October PHE once again wrote to directors of public health explaining that the concessionary price had remained higher than the reimbursement price, and stressing that PHE had continued to work closely with DHSC and treatment providers to ‘understand the issues and their impact, and what can be done to mitigate any resulting problems’.

This most recent letter states that while the original supply issue has been resolved, supplies of generic buprenorphine remain limited and pharmacists have continued to rely on more expensive branded products, meaning that treatment services and commissioners will ‘see increased drugs bills for most, if not all, of 2018 and potentially beyond that’.

The letter ends with a statement that local authorities may need to ‘reflect on the medicines element in their budget for drug treatment’. Given this, what is a realistic timescale until the situation might be resolved? ‘The bottom line is that no one knows,’ Pete Burkinshaw, alcohol and drug treatment and recovery lead at PHE, tells DDN.

Pete Burkinshaw: Alcohol and drug treatment and recovery lead at PHE.

‘The price is determined by the market conditions, and they can change rapidly. Essentially the old tariff price was the market price for buprenorphine in this country and it was low for a long time, particularly in comparison to other countries in Europe. Perhaps it was unsustainably low and the recent changes may be to some extent a natural correction, or competition may increase again and the price would then fall.’

What PHE was communicating in its recent letter to local authorities was that their planning needs to be done ‘in the context that the recent changes may well be long term and not a temporary blip’, he adds. ‘The medicines market is fluid and all we can say with any confidence is the market conditions have changed, and that no one can predict them with any absolute certainty.’

On calls for the government to put contingencies in place he states that PHE is ‘raising questions within government persistently, and making the relevant people aware of the unique set of circumstances and the impact on drug treatment. However, it is very difficult and unprecedented for government to intervene in markets. This is a very complex issue and no centralised solution or mitigation is likely or perhaps even possible in the immediate future. We have explored many options with colleagues but none have been possible.’

Fluctuations in the medicines market are common and appear to be ‘particularly frequent at the moment’, he states. ‘The NHS and DHSC regularly have to deal with these issues but on a far larger scale than the current buprenorphine issue. However, we have gone to great lengths to point out that this is being felt particularly acutely by the drug and alcohol treatment sector and that there are – and will be increasingly – direct and immediate consequences. This is largely because of the very small number of medicines used by the sector which are funded from discrete budgets, which means that any peak cannot be absorbed by reductions in the price of other medicines.

‘This is further compounded by the financial pressures local authorities and services are currently under. We are confident that message is now understood, and we will continue to do everything we possibly can.’

‘Never forget kindness in a results-driven age’

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DDN
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DDN Magazine November2018Never under-estimate the power of kindness and a safe space. The SWOP project featured in our cover story showcases the best kind of outreach – meeting people at the stage they’re at, offering comfort and safety first and foremost, and then providing the first links to a network of support. It’s a way of working, and a set of values, that we shouldn’t forget in this results-driven age. Outreach work can be so very undervalued as budget cuts bite, but without projects such as this many people would stay under the radar, scarred by trauma and unable to move on.

As so many of you are striving to do your best with limited budgets it’s frustrating to see the spiralling costs of buprenorphine and extremely worrying to think about the effect on clients’ stability and progress. The issues behind the price increase are complicated (page 9) but we are in complete agreement with Roz Gittins (page 8) that the situation must be resolved as quickly as possible.

Getting the medication right is among the many things we know will help to prevent drug-related deaths. After listening to the latest ONS figures, participants of a recent parliamentary meeting wanted more information around the personal stories of those who are recorded as statistics (page 12) – and we already know that austerity, homelessness and leaving prison without the right support are major contributors.

We also know that a clear, evidence-based alcohol strategy could make a vast difference to many lives. The charter (page 15) gives measures that would improve treatment, find those in need of support and protect public health – all the while bringing a substantial return on investment and reducing the burden on the NHS. We hope that government will respond to this important document.

Claire Brown, editor

Download a PDF or view the online magazine

Numbers seeking treatment for crack up nearly 20 per cent

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DDN
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There was an 18 per cent increase in the number of people seeking treatment for crack problems in 2017-18, according to the latest PHE figures. This follows a 23 per cent increase the previous year (DDN, December/January, page 5), with the figure now standing at more than 4,300.  

Crack Cocaine
18 per cent increase in the number of people seeking treatment for crack cocaine

The numbers, taken from National Drug Treatment Monitoring System (NDTMS) data, show more people in treatment for crack problems across all age categories, including younger age groups ‘where there had previously been years of decline’. The increase likely reflects the rising prevalence of crack use, says the document, while the rising numbers of new users ‘may be in part caused by changes in the purity and affordability of crack cocaine and patterns of distribution over the last few years.’ The number of people entering treatment for both crack and opiate problems was also up, by 3 per cent to 22,411.

Overall, there were 268,390 adults in contact with drug and alcohol services in 2017-18, 4 per cent down on the previous year. The number of people seeking treatment for problems with NPS was down by 16 per cent to 1,223, while the number of people in treatment for alcohol problems alone fell by 6 per cent to 75,787 – 17 per cent lower than the figure for 2013-14.

PHE was working with the Home Office to ‘get a better understanding of the issues behind the increase in crack use and has engaged with areas seeing the largest increases’, said the agency’s director of alcohol, drugs and tobacco, Rosanna O’Connor. She also stressed that the falling numbers in alcohol treatment were not because fewer people were dependent. ‘We estimate that four out of five alcohol-dependent adults aren’t getting the treatment they need. There is a big gap between people needing treatment and those accessing it.’

There is a big gap between people needing treatment and those accessing it.

PHE has published a separate enquiry into the declining numbers in alcohol treatment, which found that ‘the context in which treatment is currently commissioned and provided – including financial pressures and service reconfiguration – has affected alcohol treatment numbers more than treatment numbers for other substances’. Areas where there had been a fall in numbers ‘more often reported an erosion of effective referral pathways’, it adds. ‘This was partly due to staff and commissioners having less time to maintain working relationships with partners, or referrers losing confidence in the service following a period of upheaval.’

Substance misuse treatment for adults: statistics 2017 to 2018, and PHE inquiry into the fall in numbers of people in alcohol treatment: findings, at www.gov.uk

Hepatitis C and Health Guide

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DDN
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Hepatitis C represents a major public health challenge but patients now have the opportunity to be completely free of the virus through a short course of treatment. This Hepatitis C and Health guide will help you to recognise stages and symptoms and offer people the targeted help they need.

Hepatitis C and Health GuideRead it online as a E-Magazine or download the PDF.

 

 

Playing the long game

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DDN
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Tony Adams’ glittering football career could not mask deep-seated problems that needed to be tackled. He shared his story at the NHSSMPA conference.

‘You don’t suddenly become an addict – there’s a path, a journey,’ Tony Adams told the NHSSMPA conference. Adams’ 19-year football career had included 669 matches for Arsenal and 66 for England since his debut in 1983, but over much of that time he had become increasingly addicted to alcohol.

Read the full article in October’s DDN Magazine

‘I was very shy as a kid, full of fear. I had the worst attendance at the school – I just couldn’t do it. The book would be going round the class and I’d be having a panic attack. When I got the book I was such a mess, I couldn’t say the words.

‘My family would say “how was school today?” and I would just shove it in a box, bury it as deep as I could. Football was my escape, psychologically, emotionally. I was as free as a bird out there, kicking the ball. I did that instead of facing the fear and going to school. I couldn’t do real life, I couldn’t do interaction, I couldn’t do school. I couldn’t do thoughts and feelings. So I’d pick up the ball. On the football pitch I was comfortable in my own skin.

