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PHE alcohol adviser resigns over industry partnership

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Prof Sir Ian Gilmore: This is a clear conflict of interest.

The co-chair of Public Health England’s (PHE) alcohol leadership board has resigned over the agency’s partnership with industry-funded Drinkaware for its new ‘Drink Free Days’ campaign. Professor Sir Ian Gilmore, who is also chair of the Alcohol Health Alliance, had previously expressed objections to the partnership, citing a ‘clear conflict of interest’ between the drinks industry’s objectives and public health goals.

The campaign marks the first time that PHE has joined forces with an industry-funded organisation, and members of the alcohol leadership board expressed their concerns about the partnership at a meeting with PHE chief executive Duncan Selbie in late August.

A joint letter from Professor Gilmore and director of the UK Centre for Tobacco and Alcohol Studies, Professor John Britton, was also published in the Times the day after the campaign launched. The partnership marked ‘a major shift in PHE policy in its willingness to share a platform with the alcohol industry’, it stated, and also demonstrated ‘a failure at senior level’ to learn the lessons of how voluntary agreements had been used by the drinks and tobacco industries to ‘undermine, water down or otherwise neutralise’ policies to cut consumption.

The partnership has proved controversial across the public health field. Prior to the launch a letter expressing concerns about a conflict of interest was sent to PHE, with signatory organisations including the royal colleges of physicians, psychiatrists, nursing and emergency medicines, the BMA and the Association of Directors of Public Health.

Treatment charity Blenheim said it was ‘deeply concerned’ about PHE’s decision to run a campaign with an industry-funded body, and felt that the campaign’s messages would ‘influence people to do nothing’.

‘Blenheim welcome a government-funded programme of health campaigns but this has to be without industry involvement and in line with the chief medical officer’s guidelines to increase public knowledge of alcohol and its links to a wide range of physical and mental health conditions,’ said chief executive John Jolly. ‘From research around social influence and influence psychology we know that people want to conform to the norm. The campaign gives the message most people find it hard to reduce their alcohol use which essentially drives people to do nothing as the take home message is that change is seen as too hard.’

 Times letter at www.thetimes.co.uk/edition/comment/vince-cables-leadership-of-the-lib-dems-qcxcsgd38 (paywall)

 

Extra 3p on beer would ‘raise £100m for alcohol treatment’

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Increasing alcohol duties by just 1 per cent would raise around £100m a year to invest in treatment services, according to a new briefing paper. While this would equate to an extra 3p on a pint of beer or 5p on an average bottle of wine, it could increase alcohol treatment budgets in England by 50 per cent, says The alcohol treatment levy, which is produced by the charity formed by the merger of Alcohol Concern and Alcohol Research UK.

More than two thirds of local authorities cut their alcohol treatment budgets between 2016 and 2018, says the document, with 17 making cuts of more than 50 per cent. More than half of the authorities experiencing the most severe cuts were also in areas with high percentages of dependent drinkers.

A ‘significant proportion’ of alcohol’s annual £3.5bn cost to the NHS comes from ‘a relatively small group of individuals with very complex needs’, the paper points out, with lack of adequate treatment meaning the burden frequently falls on A&E departments.

‘While every year the alcohol industry generates around £8bn from the 4 per cent of the population who drink most heavily, cuts to alcohol treatment services are having a devastating effect across the UK,’ said the charity’s director of research and policy development, Dr James Nicholls.

‘This is out of balance. We should not leave people with severe alcohol problems unsupported, nor should we leave the 200,000 children living with a dependent parent to fend for themselves. We as a society urgently need to find more money to support essential services. That will help people who drink too much and their families, but it will also save the taxpayer money by avoiding higher costs down the line that could be avoided with treatment.’

Briefing paper here

In safer hands?

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When should the Mental Capacity Act be used to make decisions on behalf of vulnerable people? Mike Ward unpicks a complicated issue.

Read the full article in DDN Magazine

Mike Ward is senior consultant for the charity formed by the merger of Alcohol Concern and Alcohol Research UK

In my June article (DDN, June, page 23) I highlighted how the UK’s Mental Health Act poses problems when managing high-impact and change-resistant dependent drinkers. However, the piece of legislation which more commonly causes problems is the Mental Capacity Act (2005).

Let’s start with a real-life case.

Joe is a 55-year-old man who is chronically dependent on alcohol. He lives in a small housing association flat. His drinking is a problem, but the real concern is that drinking ‘friends’ are entering his flat and causing a nuisance. This causes worry to neighbours and landlords. In addition, Joe appears to be giving them money, alcohol and even his belongings. He has been warned about allowing these people into his flat, and he has spoken in his more sober moments about his desire and intention to stop it happening. However, nothing has changed, and the landlords are serving him with eviction notices.

The Mental Capacity Act’s primary purpose is to provide a legal framework for professionals acting and making decisions on behalf of adults who lack the capacity to make particular decisions for themselves. For example, can a paramedic take a resistant patient to hospital for treatment? Can a social worker manage the finances of someone with a learning difficulty?

The act is decision-specific: it does not enable professionals to make a general statement that someone lacks capacity (although this often happens). It only allows the worker to say that a person lacks the capacity to make this particular decision at this point in time. If an adult can be assessed as lacking the capacity to make a particular decision, professionals can take appropriate action in the best interests of the individual.

The act does apply to people with alcohol and drug problems; a person can be assessed as lacking capacity because of intoxication. However, the act suggests that if someone is likely to regain capacity in the near future, ie become more sober, then the capacity assessment should wait until that point, if possible. Herein lie the problems.

Alcohol Research UK has analysed 11 Safeguarding Adult Reviews published in 2017 which related to the deaths of people either with chronic alcohol problems or alcohol use surrounding their death. These reviews suggest that the understanding of the act is poor in general. However, more specific problems exist in relation to people with alcohol misuse.

The application of the Mental Capacity Act was a concern in all 11 Safeguarding Adult Reviews published by Alcohol Concern UK in 2017

For example, a review from Waltham Forest highlights that: ‘The Mental Capacity Act advises you need to wait until a person is sober before you think about capacity. However, when a person is a chronic alcohol user it could be argued that they are never sober. More so that their ability to reason about whether they want to stop drinking is significantly impaired due to the addictive nature of their alcohol use. Therefore, is someone who is a chronic alcohol user ever in a space where their addiction is not impacting on their ability to reason?’

A review from Newcastle highlights that workers’ attitudes can also impede capacity decisions: ‘agencies… see Lee as more troublesome than troubled, a nuisance offender, an abuser of alcohol and drugs who chose a lifestyle that laid him open to risk. The fact that he did not have the mental capacity to make such choices was not recognised by some of the professionals who had contact with him.’

The biggest problem is that people like Joe continually move in and out of capacity due to their repeated intoxication: they have ‘fluctuating capacity’. A more sober Joe will demonstrate that he understands the problem of allowing people to come into his property and wants to do something about it. Four hours later he will be drunk again and will do none of the things that he has discussed. Does he have the capacity to manage his property and prevent the potentially abusive behaviour of his ‘friends’?

This is not merely an interesting legal debate – for people like Joe this can be a matter of life and death. The most crucial example of this is the review of the death of ‘Carol’, who was beaten to death by two teenage girls in Teesside. They were among a number of people who were regularly exploiting Carol’s vulnerability and using her property through coercion.

The review into her death suggests that it is important to assess both decisional and executive capacity. This concept has been proposed by Braye, Orr and Preston-Shoot (2011).

A person has decisional capacity when they can understand, retain, use and weigh up the information needed to make a decision. This is covered by the Mental Capacity Assessment outlined in the act. However, executive capacity is the ability for a person to actually carry out that decision, which can be impaired by alcohol misuse.

For an individual such as Carol or Joe, the assessment of executive capacity is unlikely to be straightforward. When more sober they may appear able to take rational decisions, but repeated history shows they are never able to put these decisions into effect. Do they have the executive capacity to manage situations, for example where unwanted people are entering their property?

In part, the problems highlighted here are about training and understanding. Every local authority area in the country should be bringing professionals together to ensure a shared understanding of how the act applies to people with alcohol and drug problems. However, the notion of executive capacity is not mentioned in the act. There is a need to consider new guidance on the act, or even revised legislation, if we are going to protect some of the most vulnerable people in our communities.

Mike Ward is senior consultant for the charity formed by the merger of Alcohol Concern and Alcohol Research UK, www.alcoholresearchuk.org. His next article will look at criminal behaviour orders.

In a spin: an insight into gambling addiction

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With the depth of painful personal experience, Owen Baily explains why gambling treatment is still a lottery.

Read the full article in DDN Magazine

Former gambling addict Owen Baily
Owen Baily tells his story of accessing treatment for gambling addiction.

With sweaty hands, deep physical anxiety in my chest and a sense of panic, I committed to placing my last bit of money on the roulette terminal in the casino. With acute anticipation, I watched the ball spin chaotically around the wheel and waited for it to land. It landed, as the ball always eventually does, but not on a number I had placed the bet on. I lost, and I had no more money. Literally.

Right there and then, the emotional roller coaster of a journey I had been on for the past two months came to a sudden and abrupt stop and it hurt badly. I was winded. I couldn’t breathe. The panic turned to dread. Starting to comprehend what I had just done and not quite knowing what to do I walked, numb to my surroundings, out of the casino, completely consumed in a self-flagellating internal dialogue.

Two months earlier things couldn’t have been any better. Just a few days before Christmas I was in the same casino and had fulfilled a fantasy – I had had a ‘Big Win’. Confident, flush, feeling powerful and with the freedom of having so much money to spend, I had a very enjoyable Christmas.

Accessing treatment for problem gambling is still a lottery.