‘When I was 17 I broke the metatarsal in my foot and I couldn’t go to football to escape those thoughts and feelings. But I found that alcohol did exactly the same thing for me. It took me away from all that stuff – everything.

‘When I first picked up alcohol, I didn’t like the taste. So I had to work on it because I loved that feeling of numbness, that escape. I’d wet the bed and it became normal – I’d just roll to the other side. It got to the stage where I’d do that and then sleep on the floor – no personal hygiene, no dignity, no self-respect.

‘My football career and my using career went side by side. Every time I didn’t have football, I needed something else to numb all those thoughts and feelings in life.

‘I was spending a lot of time in pubs and clubs and I married a barmaid. She’s part of my story, and I’m part of hers. Her drug of choice at the time was crack cocaine. I knew she took a little bit but over the six years we were together it developed. It was a very volatile relationship – we were soulmates in sickness really. I’d think, “at least I’m not like her – she’s the druggie.” So I’m out there sleeping with other women, pissing myself, going to prison – but thinking, “at least I’m not as bad as you because you do crack and I do booze.”

‘I was trapped in denial. If you’d have told me I had a problem with alcohol I’d have told you to get lost. The consequences then started to happen and the pain became unbearable.

‘I put my wife into treatment at Clouds House to sort her life out – “cos it’s her fault” – and I saw the 12-step programme on the wall. I thought, what the hell’s that? I sat down with two counsellors and they looked at me as if they could see straight through me. I said “I haven’t got a problem – sort her out and we’ll be ok. She’s got to stay in here for a couple of months and I’ve got three kids at home I’m looking after. Sort her out.”

‘So the wife’s gone. Then I got injured and couldn’t play. As long I was on the pitch I was getting rid of all that anger – and getting paid for it!

‘I took the kids out one Sunday to an Indian restaurant and got absolutely smashed. I brought them home and passed out. The next thing I know, my mother-in-law’s slapping me round the face – and she took the kids away. My first thought was “holiday!” Then the consequences became more and more painful: “Wife’s gone, football’s gone, kids have gone.”

‘It was starting to dawn on me. My mother-in-law gave me the name of a therapist. It was the first time in my 12 years of drinking that I didn’t want to drink again – yet I was still getting drunk. I had crossed the line and I couldn’t get back. I had completely lost all control over it and it frightened the hell out of me.

‘I tried to do it with willpower – “I’m not going to drink again.” But with no tools and no idea how to stay stopped, I continued to use. There was the big tournament in ’96, the European Championships, and I white-knuckled it – football had always worked for me. I locked myself in my room on the 15th floor of the hotel, with my life falling to bits. I said to the lads, “when we win it I’ll go and have a drink with you, we’ll celebrate,” but until then I was scared – I didn’t know how to drink. As soon as the last game of that competition was kicked and Gareth missed that penalty, I went back into the bar in the corner of the dressing rooms and I was off.

‘I had my moment of clarity, my surrender moment at 29 years of age. I started to cry. “I don’t want to drink, I’m still getting drunk. All this behaviour I’m doing, I don’t want to do.” My life was a complete and utter mess.

‘But as soon as I surrendered, as soon as I gave in, it was a release. Somewhere inside of me I had a moment of clarity, something shifted within me that let a shaft of light in and the therapy got me well.

‘The best thing about recovery is that you get your thoughts and feelings back – and the worst thing about recovery is that you get your thoughts and feelings back!

‘My life is fantastic today. I get angry, but I express that anger appropriately. I’ve had to learn absolutely everything from people who are down the journey a little bit further.

‘I’ve had many “surrenders” and emotional “bottoms” – things that took me to a very dark place. But I got through it with different tools, including talking about it. We don’t know what the triggers are for other people – all we can do is to lay out the tools in front of them, whether it’s a treatment centre, a counsellor, a friend, or a coffee with someone.

‘If one programme doesn’t work for you, try everything. And as professionals, put everything in front of people and they might pick up one of the tools. It’s the pain that gets them usually. The consequences of your life become so unbearable, you’ve got no other choice.’

Tony Adam’s book Sober was published in August by Simon & Schuster, ISBN 9781471156755. He has used the proceeds of his books to set up Sporting Chance Clinic to support current and former professional sportspeople.

UN drug policy a ‘spectacular failure’, says IDPC

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DDN
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The UN’s ten-year strategy to eradicate the international illegal drugs market has been a ‘spectacular failure of policy’, says a new report from the International Drug Policy Consortium (IDPC). UNODC strategy is based on a ‘discredited “war on drugs” approach that continues to generate a catastrophic impact on health, human rights, security and development, while not even remotely reducing the global supply of illegal drugs’, says Taking stock: a decade of drug policy.

President Duterte’s approach has contributed to ‘catastrophic impact’

More than 30 jurisdictions still have the death penalty for drugs offences on their statute books, it says, with almost 4,000 people executed over the last decade. Meanwhile, President Duterte’s violent crackdown on drug users in the Philippines has so far seen around 27,000 extrajudicial killings, and there were more than 71,000 drug overdose deaths in the US last year alone. Restricted access to controlled medicines has also left 75 per cent of the world’s population without proper access to pain relief, the document states.

This ‘failure of international strategy’ is also reflected at UK level, it says, with increasing levels of class A drug use and record drug-related death figures. Drug law enforcement is also a ‘key driver of ethnic disparity’ in the criminal justice system, says IDPC, with a recent Release report revealing that black people are stopped and searched for drugs at nine times the rate of white people.

The report calls for global drug policy debates to ‘reflect the realities of drug policies on the ground, both positive and negative’, and for UN member states to ‘end punitive drug control approaches and put people and communities first’.

‘The Home Office claims that drug policy in the UK is working on the basis that drug use is falling,’ said Release executive director Niamh Eastwood. ‘This is a blatant disregard for the facts. Drug policy in the UK has not only failed, but is damaging – more people are dying than ever before, class A drug use is increasing, drug purity is at one of its highest rates ever and the drug laws are applied in a discriminatory manner. The Home Office policy on drugs is directly contributing to these harms by refusing to engage in evidence based approaches to drugs, such as trying to block drug consumption rooms or refusing to look at the evidence for ending the criminalisation of people who use drugs.’

Read the IDPC report here

State of the sector: Time to talk

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DDN
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When the going gets tough, is it time to get round the table, asks DDN.

Read the full article in October’s DDN Magazine

A couple of years ago, addressing an audience at The King’s Fund, Lord Victor Adebowale commented, ‘There should be no wrong door and every service should reverse the Inverse Care Law, which simply states those people in need of health and social care the most get them the least.’ Since then, this conversation has grown louder. As the threat of disinvestment has become reality and more of the smaller treatment agencies are forced to close their doors, we find ourselves looking at escalating mortality figures relating to drugs and alcohol and wondering why this is allowed to happen.

Lord Victor Adebowale, Chief Executive of Turning Point

If, as Lord Victor suggests, we are drifting towards the opposite of community-based care, what should we do about it? Can we overturn the mentality of ‘survivalism’ we’ve been forced to adapt to and harness an appetite for revolution? Are our systems and processes wrong – and what specifically isn’t working?

According to Annette Dale-Perera, an international consultant who has spent many years working in UK drug policy, we have lost much of the perspective that comes with being a comparatively rich country. ‘We are seen as a high investor, but our systems aren’t comparable to some other countries,’ she says. ‘We get criticism around the world for focusing on getting people out of treatment.’