It was not to last. I became intensely consumed with recapturing the potency of emotions attained by the ‘Big Win’ and I began to gamble as often as I could, dangerously and chaotically. For the next two months, my dopamine levels were experiencing unnatural and extreme peaks and troughs, ending abruptly with that moment when I placed my last bit of money on the roulette wheel and lost.

That experience was 17 years ago. I was 18. And the experience of the ‘Big Win’ and subsequent loss of all the money I had was, and said with no exaggeration, traumatic. I became depressed, with no confidence or self-esteem and even became suicidal. To cope I escaped and bought into the fantasy of going on a working holiday in Europe. I quit my job, left home, put my belongings in storage, bought my ferry ticket to Holland and went.

Naturally excited, I boarded the ferry, forgetting the past and looking forward to the adventure that lay ahead – except, when I explored the ferry, I came upon a roulette table. Unaware and unable to challenge the gambling thoughts and cravings, and despite my previous experience, I began to play.

A few hours later the ferry docked into the Hook of Holland. And again, I lost all my money. Only this time, I was in a foreign country, with no home and no job.

Read the full article in September DDN Magazine

After spending a day talking to the British Consulate in Amsterdam, I was given enough money to travel back to the UK. Fearing being street homeless in London I got off the coach at Canterbury, Kent. I sought help from the nearest homeless shelter and with what I had just put myself through, I found a will to seek help to try to stop gambling.

But I came up against a problem. I realised that there was no accessible face-to-face support at all for those who have gambling problems. And what became evidently clear as well, was that knowledge and awareness around problematic and excessive gambling behaviour among staff was very poor, bordering on non-existent. Here I was, with a serious problem, desperately wanting help, but because there was no help and staff were unknowledgeable, I felt excluded and marginalised.

Unintentionally, and by some odd fortune, I developed an alcohol dependency. And straightaway, treatment options opened for me. I was referred to what was then a dedicated NHS alcohol Treatment service and periodically, for the next few years, I participated in a whole array of help and support that is commonly found in addiction treatment services. And because I was engaging in treatment, I was able to take a good look at my gambling behaviour too.

I managed very successfully to address my alcohol use and in a matter of months was able to get to a point where I was able to abstain – and I stayed stopped for four years. My gambling, however, persisted. I felt something was missing and I still felt marginalised. I wasn’t getting something from the all the treatment I was receiving through the alcohol service.

As with thousands of other people facing the challenges of overcoming addiction, I had a serious relapse – time for rehab. I began the search in October 2009 when I was 27 and come March 2010 I was walking up the drive to the therapeutic community where I stayed for 20 months. It was a therapeutically difficult and painful experience but one which I am so grateful for. But still I felt marginalised because I had a predominant gambling problem – and just as with my experience of the workers in the homeless hostel, I felt this recurring sense that awareness and understanding of gambling-related harm (GRH) was inadequately low.

Although I’d make positive advances in areas of my being and recovery, I struggled to maintain my 20-month abstinence from gambling, and relapsed.

This was when, after ten years of trying to get a handle on my gambling, I decided to approach the Central and North West London NHS Foundation Trust (CNWL) National Problem Gambling Clinic (NPGC) – currently the only dedicated NHS service that provides gambling-specific support. I self-referred and in a few weeks joined an eight-week cognitive behavioural therapy (CBT) course.

Unlike all the hours of CBT I had done previously, this course has been brilliantly modified and refined to meet the needs of individuals with gambling problems, just as the person with issues relating to alcohol or opioids needs tailored support. Furthermore, I was able to meet others like me and for the first time didn’t feel excluded or marginalised. I found the something that was missing. And I haven’t looked back.

No quick fix on painkiller addiction

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We need to rethink our relationship with pain, says Dr Simone Yule.

Read the full article in DDN Magazine

Dr Simone Yule is an NHS doctor and Action on Addiction’s clinical lead

It’s becoming a well-told and oft-repeated story: a patient that either had an accident or injury or a major illness is started on high dose opioids for pain relief in hospital, and is discharged with a prescription of something like the highly addictive liquid oramorph. They are offered little explanation of how to treat this drug and then have an expectation that they need it and will be prescribed it until the pain stops.

Because of how opioids work, the body builds up a tolerance and if the prescription does not facilitate that pain relief then patients will take more and more to reach the same level of relief. This can then result in patients seeking the medication through alternative sources such as buying illicitly or online. Wherever there is demand, there is supply.

Unless we rethink how we tackle pain management and pain relief we will hear this narrative more and more. It has become a regular story in my work with Action on Addiction, with the number of patients at our treatment centre seeking help from prescription medication addiction now matching those seeking help from illicit drugs.

Unless we rethink how we tackle pain management and pain relief we will hear this narrative more and more.

This is not one person’s fault – not the surgeon, the GP, the patient, the outpatient care nor the treatment centres. But every part of this chain needs to come together to create a healthy and holistic solution to pain management that quickly gets patients off drugs and back to living a realistic pain-managed life.