We need a switch in focus to ‘really work together, providers and commissioners’ and reach a consensus to ‘not go below the line, or treatment will suffer’, she says. By going ‘below the line’, she means cut-price tendering – and the frequent recommissioning (‘bloody waste of money’), ‘political yo-yo-ing’ and ‘bean counting’ that has helped to deprioritise investment in addiction services.

Annette Dale-Perera: We need a switch in focus to ‘really work together, providers and commissioners’

What we’re left with is a state of growing inequality and what she describes as the ‘really shit life’ syndrome. ‘We’ve got to ask ourselves why we’ve got people living in worse situations than in war zones,’ she says. ‘Maybe it’s our systems and processes that are wrong. Have we built processes that don’t work? There are structural inequalities and our benefits system is shocking.’

Furthermore, she believes we are missing the public health and human rights approach to drug use, which UNGASS (the United Nations General Assembly Special Session on Drugs) brought to global policy in 2016. At this latest session, 193 member states agreed the need to move from a criminal justice to a public health approach, and supported the concept that people can recover through evidence-based treatment and social support.

‘There have been calls for solutions that dovetail with the mainstream – long-term recovery and support,’ says Dale-Perera, and these should include strong elements of harm reduction – community OST, more needle exchanges, and better coverage with naloxone.

Mike Dixon, chief executive of Addaction, believes we need to ‘change the feel of services’ – a strong message from one of the larger treatment agencies. ‘Many services operate from a room that local authorities don’t want to use for other stuff,’ he says.

Mike Dixon, chief executive of Addaction, believes we need to ‘change the feel of services’

Changing the welcome to clients is part of changing something much bigger, he adds. ‘We need to reach out to a lot more people, particularly for alcohol and non-opiates. We divide people by substances [to treat them] but have no idea who’s using other substances and how many people are using problematically.

‘We don’t think about the chance people have as they walk through the door. We have been conditioned to think about completion rates.’

If addiction services are losing profile and suffering from disinvestment, what should – and could – happen at a political level? Jonathan Ashworth, shadow health and social care secretary, says that in power, Labour would ‘give addiction services the profile they need’. He acknowledges that we’re ‘facing an addiction crisis’ and that despite high demand, ‘people receiving treatment have fallen to their lowest levels’.

‘Overall it’s a bleak picture, with more cuts to come,’ he told the National Substance Misuse Conference in September, pledging to expand treatment services if he became health secretary. Labour would reverse cuts, spend an extra £7.7m on prevention, and address gaps in the workforce, he said. He talked about how the loss of addiction psychiatrists meant that we were unable to provide services for complex dual diagnosis early in the treatment cycle, and wanted to improve links between mental health and addiction services. Another priority he had learned from talking to the sector was the need to address patchy naloxone provision across the country.

Jonathan Ashworth, shadow health and social care secretary, says that in power, Labour would ‘give addiction services the profile they need’.

‘I don’t believe we can go on cutting drug and alcohol services – we need to completely change the landscape,’ he said. ‘If I become health secretary I will put in a proper strategy for care, support and rehabilitation, backed up by the resources needed.’

The political pledge from the shadows is one thing; working with the ramifications of complex and illogical drug laws is another. Dr Prun Bijral talks from experience as CGL’s medical director and draws a direct line between ‘the prohibitive situation’ and more potent forms of drugs finding their way into the mainstream.

‘Drugs become more potent because there is more profit from stronger drugs,’ he says. You don’t have to look too far to buy these drugs online, he points out – ‘the UK has the largest number of dark net sales in Europe. We also know the impact of fentanyl and the increase in drug-related deaths from it.’

Katy MacLeod has expertise from her work in training and development at the Scottish Drugs Forum (SDF) and also as director of Chill Welfare, a social enterprise created in response to drug-related deaths at music events. She, too, is concerned about ‘super-strong’ versions of drugs, and comes across ecstasy tablets on the festival circuit that are ‘three times the strength they were’ – a particular issue for people returning to ecstasy at festivals. Many of the people she comes in contact with have undiagnosed mental health issues. She knows of prisoners who aimed to become drug free but who are now on synthetic cannabinoids – just because these drugs are such a regular part of prison life.

‘If it was any other public health issue we were talking about there would be an outcry,’ she says, and believes that drug services are hard to reach: ‘We have to do something about that. If we do what we always did, we’ll get what we always got.’

So how do we go about doing things differently? Many deep-rooted problems stem from lack of investment or outdated legislation. But there is an argument for grabbing the things we can influence by the scruff of the neck.

Dr Prun Bijral, Medical Director CGL

Many believe that education is of primary importance, in every context and to every audience. ‘Drug education in schools is terrible – we need to be honest about the harms and benefits,’ says Dr Prun Bijral, while Mike Dixon suggests that ‘small conversations at home’ with parents normalising information about drugs, could make a big difference. On a wider scale, those of us working in the sector can audit our language and practice to make sure we are challenging stigma at every opportunity. ‘Until I worked internationally I didn’t realise my language was stigmatising,’ says Annette Dale-Perera. ‘International colleagues do not accept the term drug users – it has to be people who use drugs.’

‘We really need to up the ante and become more dynamic’ in response to the loss of infrastructure and expertise, suggests Danny Hames, chair of the NHS Substance Misuse Providers Alliance (NHSSMPA). ‘One of the things we could be doing better is finding allies and forming alliances. We need to up the game on how we improve influence in local authorities, where decisions are being made.’

A positive sign is the willingness of police and crime and commissioners (PCCs) to join the conversation. A recent meeting of the Drugs, Alcohol and Criminal Justice Cross-Party Parliamentary Group heard from four PCCs keen to declare that ‘our approach to drugs is failing’ and find an effective, evidence-based way forward. (DDN, April, page 6). ‘By joining up with different groups, we can make positive steps in the right direction,’ said Derbyshire PCC, Hardyal Dhindsa.

Vital to the debate are those who use services, and Hames is among many who see the value of a ‘strong and equipped service user voice’. ‘We need to create a strong service user movement in this country,’ he says. ‘If we lock in this powerful movement, we have a chance of fighting cuts.’

With less time and fewer resources, it can be difficult to make time for debate. A comment at the National Substance Misuse conference, from a worker at a homeless service, could serve as a reminder that a little action can go a long way: ‘We had a grown man cry because we gave him underwear,’ he said.

This article has been produced with support from an educational grant provided by Camurus, which has not influenced the content in any way.

Cannabis becomes legal in Canada

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DDN
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Adults in Canada are now able to legally buy and possess up to 30g of dried cannabis or its equivalent from authorised retailers across the country. After ‘extensive consultation’ with law enforcement agencies and health organisations, the Canadian government has implemented its legal framework to legalise and regulate access to the drug.

Adults in Canada are now able to legally buy and possess up to 30g of dried cannabis.

The legislation, which was first announced at the UNGASS in New York in 2016 (DDN, May 2016, page 4), aims to ‘keep profits from going into the pockets of criminal organisations and street gangs’, says the government, and makes Canada the second – and largest – country to legalise the drug after Uruguay (DDN, May 2017, page 4). ‘The old approach to cannabis did not work,’ the government states. ‘It let criminals and organised crime profit, while failing to keep cannabis out of the hands of Canadian youth. In many cases, it has been easier for our kids to buy cannabis than cigarettes.’

While the Cannabis Act means that possession of small amounts of the drug is no longer against the law, the government has created a new criminal offence making it illegal to sell cannabis to a minor and has ‘added significant penalties for those who engage young Canadians in cannabis-related offences’. It has also toughened laws relating to drink- and drug-impaired driving.