Drug education

We have seen many more patients, particularly orthopaedic patients, prescribed high-dose opioids such as the fast-acting liquid oramorph, with no clear guidance of how long they should be on this medication and no clear understanding of what it does and how powerful it is. In my experience, patients are often discharged with a significant amount of medication and no direction given to the primary care team as to what the ongoing treatment plan is.

We need better education for the patient, and better planning and communication between hospitals and the primary care team regarding the patient’s discharge, so the whole team including the patient are part of the process and understand the required outcome.

Prescription management

GPs could improve methods for policing repeat prescriptions. In our surgery group we have strict monitoring of opioid prescriptions and we now have a warning on our computer, for anybody on a long-term prescription to be reviewed.

I saw a patient recently who had previously suffered a major road traffic accident and was quite debilitated and on high-dose opioids. It was highlighted that he was requesting more than he should be, so I brought him in. It turned out that he was desperate to get off medication, but because he had not had the support from physiotherapy and the rehab service following his accident, he had no alternative other than to continue taking painkillers. Without a warning system it could have been many more months of repeat prescriptions before his desperate situation was clinically managed.

Better access to rehabilitation

I fully believe in the holistic approach to pain management. The drugs are a quick fix and should only be used in the immediate aftermath of an accident or illness. I think true rehab, where you are looking at the psychological aspects and physical rehabilitation to manage and help alleviate the pain, is not nearly accessible enough.

I have one patient, in significant pain, who has to travel 25 miles to their nearest rehab centre. Taking the time and considerable effort to make that journey once a week for him was not possible and so his recovery time extended, meaning his time on high dose painkillers also extended. In some parts of Britain the distance is much further than 25 miles.

De-stigmatising treatment

There is still a public perception that drug treatment centres are for illicit drug addiction and somehow patients should be able to come off prescribed drugs without help. We need a lot more publicity about prescribed medication treatment and how you can access it, and the long-term benefits of seeking this treatment.

Action on Addiction’s treatment centre – Clouds House

At Clouds House, the treatment centre run by Action on Addiction, we are seeing considerably more people coming in addicted to not only opioids, but drugs like pregabalin, a prescribed non-opiate medication. The fortunate ones who seek help, or are guided to that help by a GP or family member, come to realise that this addiction is serious but with the right treatment it can be overcome.

Obviously, to create healthier planning around pain management, making it accessible for all patients, requires funding. The pressure to discharge patients quickly, to reduce waiting times in GP clinics and to cut outpatient services, all means we reach for the quick fix and we will all pay the price somewhere else down the line. The only winner is the drug company.

 

 

Have more alcohol-free days, drinkers urged

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DDN
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A new campaign by Public Health England (PHE) and industry-funded Drinkaware is urging middle-aged drinkers to have more alcohol-free days, as ‘a way of reducing their health risks’. The campaign marks the first time the two organisations have worked together.

Middle-aged drinkers are being urged to have at least two alcohol free days a week.

The ‘Drink Free Days’ campaign is designed to be ‘clear to follow, positive and achievable’. A YouGov survey of almost 9,000 adults found that one in five people were drinking above the recommended guidelines, two thirds of whom said that they would find cutting down on drinking harder than other lifestyle changes such as taking more exercise or improving their diet. Middle-aged drinkers are more likely to be consuming more than the 14 units a week ‘lower risk guidelines’ than the population as a whole.

‘It’s all too easy to let our drinking creep up on us,’ said PHE chief executive Duncan Selbie. ‘While the link with liver disease is well known, many people are not aware that alcohol can cause numerous other serious health problems, such as high blood pressure, heart disease as well as several cancers. It’s also an easy way to pile on the pounds. About 10m people in England are drinking in ways that increases the risks and many are struggling to cut down. Setting yourself a target of having more drink free days every week is an easy way to drink less and reduce the risks to your health.’

However, chair of the Alcohol Health Alliance, Professor Sir Ian Gilmore, said that the alliance had ‘serious concerns’ about the campaign, and the ‘fact that it represents the beginning of a relationship between the alcohol industry and PHE. We strongly believe that the alcohol industry should not have a role in providing health information to the general public,’ he said.

PHE was making a ‘serious mistake in partnering with the alcohol industry’, he added. ‘Instead, we urge them to work with the wider public health community and others in persuading the government to take a more evidence-based approach to tackling alcohol harm.’

Gambling with public health

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Let’s increase the chances of a good outcome for gambling addiction, says Lord Victor Adebowale.

Read the article in September DDN magazine

Lord Victor Adebowale is co-chair of the APPG on Complex Needs and Dual Diagnosis, and CEO of Turning Point

Gambling is a common part of everyday life, accessible online 24/7 and unavoidable across media and advertising platforms. Yet for some people, it can become harmful and problematic, affecting relationships, housing, employment and health.

The timing of the recent APPG on Complex Needs and Dual Diagnosis meeting on ‘harmful gambling’ coincided with the football World Cup – four weeks of sporting action that gripped the nation and over which it was expected that the amount spent on gambling in the UK rose to £2.5bn; an alarming figure.

In the UK nearly 9m adults will gamble over any four-week period, of which 430,000 can be identified as ‘problem gamblers’. It is an addiction that impacts all pockets of society, yet one which only now is starting to be addressed as a public health issue.

Dr Steve Sharman from the University of East London presented his recent research findings on the correlation between homelessness and gambling – a pocket of society many would not commonly associate with gambling, despite 82 per cent of homeless problem gamblers interviewed experiencing these issues prior to homelessness. He explained how 24/7 casinos, which provide a warm, safe haven for those otherwise on the street, and incentives such as free bathrooms and hot food and drinks, become attractive but are only available if you are gambling – a morally corrupt pay-off in my opinion.

Lawrence Goode from the Gordon Moody Association, a charity that provides advice, education and high-quality innovative therapeutic support to male problem gamblers and those affected by problem gambling, reiterated the wider non-direct impact gambling can have on families and children. Of the 74 people who went through their residential treatment last year, 72 relationships broke down and 69 children were temporarily without a father.

The government is making some effort to address harmful gambling, for example recent government policy has cut the maximum permitted stake on fixed-odds betting terminals from £100 to £2 – a controversial move welcomed by some in the bookmaking industry – and PHE have committed to carrying out a review of the damage to health caused by gambling. However, to make any real and effective progress it is obvious that more funding, research and treatment options are needed to address the health and social concerns harmful gambling presents in the UK.

Addiction is addiction, whether drugs, alcohol or gambling. It’s a behaviour pattern and what the sector and NHS commissioning services need to realise is that we should be providing holistic support, treating the person rather than an individual problem.

 

Height of awareness: peer-to-peer overdose prevention

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Peer-to-peer naloxone initiatives are proving an effective way to tackle overdose risk. Lee Collingham describes how SCUF are grasping the opportunity in Nottingham.

Read the full article in DDN Magazine

Lee Collingham: SCUF Nottingham

The latest release of worsening statistics has kept drug-related deaths (DRDs) at the forefront of everyone’s mind, whether treatment providers, family members, friends or peers.

In May Nottingham’s user-led campaign group, SCUF, was approached by the European Network of People who Use Drugs (EuroNPUD) to discuss the possibility of a partnership. The suggestion was to work together for a three-month period to promote peer-to-peer distribution of naloxone.

The initiative started on International Remembrance Day on 21 July, when drug using communities across the world come together to remember those we’ve lost during the year and highlight the war on drugs – especially with budget cuts and services being decommissioned.

Local service users came together for action, and through working with neighbouring specialist support services, the P2POD (Peer to Peer Overdose) group was formed. We have the firm belief that it will be beneficial to all in reducing the unnecessary deaths of our friends and peers by ensuring all users, as well as their families and carers, have access to naloxone – the drug that temporarily reverses the effects of opioid overdose and buys time for medical professionals like the ambulance service to arrive.

A lack of knowledge around naloxone has meant that there has often been confrontation when the ambulance arrives, and we believe by informing service users properly we can avoid this.

Training on how to administer naloxone

P2POD group have met a number of times this year. We arranged events for International Remembrance Day on 21 July and Overdose Awareness Day on 31 August, as well as organising naloxone training for our local harm reduction week at the end of August. We have been able to raise awareness, distribute naloxone to peers, and cement future working relationships for peer-to-peer distribution of naloxone in Nottingham. This also demonstrated once again how important engaging with service users is to the success of any project and the annual release of DRD figures only cemented the group’s commitment.

Local service providers and commissioners came along to the events, where service users were trained in basic overdose response. Participants were shown how to administer naloxone by one of their peers and issued with a naloxone kit before leaving, and were told exactly what happens when it is administered. It’s our firm belief that if people understand what’s going on, and that it momentarily reverses an overdose, they are less likely to hit out at the person administering it. This information also prevents the person from running off to score again, only to collapse as the effects of the naloxone wear off.

We are grateful to the team at EuroNPUD and local service providers, not only for their support, but for backing the possibility of peer-to-peer distribution of naloxone in Nottingham.

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Peer to peer

Mat Southwell shares EuroNPUD’s strategy to spread the initiatives far and wide.

Mat Southwell – Project Coordinator EuroNPUD

The European Network of People who Use Drugs (EuroNPUD) has undertaken a project to understand barriers to accessing naloxone in the UK. The project has been funded by an unrestricted educational grant from Martindale Pharma, which has also enabled us to explore peer to peer overdose prevention training and naloxone supply.

We began by selecting three areas with at least twice the average number of opioid overdoses and where we have strong local peer partners – Liverpool, Burnley and Blackpool. The partners in these areas initially undertook a mapping exercise identifying local planners, service providers and community stakeholders.