People need to be 18 – or 19, depending on the territory – to legally buy, possess or use cannabis, with legal drugs displaying an excise stamp on the product label. However, anyone either bringing cannabis or cannabis products into – or taking them out of – the country still risks ‘serious criminal penalties’, the government states, including if the drug is being used for medical purposes. Central and provincial government will also continue a programme of public education about the new legal framework, as well as responsible use, health and safety, and the dangers of drug-impaired driving.

New criminal offences have been added making it illegal to sell cannabis to a minor.

‘The implementation of this progressive public policy marks an important shift in our country’s approach to cannabis,’ said justice minister and attorney general, Jody Wilson-Raybould. ‘With a strictly regulated market for adults we will help keep cannabis out of the hands of youth and profits out of the pockets of criminals. Along with new laws and regulations on cannabis, our government has also implemented stronger laws on drug- and alcohol-impaired driving. I am very proud that Canada now has one of the toughest impaired driving regimes in the world.’

‘While we still have a lot of work to do, we are confident that the more than two years of work that went into this process have resulted in legislation that will help us achieve our public health and safety objectives,’ added border security minister Bill Blair.

Time to publish ‘evidence based’ alcohol strategy, government told

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DDN
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A new government alcohol strategy needs to ‘lead the way internationally’ in reducing the damage caused by alcohol misuse, according to a document from the Drugs, Alcohol and Justice Cross Party Parliamentary Group and the All Party Parliamentary Group (APPG) on Alcohol Harm.

The Alcohol Charter – which is published in consultation with Alcohol Concern, Alcohol Research UK, the Institute for Alcohol Studies and the Alcohol Health Alliance, and backed by 30 other organisations including Cancer Research, Blenheim and Adfam – says a new strategy is essential to protect public health, improve support and address alcohol-related crime.

Liver disease is now the only major cause of death that is rising in the UK

It wants to see the government ‘outline concrete measures’ to moderate harmful drinking and address England’s million-plus annual alcohol-related hospital admissions. Without action, alcohol is set to cost the NHS £17bn over the next five years and lead to 135,000 cancer deaths over the next 20, it states.

An effective alcohol strategy will need to tackle the increased availability of cheap alcohol, provide proper support for dependent and non-dependent drinkers, and ‘empower the public to make fully informed decisions’ about consumption. It should also be based on the ‘evidence of what works to reduce alcohol harm, as outlined in the PHE alcohol evidence review’, it says. [DDN’s report on the PHE review is here.]

Among the specific measures called for are the introduction of minimum pricing ‘following the lead of other home nations’, adding a 1 per cent levy to alcohol duties to fund treatment, and mandating local councils to provide a ring-fenced resource for treatment and early intervention services. Councils also need to address the issue of age inequalities in existing services and provide adequate provision for people with complex needs, it stresses.

The charter also calls for statutory minimum requirements for labelling, including health warnings, tighter restrictions on marketing – also enforced by statutory regulation – and a government-funded programme of health campaigns ‘without industry involvement’. PHE’s recent partnership with Drinkaware for the ‘Drink Free Days’ campaign proved controversial and led to the resignation of Professor Sir Ian Gilmore as co-chair of PHE’s alcohol leadership board (DDN, October, page 5).

‘With dozens of alcohol-related deaths across the UK every day, we decided that rather than wait ages for the government’s alcohol strategy, we should promote a programme of actions which could reduce harm levels dramatically,’ said co-chair of the Drugs, Alcohol & Justice Cross-Party Parliamentary Group, Mary Glindon MP.

‘This Alcohol Charter is an important document which outlines many policies that the AHA has been calling for,’ added Prof Gilmore in his capacity as Alcohol Health Alliance (AHA) chair. ‘The government needs to ensure that the upcoming alcohol strategy includes evidence-based policies which work to reduce alcohol harm and tackle the increased availability of super cheap alcohol. The best ways to do that are by introducing minimum unit pricing in England – which we already have in Scotland and will soon have in Wales – and increasing alcohol duty.’

Alcohol charter available here

Racial disparity in stop and search increasing, says report

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DDN
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Black people are nine times more likely to be stopped and searched for drugs in England and Wales than white people, according to a new report from Release, Stopwatch and the London School of Economics and Political Science. While the use of stop and search overall has fallen significantly there has been a ‘shocking increase in racial disparities in the policing and prosecution of drug offences’, says The colour of injustice: ‘race’, drugs and law enforcement in England and Wales.

Drugs searches account for 60 per cent of stop and searches, says the document, although in some areas the figure is far higher – more than 80 per cent of searches by Merseyside Police in 2016-17 were for drugs. In 2010-11 black people were six times more likely to be stopped and searched than white people (DDN, September 2013, page 4), and while this rate has now increased still further, black people use fewer drugs than white people, the report states. In 2016-17 every police force in England and Wales stopped and searched black people at a higher rate than white people.

Black people are also treated more harshly when found in possession of drugs, the report continues. While the detection rate for stop and search is similar for all ethnic groups, black people are arrested at a higher rate and given out of court disposals at a lower rate. Stop and search-related drug arrests fell by 52 per cent for white people between 2010-11 and 2016-17, however for black people they remained unchanged.

Much of the disparity in prosecution and sentencing is driven by cannabis possession, with convictions for black and Asian people at 11.8 and 2.4 times the rate for white people respectively, despite ‘lower rates of self-reported cannabis use’. Police forces are ‘making operational decisions to target low-level drug possession offences over other, more serious, offences’, it adds.

‘Not only are black people being discriminated against in the use of stop and search but they are being prosecuted at a much higher rate than white people for possession offences, especially in relation to cannabis,’ said co-author of the report, Zoe Carre. ‘This is an appalling indictment of the criminal justice system, which is acting as a conveyer belt for the criminalisation of young black people for low level offending, whilst treating white people more leniently for the same offences.’

‘If Theresa May is serious about tackling racial disparity in the criminal justice system then she has to address drug law enforcement, which she has abjectly failed to do,’ added Release executive director Niamh Eastwood. ‘As our report shows police forces in some parts of the country are implementing innovative diversion programmes for those caught in possession of drugs – this should be rolled out nationally to prevent the over-criminalisation of young black men.’

Read the report here

Prisoners dying ‘preventable deaths’ because of NPS, says ombudsman

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DDN
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Prisoners are dying ‘preventable deaths – particularly as a result of the alarming levels of drug abuse in jails’, says the annual report of the prisons and probation ombudsman. Acting ombudsman Elizabeth Moody said she was ‘gravely concerned’ at the destructive impact of NPS, with some prisons and their health providers ‘struggling to learn’ from investigations into deaths.

There continues to be ‘significant’ numbers of deaths where illicit drug use has played a role, says the report. These include ‘accidental or deliberate overdoses, suicides precipitated by drug-related mood changes or in response to drug-related debts and bullying, and heart attacks and respiratory failure in apparently fit individuals’.

While ‘all kinds’ of drugs were involved, the ‘destructive epidemic’ of NPS is now the ‘new normal’ in prisons, it states. Prisons often struggle with the consequences of ‘bad batches’ of NPS which can result in ‘simultaneous multiple collapses of prisoners, unsustainable demand on prison resources, ambulances queuing up at the prison gate and, all too often, death’.

The ease with which prisoners are able to obtain drugs in prison is ‘truly alarming’, the document adds. ‘A further concern is that staff too often tell us that they had no idea a prisoner was using illicit drugs before he was found dead in his cell.’

Prisons have been left to develop their own local strategies to cope with NPS ‘as best they can’ in a piecemeal fashion, it states. ‘Some are doing everything they can, some are trying but struggling, and others appear to have given up. In our view this is another area where there is an urgent need for a properly resourced national strategy, involving other agencies such as the police and healthcare providers, to reduce supply and demand.’