EuroNPUD and our local peer partners then ran a focus group in August, with eight to ten local community stakeholders in each area. This involved a range of drug users and family members with different experiences of drug use and drug services. We also trained the local peers to deliver a mystery shopper activity, testing access to naloxone for drug users and family members.

Drawing on case studies from London and Glasgow in the UK, Kachin in Myanmar, Minnesota in the USA, and Canberra in Australia, EuroNPUD has researched and written a technical briefing on the peer-to-peer distribution of naloxone. This gave examples of drug users distributing naloxone to their peers and shared good practice tips from the peer experts that have been interviewed for the project.

The peer-to-peer technical briefing provided the focus for a second local event in on 31 August, International Overdose Awareness Day – a lunchtime briefing that targeted peers, families and professional partners. Its purpose was to engage stakeholders in hearing the findings on local drug users’ assessment of access to naloxone. This also supported an advocacy planning exercise to design a peer-led advocacy initiative, which has been backed up with a £1,000 local advocacy grant.

The EuroNPUD project team has also produced a report describing the methodology and learning, launched at a media event alongside the naloxone technical briefing, where peer experts from across the UK showcased peer-to-peer distribution of naloxone. We are now producing an open source standard toolkit, supporting the delivery of this activity in other areas or national settings.

In search of excellence – new phase of CQC

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David Finney gives his guide to understanding the next phase of CQC Inspection.

Read the full article in DDN magazine

David Finney is an independent social care consultant who has worked with government inspection bodies

The Care Quality Commission (CQC) has begun a new phase of inspections, where the legal authority to award ratings to providers of substance misuse treatment services will come into effect. Also, some of the lessons learned will begin to impact upon the knowledge bank which inspectors are accumulating.

These ratings, once awarded, have to be published and displayed, according to the regulations – so there will be no hiding place if your service is failing in any way. Commissioners and people who wish to use your service will definitely be able to find out how you have fared.

Most providers honestly believe that their service is a good one, but I believe that many are providing an outstanding service – they just don’t realise this or give it that name. The question is, can you convince CQC that a service is good, or even outstanding?

First of all, ensure that all the basics are in place. There is no point in trying to highlight some excellent practice if matters such as health and safety, staff training and supervision, medication administration, quality assurance, governance arrangements etc are not being well run.

Secondly, look to the NICE guidance which is relevant. This will be a secondary document that CQC will refer to when assessing practice. This is especially important for detoxification services.

Thirdly, examine the CQC rating characteristics listed in their methodology, (otherwise known as the Key Lines of Enquiry). When you write the pre-inspection material required from you by CQC, directly refer to their own criteria. This is a chance to shine and highlight what is outstanding about your service.

Fourthly, look at other CQC inspection reports to see what has already been identified as good practice and ask whether CQC would find that in your service or not. If not, is there any way that it could become part of your practice?

Meanwhile, these are some of the areas that may demonstrate good practice:

Understanding risk

CQC criteria are that risks are proactively anticipated and that service users are actively involved in managing their risks. Good recovery involves people building and owning their resilience to maintain sobriety or whatever goals they have chosen. To do this, an awareness of risk and an ability to personally own the strategies to overcome their risk factors are vitally important and could be demonstrated through documents as well as conversation with service users.

Developing staff skills and knowledge

CQC criteria involve the continuing development of staff skills, competence and knowledge alongside proactively supporting staff to acquire new skills, use transferable skills and share best practice. There are examples of opportunities to share best practice in staff briefings, and skill development is actively encouraged through clinical supervision and in-house workshops. Also, many services actively encourage external training and development.

Access to support networks in the community is actively encouraged

Many services offer regular opportunities to be involved in AA, NA, Smart Recovery etc, as well as their own after­care, which offer ongoing community-based support.

Integrated person-centred pathways of care

Many treatment services effectively combine the wide-ranging complex needs of their clients in one integrated care plan, which enables people to understand and build their own recovery.

Leadership

This is a crucial domain for CQC, so demonstrating that staff are passionately motivated in their work and that there are robust quality assurance processes in place will score highly.

There are many more examples to explore further. Our conference on 17 October will seek to discuss ways to prepare for the next phase of inspection. We hope that there will be a representative from CQC present alongside other key professionals to assist us.

 

 

 

DDN September 2018

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DDN
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‘The call for support on gambling has to be heard’

You’re in the casino chasing the big win. Everything you ever wanted could be yours. The wheel spins and the ball jumps from red to black to red to black… you’ve risked everything… so what if the unthinkable happens? Owen’s story (page 6) gives valuable insight into this potentially problematic recreation, adding to last month’s gambling feature that many of you found useful. The call for support has to be heard and incorporated more widely into our treatment system so we can offer help at the first sign of struggle.

The theme of peer-to-peer expertise runs deep through this month’s issue. Local user groups are networking with naloxone initiatives (page 16), while EuroNPUD are rolling out a far-reaching overdose prevention project. We’ll follow its progress with interest.

Three minutes isn’t long to tell your story, particularly when you need to convey the significance of the ‘lightbulb moment’ when you decided to do things differently. But that’s exactly what entrants to this year’s Recovery Street Film Festival achieved (page 15). Each film was astonishingly powerful and I would urge you to visit the YouTube channel and watch them for yourself. Any one of them would demonstrate the case for investment in drug and alcohol services.

We hope you’ve had a good summer. As the autumn approaches it’s time to start planning in earnest for the next DDN conference – the best place ever for peer-to-peer networking. Put 21 February in your diary and please join the consultation through our website!

Read the issue as a PDF or virtual magazine

Claire Brown, editor

Keep in touch at www.drinkanddrugsnews.com and @DDNmagazine

 

New campaign calls for national focus on preventing drug-related deaths

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DDN
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A new initiative launched at the Scottish Drugs Forum (SDF)’s annual conference is calling for a national focus on preventing drug deaths, and reinforces the message that ‘prevention is possible and we all have our parts to play’.

David Liddell: #StopTheDeaths is a call to refocus our actions

#StopTheDeaths, which is timed to mark International Overdose Awareness Day on 31 August, wants to see all stakeholders make the agenda a priority and also offers a ‘message of hope’ – that ‘we can respond to record drug deaths by developing a world-leading response to this national challenge and aspire to eliminate drug overdose deaths’.

The last three years have seen record drug deaths in Scotland, with 867 in 2016 – 23 per cent up on the year before, and almost double the figure from a decade ago (DDN, September 2017, page 4) – rising by 8 per cent to 934 in 2017 (DDN, July/August, page 4). The #StopTheDeaths initiative also focuses on drug-related fatalities that are not the result of an overdose, such as those caused by the health effects of chronic drug use. The campaign is aimed not just at policy makers and service providers, but people who use drugs and their families and communities.

‘From speaking to our members across Scotland, it is clear that the number of drug-related deaths continues to rise at what now seems an exponential rate,’ said SDF CEO David Liddell. ‘This means that in 2018 Scotland will almost certainly suffer over 1,000 preventable overdose deaths. #StopTheDeaths is a call to refocus our actions and to draw attention to evidence-based approaches and protective factors that can be deployed now.’

These included making sure people had fast access to, and were retained in, high quality treatment services, as well as provision of a wide range of therapies – including heroin-assisted treatment – and improved access to take-home naloxone. SDF is also launching a free e-learning course to coincide with the campaign, covering how to recognise an overdose and use naloxone to reverse it.

‘The good news is that drug deaths are being prevented every day in Scotland,’ Mr Liddell added. ‘However, we need a step change in terms of a co-ordinated approach and further innovation that can meet the scale of this challenge if we are to avoid the course we appear to be on. The Scottish Government’s new national drug strategy is an opportunity to show leadership, redirect the nation and decide to end this tragic situation.’

www.overdoseday.com

Naloxone course at www.sdfworkforcedevelopment.org.uk

More on International Overdose Awareness Day and naloxone initiatives in September’s DDN, out on 10 September

Alcohol and Health

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DDN
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We all know that alcohol is linked to health problems. The range and scale of those harms is far wider than many of us think. In particular, drinking very heavily brings with it a number of serious physical risks. This special publication provides a clear and detailed overview of those risks, as well as advice for people likely to encounter such problems in their day-to-day work.
Alcohol Treatment SupplementRead it here as a mobile magazine or download the PDF

Supported by: 

Would you like printed copies for your organisation?

The publication was a printed supplement in the June 2018 DDN magazine, but we would be happy to post additional copies to your organisation free of charge to distribute to members of staff. Please fill in the form below.

Alcohol and Health

Order free copies of DDN Alcohol and Health for your organisation.

  • To help us grow our free distribution please let us know how you heard about the publication.

 

 

DDN Conference Consultation 2019

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We know it is still a long way away, but in order to make the next DDN Conference bigger and better than ever we need to know what you want.

You are invited to the 2019 DDN Conference on 21 February in Birmingham.

PLEASE CLICK HERE TO LET U KNOW WHAT YOU WANT AT YOUR CONFERENCE

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[embedyt] https://www.youtube.com/embed/live_stream?channel=UC9is5h3vEN3u90sYjZyvxXw[/embedyt]

‘No safe level’ of alcohol consumption

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DDN
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The health risks associated with drinking are ‘massive’ and there is no safe level of alcohol use, according to a major new study published The Lancet. Almost 3m deaths worldwide were attributed to alcohol use in 2016, including 12 per cent of deaths for males aged 15-49, it states.

Researchers used data on all alcohol-related deaths and ‘related health outcomes’ for the study, which is part of the annual Global Burden of Disease (GBD) programme. It looked at figures for almost 200 countries over a 26-year period for consumption levels, deaths and more than 20 alcohol-related conditions including cirrhosis, pancreatitis, cancers and cardiovascular diseases.