Earlier this year the prison service took over the running of HMP Birmingham from G4S after inspectors found the highest levels of violence of any local prison and an estimated one third of prisoners using illegal drugs (DDN, September, page 5).

Prisons & probation ombudsman annual report 2017-18 available here

Fighting for a C change

By
DDN
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A once-in-a-lifetime opportunity to finally eliminate hepatitis C is within our grasp, says Professor Ashley Brown.

Read the full article in October DDN Magazine

Prof Ashley Brown is vice chair of the Hepatitis C Coalition and hepatitis C lead for North West London

When I first graduated in medicine, hepatitis C didn’t even have a name, let alone a cure. The clinical condition characterised by low-level inflammation leading to liver fibrosis, and in some cases to cirrhosis, liver failure and liver cancer, was known as ‘non-A-non-B hepatitis’. Once the virus had finally been isolated and identified in the late 1980s, it acquired a catchier name, joining the alphabet of viral hepatitides as hepatitis C (HCV). In the 30 years since I began practising, the shift from this earlier era of ignorance to the current possibility for elimination has been unprecedented in the history of medicine.

Hepatitis C is a blood-borne virus, meaning that it is transmitted through blood-to-blood contact, such as getting a tattoo with an unclean needle or receiving treatment in a country or environment where inadequately sterilised medical or dental equipment is reused. An estimated 4,000 haemophiliacs in the UK were infected with HCV when they received contaminated blood products prior to the initiation of screening blood donations in 1991. But the most common method of transmission in the UK today is through the sharing of needles and other drug paraphernalia. 

It has been estimated that around half of all people who inject drugs (PWIDs) have been exposed to the virus at some point. Because of the social stigma and legal issues surrounding drug use, hepatitis C brings with it a raft of shame, ignorance, and fear. Many people resist testing because they don’t want to be ‘in the system’, while others experience no symptoms so feel there is no hurry to test. Sadly a stigma exists that rivals HIV in the 1980s, which we need to dispel so that people are less fearful about finding out their HCV status.

In the early years of attempting to treat this virus, clinicians believed that by boosting the immune system with very high doses of interferon – a substance produced naturally in response to viral infections – HCV infection could be overcome. This early treatment was successful in beating the virus in between 30 and 60 per cent of cases, but this limited success came at a high price. The flu-like side effects were deeply unpleasant and often intolerable, and the treatment could also trigger depression and exacerbate other mental health issues. Worse still, the drug had to be injected, a major deterrent for many recovering drug users. This meant that many people at risk refused even to test for HCV, let alone contemplate treatment.

Thankfully we have moved on from the dark days of interferon-based treatments to an era where cure is not just possible but highly probable. A pharmaceutical revolution has resulted in the development of a whole range of highly effective drugs called direct-acting antivirals (DAAs) that target the virus directly, with minimal side effects, and can cure it in more than 95 per cent of cases.  

These incredible medicines provide us with an opportunity to eliminate HCV as a public health concern. The challenge has already been laid down by NHS England, which announced earlier this year that it was aiming to make England the first country in the world to eliminate hepatitis C by 2025 – a full five years ahead of the World Health Organization (WHO) global target.

However, two major obstacles remain in our way. Firstly, since the majority of people living with HCV are unaware of their infection we need to ensure that all those who may be at risk are given appropriate information and offered testing and pathways into treatment. Secondly, there are many who have been diagnosed but due to lifestyle, stigma or ignorance of advances in treatment have disengaged from treatment services.
To overcome the first obstacle we need to understand that hepatitis C is a disease of vulnerable people who might lead chaotic lifestyles, which means testing and treatment must be available where these groups access care – not only in hospitals and GP surgeries but homeless shelters, needle exchanges, sexual health clinics, pharmacies and amongst the prison population.

We know from peer-to-peer conversations that out-of-date misinformation about diagnosis and treatment persists, dissuading those who would benefit from treatment from coming forward to receive it. All healthcare professionals therefore need to make it clear that the days of the brutal interferon treatments are over, and that simple, short, well-tolerated oral drug combinations are available to all.

In order to overcome the second we need to radically reconfigure existing HCV treatment services. Commissioners need to be asking about HCV treatment delivery in their area, and we have to accept that many who need treatment will simply not conform to classical care pathways. New treatments are straightforward to take and can be delivered effectively in the community, and those who have adapted are already seeing the benefits in terms of increased treatment numbers and patient satisfaction.

Here in West London I am fortunate to work with a team people who are proactive and committed, and prepared to go beyond the normal call of duty. My specialist nurses already offer counselling, testing and treatment in a whole range of locations including drug and alcohol services, sexual health clinics, homeless hostels, needle/syringe exchanges and mental health facilities. One consultant colleague is offering clinics in a GP surgery that caters to marginalised communities and another is piloting a scheme for point-of-care testing in community pharmacies.

Along with my PhD fellow I have established an in-reach service at the local prison, HMP Wormwood Scrubs, and while it has taken some time to navigate the prison bureaucracy the service is already paying dividends with increasing numbers of prisoners accessing treatment. Additionally, I am working hard to reconnect with patients who have fallen out of contact with services.

While NHS England and Public Health England quite rightly focus on the statistics – already we have seen a significant decrease in the demand for liver transplant for HCV and hospital admissions due to HCV-related liver failure – what drives those of us who work on the ground is the individual human benefit that each and every patient derives from treatment. The physical and psychological benefit of clearing a virus that can potentially lead to cancer or premature death is immeasurable, as are the benefits to society of a healthier, happier workforce. The walls of our clinics are covered with ‘Thank You’ cards from grateful patients – one that brought a tear to my eye was from a young girl who simply said ‘Thank you for giving me my Grandpa back.’

The transformation of HCV from an unknown virus to potential global elimination within a single career lifetime is truly a one-off event, and the possibility for a genuine public health success story remains within our grasp. But this will only be achieved by education of public and professionals alike, and a willingness from all parties to adapt. With your help, I hope we can put this ‘silent killer’ to bed before I collect my pension.

Giving the best chance

By
DDN
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This year’s NHSSMPA conference was dedicated to creating lasting behaviour change, as DDN reports.

Read the full report in October’s DDN Magazine

‘How can we give the best chance of long-term behavioural change?’ This was the question 13 NHS trusts gathered to discuss at the NHS Substance Misuse Providers Association (NHSSMPA) conference in London.

The context for this debate was not easy, said NHSSMPA chair Danny Hames. There were many challenges – loss of expertise, disinvestment and diminishing resources, and increasing needs from all areas of the population.

NHSSMPA chair Danny Hames

‘As a sector we really need to think about how we do stuff and the quality of what we do,’ he said. While the sector had ‘held up pretty well’ against recession, we should not be measuring success by successful completions.

We needed to address the critical loss of expertise right the way through the workforce – from addiction psychiatrists, to recovery workers, to commissioners. Add to this the loss of many small valuable organisations and it gave a ‘bleak picture’ and many separate challenges. ‘We need to up the ante and be more dynamic,’ he said. We had lost ‘vital capital’ so we needed to understand how to use investment to the best effect.

‘One of the things we could be doing better is finding allies and forming alliances,’ he suggested. We needed to think about how we worked with commissioners, improved influence in local authorities, and sought out meaningful partnerships with service users. Our culture should focus on being transparent – making the effort to understand where risk is, focusing on evidence and ‘sharing what works more openly’.

Cutting the numbers of specialists was a backward step, agreed Dr Luke Mitcheson, a consultant clinical psychologist at South Maudsley NHS Foundation Trust, who said that the loss of clinical psychologists was one of the biggest challenges faced by the sector.

Luke Mitcheson and Danny Hames take questions at the NHSSMPA Conference

Psychosocial interventions (PSI) contributed significantly to positive treatment outcomes, but delivering them effectively depended on highly trained staff and good governance, he said. Cutting down on the level of supervision and on skills such as motivational interviewing undermined our capacity to use PSI effectively.

Many clients had experienced trauma and abuse – in fact ‘we should start from the premise that clients have trauma,’ he suggested. The skills to deal with this had to go hand in hand with a flexible approach – the capacity to do different things at different times and ‘step things up or down’.

It was important to keep the perspective of delivering PSI as part of an integrated service that included opioid substitution treatment (OST) and other harm reduction initiatives, said Mitcheson. ‘Some recovery services don’t understand harm reduction, and that’s a problem.’

Another major challenge was the ever-changing drugs market – how was the sector meant to keep abreast of new information? Since 2009 there had been 803 new substances identified by the UN, said Dr Dima Abdulrahim, of the Central and North West London NHS Foundation Trust. She was the main author of guidance for NEPTUNE – the Novel Psychoactive Treatment UK Network – which had been developed to improve knowledge around club drugs and NPS and was funded by the Health Foundation.

Many clinicians lacked confidence in dealing with the rapid growth in new substances, she explained. A panel of experts, including experts by experience, had developed a system to simplify guidance to new drugs by categorising them into stimulants, depressants, hallucinogens and synthetic cannabinoids. This framework had proved effective in helping clinicians to orientate themselves when they came across a drug they were not familiar with.

More than 70,000 downloads over the past two years had confirmed the need for this information, leading to an e-learning course evaluated by the Royal College of Psychiatrists, to disseminate the information more widely. As well as increasing their knowledge, participants had reported improvements in their confidence and morale through being able to identify NPS.

Another area of the sector where information and support were needed urgently was for problematic gambling, and Dr Henrietta Bowden-Jones shared her expertise as a doctor, neuroscience researcher and founder/director of the National Problem Gambling Clinic. With half a million problem gamblers and 2m people at risk, there were ‘many organic reasons why people gamble,’ she said. ‘It’s not all about the bookmaker around the corner.

‘Gambling was something I came across by chance in my research on alcohol dependency and I became obsessed with understanding the illness,’ she explained. People used to wait years to come forward, but it was now becoming recognised as a condition to be treated.

‘Most people will walk away from a table when they are losing,’ she said, describing the pattern of behaviour that could become a preoccupation from first thing in the morning and escalate into lies and deceit.

Cognitive Behavioural Therapy (CBT) was being used to treat gambling – very successfully in many cases. For those who didn’t respond to CBT, naltrexone (as used to reduce cravings for alcohol) had been trialled successfully. Bowden-Jones had written guidelines on naltrexone and found that it ‘gives an opportunity’ if CBT had been ineffective.

The National Problem Gambling Clinic was the only multidisciplinary treatment centre in the UK for problem gambling and had been inundated with referrals since opening ten years ago. With a gambling culture that was rife – including in prisons, where inmates could inherit a bunk with debts – NHS England really needed to take the problem on board, she said.

Another extremely valuable – and under-used resource – was families, according to Vivienne Evans OBE, chief executive of the national support service Adfam. There was still a culture of seeing family members as part of a patient’s problems, but in fact they could be agents for change, she explained.

Commissioning family support should also be viewed as an investment – Vivienne Evans Chief Executive, Adfam

Commissioning family support should also be viewed as an investment, rather than an ‘add on’ to recovery services. The effects of substance misuse were a high factor in incidents of domestic violence, family break-up and divorce so it made sense to commission strategically: ‘They should be seen as more than supporting an individual’s recovery and receive the support they deserve in their own right,’ she said.

Throughout the conference there had been frequent mention of the need to harness the power of service user involvement – in his opening speech Danny Hames talked about the value of a ‘strong and equipped service user voice’.

In the final session Rob Eyres, founder of the Telford After Care Team (TACT), demonstrated what that could mean. Caught up in a destructive cycle of drug dealing and addiction, he served time in young offenders’ units and then prison. He carried on using drugs and drink after he was released, right through his relationship and break-up of his family, until a new key-worker confronted him with the responsibility of changing his attitude to his addiction, telling him ‘it’s your addiction – I’m here to support you’.

Rob Eyres, founder of the Telford After Care Team (TACT)

Committing himself to treatment (which involved a subutex script) Eyers discovered the support of SMART Recovery meetings, then decided to begin his own support group. He rented a room in a leisure centre and for 12 weeks no one came – ‘the cleaner used to hoover around me’. Then people started to join him and when the group began to become more established, they began a gardening project, alongside regular meetings.

Seven years on, their blossoming project had its own premises and works on four NHS projects, running social enterprises that include a café, a landscape gardening company and a printing business. With 28 full-time staff and more than 40 volunteers, they had around 100 people accessing their services each day.

The peer support was an essential element; staff all formerly had problematic substance use and now worked with people at all stages of recovery. ‘If people turn up and are intoxicated, we will talk to them and get them to come tomorrow and try again,’ said Eyres. ‘We don’t turn people away – it’s a recovery centre, not a recovered centre.’

 

The space to grow

By
DDN
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Far away from the usual distractions, Kenward’s residents are given the chance of a new start. DDN reports.

Read the full article in October’s DDN Magazine

Turning away from the traffic of Maidstone, you take the narrowest and windiest of lanes and the longest and stoniest of drives until a vast Georgian mansion appears before you. This is the sight that confronted Wayne Smythe as he arrived at Kenward – just 30-odd miles but a whole other world away from his home in Plumstead, south London.

Wayne Smythe’s struggle was with alcohol, and he had ‘died from it twice’.

Fresh out of detox in November 2017, he was given three options by the drug and alcohol team who sorted out his funding – the first on the list was Kenward. ‘I said, I’m going there. It’s right in the middle of nowhere – you’ve got a long walk to the shops. You’ve got a long time to think what you’re doing,’ he says.

Wayne’s struggle was with alcohol, and he had ‘died from it twice’. A year earlier, in the run-up to Christmas, ‘they gave me five days to live,’ he says. ‘It was my last chance. Basically, I can’t pick up another drink, and if I do I’m six foot under.’

After ’32 years of the drink’ (he’s nearly 42 now), he had to learn to walk again, to speak properly, and to write. ‘I was writing like a four-year-old,’ he says, ‘so I’ve had to rebuild myself.’

Still wobbly – he had been walking with a zimmer frame until three weeks before – he arrived at Kenward, finally realising he needed help. ‘I tried to do it my way and couldn’t,’ he says. ‘When I arrived, I wanted to get back out drinking again, but I forced myself to stay there – and I’m glad I did.’

The first week was all about survival – ‘I was just taking five minutes at a time.’ After a week, he felt like he had stabilised a little bit, ‘I was still falling asleep in every group – I just couldn’t stay awake. I was still listening, but I was drifting off. They were very tolerant and helped me through that.’

He was grateful that Kenward ‘took me at my own pace’. ‘Sometimes I wanted to be on my own, but it was nice to interact with other people on the same sort of level,’ he says. ‘It was very difficult at first, because I didn’t know what to do or what normal life was like.’

One-to-one sessions were mixed with therapy in a group with people at different stages of their recovery. In the early stages, he needed help with every move, ‘because I was incapable of making my own decisions’. But as he settled into his three-month programme, he began to explore his surroundings and his options for activities.

Kenward’s residents have the opportunity to work in a social enterprise three days a week, maintaining the beautiful gardens, tending the animals – including a very friendly group of alpacas – making arts and crafts in the workshop, restoring furniture or working in the onsite Sage and Time Café.

The workshop, one of Kenward’s many social enterprises.

‘I knew skills – I was a builder – and when I started to come round and get my brain into action, I was helping out with the enterprise,’ says Wayne. The talking and the recovery continued alongside his work. ‘They were inspiring me to open up a bit more than I was used to,’ he says. ‘They were encouraging me to do that.’ His knowledge and skills were perfect for contributing to the vast Georgian house’s refurbishment, and gave him much-needed confidence. ‘You start to rebuild your life,’ he says.

Since February Wayne has been living in a ‘dry house’ – a part of Kenward’s move-on accommodation – where he is doing the garden and some paintwork, while preparing for stage three. When the year’s up next February, he will move across the road and be supported for another two years in his transition back to the wider community. In the move-on house, ‘you’re mainly left to your own devices’ but have the support of other residents and can attend regular groups. There’s also professional support on hand ‘if ever you need it’.

Looking back, Wayne cannot believe how far he has come and is filled with gratitude to those who helped him. ‘What I was like last year, to what I am now, is complete change,’ he says. ‘When I look back at pictures of me in hospital… I hope my story helps someone else out.’

*************

‘We’re all part of the enterprise’

‘We’ve been a therapeutic community since May,’ says Penny Williams, Kenward’s chief executive, who only came to the role in May. Before that she was the charity’s director of marketing and communications, so when she began her new job she was excited about developing the social enterprise.

Penny Williams – Chief Executive of Kenward

‘Residents become part of the enterprise, developing their confidence, expressing themselves and learning skills,’ she says. For Kenward it means an opportunity to harness talent, to help the organisation to thrive.

Creating Kenward Enterprises Ltd as a separate company has given scope to run a business, using all the assets of a beautiful location. They run the café and are expanding their events programme. They have the perfect backdrop for exclusive events and hope to become a dry wedding venue in the near future.

‘We want to develop more activities – classic car rallies, zip wires, woodland walks – and get more animals such as donkeys,’ she says, stretching her arm towards the grounds beyond the alpaca enclosure. She is excited about the business opportunities, which go hand in hand with plans to develop accommodation at the house.

As well as a female move-on house, she talks about a homeless project using onsite accommodation and partnering with an organisation in Maidstone, where these clients would receive support. Alongside this she is ‘starting to do partnerships with business’ and is excited about the future.

She has had her own journey – coming to Kenward was her ‘starting point’ in recovering from cancer. Now, just as so many of her residents are, she feels full of possibilities. ‘There are so many opportunities here,’ she says, as she takes her leave to investigate the next.

Opening new doors

By
DDN
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After running for 25 years in Glasgow, Phoenix Futures’ Scottish residential service has moved to a new home within the city.

Read the full article in October’s DDN Magazine

‘Our Scottish residential service holds a very dear place in our hearts’, says Phoenix Futures’ chief executive Karen Biggs. ‘For thousands of people it’s where their recovery began.’ But the changing needs of service users and a desire to create a fully accessible building meant it was time to move to new premises.

‘Our Scottish residential service holds a very dear place in our hearts’, says Phoenix Futures’ chief executive Karen Biggs.

The service houses one of the only therapeutic communities in Scotland. It operates on a peer-led model, with members taking ownership of the whole community’s recovery plans.

The staff at the house try not to interfere, but have a structure in place that works well to ensure a harmonious environment.

The community’s inclusive model runs right through all aspects of day-to-day life, with members taking charge of cooking, cleaning, and tending the garden. Residents have also been involved in designing the house, right down to choosing the wallpaper and colour schemes – ‘which has made sure the service has a personality that reflects the people who will use it,’ says Biggs.

Offering both three- and six-month programmes, the service works with community members through three distinct stages. The first stage in the welcome house is about establishing a commitment to the programme and a desire for long-term recovery. After this, residents move to the main house for the primary stage, which involves members telling their stories.

Residents have also been involved in designing the house.

‘This is a big part of the programme,’ says head of house, David Brockett. People are more often than not revealing traumatic experiences that have had a direct impact on their lives and their using. This process is a chance for people to begin to develop self-acceptance and, through peer-support, ‘start to feel a bit of love’, he says.

When they are ready, residents move on to a senior stage that gradually reintroduces them to life in the wider community. They take part in in-house courses, while also being expected to commit to at least 16 hours a week attending college or volunteering projects outside of the house. It’s a very gradual process, with the emphasis on staying safe and moving towards employment and independent living, at the right pace for them.

Once residents have completed the programme they can either return home – or as many of the members are from Glasgow, they go on to rebuild their lives within the city. The service works closely with local housing associations, some of whom have property in areas needing regeneration.

Many of these see graduates of the service as very desirable tenants. ‘They like abstinent guys who want to be involved in the community, and get involved in local volunteering projects and groups,’ says Brockett. Around the city, mini Phoenix projects are sprouting up where former residents are able to make positive changes in the wider community.

Having the new premises has meant the service has been able to help even more people and since it opened in the spring, referrals have increased. ‘It’s a funny feeling, but sometimes I would be angry that the old building was holding us back,’ says Brockett. ‘This new building allows us to offer services to people we couldn’t reach before.’

Adios Recovery Riviera?

By
DDN
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Why are we sending people miles away to rehab instead of supporting them to survive in their own community, asks Mark Gilman.

Read the full article in October’s DDN Magazine

In his 2017 book Poverty Safari, Darren McGarvey explains how stress is often the engine room that fuels addictions and mental health issues: ‘For those living in poor social conditions, stress is all consuming; it’s the soup everyone is swimming in all the time.’

Mark Gilman is managing director of Discovering Health, www.discoveringhealth.co.uk

So, why is it a bad thing to be sent 300 miles away from home for a mental health issue, but a good thing for someone with a substance use disorder?

People with a substance use disorder (addiction) are still sent out of area to residential rehabilitation. I had never heard about residential rehabilitation until 1984 when I was interviewing young heroin users in the North of England. I knew a lot about drugs and had been using them myself since my first encounter with benzodiazepines in 1969 at the age of 12. Until 1995, I had known many people who had died from drugs (barbiturates and opioids) but I had never seen anyone ‘recover’ from ‘addiction’.

In September 1985, I was employed by Lifeline as the manager of one of the first community drugs teams in Trafford, Greater Manchester. I never understood the fixation on sending people away to residential rehabilitation. Some of the rationale included getting the ‘client’ away from ‘triggers’ in the places where their problems had originated. I didn’t get this because by then I had started to develop my own alcohol problem. As I sat watching TV during one of my countless DIY detoxes, I had to sit through alcohol adverts.

I had to walk past pubs, shivering and knowing that I had the money to go in and order a large brandy and port and a pint of stout (my favourite morning tipple). I could never understand why ‘addicts’ had to be sent away, out of area, to residential rehabilitation while ‘alcoholics’ like me (I never admitted this till 1995) were sent to the local psychiatric hospital for a detox and then sent home.

My perspective has been tainted by the fact that I have always lived in Bury (apart from a brief exile in Bradford and now in Burnley) and mix with people I grew up with on an almost daily basis. When I first sought help for my own alcohol problem it never even occurred to me to go anywhere other than 12-step mutual aid. I knew some real alcoholics (who I had drunk with) who had stopped drinking by going to Alcoholics Anonymous (AA). Residential rehabilitation, if discussed at all, was dismissed as a bizarre joke, but AA was treated with a degree of respect because people had seen the change in people like ‘Terry from Bury’.

Fast forward to 7 September 2018 and I am sat in the audience at the recovery conference and I hear David Best talking about building recovery communities by connecting people to hope. He seems to say, or I choose to hear him say, that sending people out of area to residential treatment is harmful because it doesn’t add to the local therapeutic landscape. I get excited and start to tweet. In my haste to tell the world that one of our leading, bone fide academics on recovery is presenting evidence that says ‘keep it local’ I fear I may have over egged the pudding. If I have, I want to publicly apologise to David Best for misquoting him.

However, I do want to state, for the record, that I certainly think that if people do need residential detoxification and residential rehabilitation they should stay as near to home as they can. We do recover and we can get well where we got sick. When we are ‘recovered’ or ‘in recovery’ and walk through our local shopping centres, people who know us, who drank and used with us but are stuck in the madness see us and they can connect to hope. They can’t do this if they are recovering 300 miles away on the Recovery Riviera.

Finally, I want to dedicate this rant to ‘Terry from Bury’ who planted a seed of hope in me that grew roots and 23 years later sprouted, and gave me a life beyond my wildest dreams.

 

 

‘We’re in danger of undervaluing vital healthcare’

By
DDN
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Personal stories are the essence of DDN. They speak volumes about good (and bad) practice and they also serve to inspire; and that’s vitally important in the land of diminishing resources.

Many of the people we speak to about their experience of treatment have a debt of gratitude that inspires them to share their story. Wayne (page 16) and Tony Adams the footballer (page 20) both fought a dangerous battle with alcohol. It’s unlikely they would be around to tell the tale if they hadn’t experienced the right intervention at that pivotal moment.

Sharon’s story (page 22) demonstrates what can happen when chances are missed – an all-too-likely scenario when services do not stretch around complex needs. If we’re serious about getting the best for our patients and service users, every stakeholder needs to be around the table. We’re turning a blind eye to processes that don’t work (page 10) and are in danger of undervaluing vital healthcare in our haste to run services to one ‘cost-effective’ template (see the letter on shared care, page 12).

Any straightforward opportunity to save lives should be an obvious move (page 6), and we hope that our hepatitis C supplement will contribute to this important public health initiative – visit our website to share the pdf and order free printed copies. Let’s all do our bit to make hep C elimination a reality.

Claire Brown, editor

Read it online as a PDF or virtual magazine.

Your letters, comments, suggestions and feedback are always welcome. Email the editor through this link, join in our Facebook page, or tweet us @DDNMagazine

DDN is a free magazine – please help us to keep our circulation up to date! Email subs@cjwellings.com to make any changes to your subscription.

 England sees ‘sharp decline’ in youth drinking

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DDN
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The last 15 years have seen a ‘sharp decline’ in drinking levels among young people in England, according to a new report from the University of Sheffield’s Alcohol Research Group. Young people are now ‘less likely to drink and, if they do drink, they start doing so later, drink less often and consume smaller amounts’, it says.

A decline in youth drinking raises questions for alcohol policy.

The study – which was funded by the Wellcome Trust – looked at age groups from 8-24 and found a ‘consistent pattern’ of reduced participation in drinking and consumption levels, and ‘less positive attitudes’ towards alcohol.

The proportion of 11-15 year-olds who had consumed a full alcoholic drink fell from 61 to 44 per cent between 2002 and 2016, while the proportion of 8-12 year-olds fell from 25 to 4 per cent. The proportion of 16-17 year-olds who had drunk over the previous year also fell from 88 to 65 per cent between 2001 and 2016, and among 16-24 year-olds the proportion fell from 90 to 78 per cent.

Young people who do drink are also drinking less, and less often, says the document, with the proportion of 16-24 year-olds who had drunk in the last week falling from 76 to 60 per cent between 2002 and 2016, with a fall from 35 to 9 per cent among 11-15 year-olds.

‘It may be that increases in internet use and online gaming are changing the way young people spend their leisure time,’ said lead author Dr Melissa Oldham. ‘Economic factors may also play a role – concern about increasing university tuition fees and the cost of housing means young people feel they have less disposable income to spend on alcohol.’

The decline in youth drinking raises ‘important questions about the direction of future alcohol policy’, says the report. ‘For example, will future youth drinking be spread across society or concentrated in specific high-risk groups, do the policy platforms of public, private and third sector organisations require updating and are new interventions needed to reinforce and perpetuate the positive trends? To date, there has been little public debate on these questions.’

Meanwhile the Welsh Government has launched a consultation on its proposed minimum unit price of 50p. The Public Health (Minimum Price for Alcohol) (Wales) Act 2018 was passed the country’s National Assembly in June, received Royal Assent in August (DDN, September, page 5), and is set to come into force next summer.

The aim of the law was to protect the health of ‘hazardous and harmful drinkers’ who consume larger quantities of low-cost, high-strength products, said health secretary Vaughan Gething. ‘The higher the level of MUP that is chosen, the greater the proportion of purchased alcohol that is captured and the greater the estimated impact on alcohol-related harms. However, there is a trade-off, as there is also a greater impact on moderate drinkers, particularly moderate drinkers in the more deprived groups.’

Youth drinking in decline – report here

Consultation here

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One in 20 global deaths caused by alcohol, says WHO

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DDN
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More than 3m people died as a result of harmful alcohol use in 2016, according to the World Health Organization (WHO), representing one in 20 deaths worldwide. More than three quarters of those who died were men, with alcohol now responsible for more than 5 per cent of the global disease burden.

It’s claimed that fewer than 10 per cent of alcohol labels in the UK carry the government’s current 14 units per week guidelines.

Despite some ‘positive global trends’, the overall burden of disease and injuries caused by alcohol is ‘unacceptably high’, particularly in Europe and the Americas, says Global status report on alcohol and health 2018. Of all the deaths attributable to alcohol, 28 per cent were the result of injuries – including traffic accidents and violence – while 21 per cent were due to digestive disorders, 19 per cent to cardiovascular diseases and the remainder the result of cancers, infectious diseases, mental health disorders and other health conditions.

Globally, an estimated 2.3bn people are current drinkers, with 237m men and 46m women suffering from alcohol use disorders. These are most common in high-income countries, with prevalence rates of 14.8 and 3.5 per cent for men and women respectively in the European region and 11.5 and 5.1 per cent in the region of the Americas. Although drinking levels in Europe have been falling since the start of the decade, the region still has the highest per capita consumption in the world.

Worldwide, 45 per cent of total recorded alcohol consumption is in the form of spirits, 34 per cent beer and 12 per cent wine, with the average consumption among those who drink standing at 33 grams of pure alcohol per day, the equivalent of two 150ml glasses of wine.

‘All countries can do much more to reduce the health and social costs of the harmful use of alcohol,’ said coordinator of WHO’s management of substance abuse unit, Dr Vladimir Poznyak. ‘Proven, cost-effective actions include increasing taxes on alcoholic drinks, bans or restrictions on alcohol advertising, and restricting the physical availability of alcohol.’

Meanwhile, a new study by the Alcohol Health Alliance (AHA) claims that fewer than 10 per cent of alcohol labels in the UK carry the government’s current 14 units per week guidelines. A review of 320 labels in 12 locations across the country found that most products displayed out of date guidelines and carried no health warnings.

‘Once again we see that the alcohol industry cannot be trusted to provide the public with health information,’ said AHA chair Professor Sir Ian Gilmore. ‘We all have the right to know what we are drinking and the fact that alcohol increases our risk of seven types of cancer, liver disease, heart disease and stroke. Few of us know or understand these risks or are aware of the CMO’s advice.’

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