Globally, more than 2bn people were ‘current drinkers’ in 2016, more than 60 per cent of whom were male. Seven of the ten countries with the highest death rates were in Eastern Europe, the Baltic or Central Asia – Russia, Ukraine, Lithuania, Belarus, Mongolia, Latvia and Kazakhstan – while eight of the ten lowest death rates were in the Middle East.

‘The health risks associated with alcohol are massive,’ said the study’s senior author, Dr Emmanuela Gakidou. ‘Our findings are consistent with other recent research, which found clear and convincing correlations between drinking and premature death, cancer, and cardiovascular problems.

‘Zero alcohol consumption minimises the overall risk of health loss. With the largest collected evidence base to date, our study makes the relationship between health and alcohol clear – drinking causes substantial health loss, in myriad ways, all over the world. There is a compelling and urgent need to overhaul policies to encourage either lowering people’s levels of alcohol consumption or abstaining entirely.’

Read the study here

Alcohol industry would lose £13bn if drinkers stuck to guidelines

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DDN
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Drinkers consuming more than the government’s low-risk guideline of 14 units a week make up a quarter of the population but provide 68 per cent of industry revenue, according to a new study. This means that if all drinkers stuck to the guidelines the industry would lose around £13bn, say researchers from the Institute of Alcohol Studies (IAS) and the University of Sheffield.

While just 4 per cent of the population drink at the higher ‘harmful’ levels, they account for nearly a quarter of sales, adds How dependent is the alcohol industry on heavy drinking in England?, which is published in the academic journal Addiction.

More than 80 per cent of sales in supermarkets and off-licences come from people drinking above guideline levels, it says, along with more than 60 per cent in pubs, restaurants and clubs. Almost 80 per cent of revenue for beer producers comes from people drinking above the recommended amount, which means the average cost of a pint of beer in a pub would need to increase by more than £2.50 – and a bottle of supermarket spirits by more than £12 – to maintain current revenue levels if everyone drank within the guidelines.

Policies to reduce alcohol harm such as minimum unit pricing had been resisted ‘at every turn’ by the industry, stated lead author Aveek Bhattacharya. ‘Our analysis suggests this may be because many drinks companies realise that a significant reduction in harmful drinking would be financially ruinous. The government should recognise just how much the industry has to lose from effective alcohol policies, and be more wary of its attempts to derail meaningful action through lobbying and offers of voluntary partnership. Protecting alcohol industry profits should not be the objective of public policy.’

Study available here 

‘A third’ of HMP Birmingham prisoners using drugs

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DDN
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Drug testing suggested that a third of prisoners in HMP Birmingham are using illicit drugs, according to a prison inspectors’ report, while one in seven said they had developed a drug problem since being at the prison. Half of the establishment’s population thought drugs were ‘easy to obtain’, inspectors said.

The prison was made the subject of an ‘urgent notification’ to the justice secretary after an unannounced inspection earlier this month, and a governor and management team from HM Prison Service have since taken over its running from private security services company G4S. There had been a ‘dramatic deterioration’ in the last 18 months, with ‘significant concerns’ about safety, drugs and lack of control, said the notification document.

Peter Clarke: Many prisoners were under the influence of drugs.

‘We saw many prisoners under the influence of drugs and the smell of cannabis and other burning substances pervaded many parts of the prison,’ chief inspector of prisons Peter Clarke wrote to justice secretary David Gauke. ‘Our own observations confirmed to us that the use and trafficking of illegal substances was blatant. I have inspected many prisons where drugs are a problem, but nowhere else have I felt physically affected by the drugs in the atmosphere – an atmosphere in which it is clearly unsafe for prisoners and staff to live and work.’ When inspectors raised the fact that drugs were ‘clearly being smoked’ on a wing the response from staff was ‘to shrug’, he added.

Levels of violence were the highest of any local prison in the country, said the inspectors’ report, with prisoners and staff frequently requiring hospital treatment as a result of assaults. More than 70 per cent of prisoners reported feeling unsafe at some point – ‘an extraordinarily high figure’, said Clarke – with the prison’s response ‘wholly inadequate’. Three prisoners were known to have killed themselves in the 18 months since the last inspection and there had also been three recent drug-related deaths. ‘Early indications suggested it was likely that misuse of synthetic cannabinoids was involved,’ the document stated.

This year’s annual report from the chief inspector of prisons said that drugs were behind much of the ‘huge increase’ in violence across the prison estate in the last five years, while a report from the Royal College of Nursing warned that the health of its members working in prisons was being put at risk from second hand inhalation of synthetic cannabinoid smoke (DDN, June, page 4).

Earlier this month prisons minister Rory Stewart announced a package of measures to address ‘acute problems’ of violence, drug use and security in ten prisons – not including Birmingham. He later told BBC News that he would quit if he failed to reduce the levels of drug use and violence within 12 months.

Full inspection of: HMP Birmingham 30 July – 9 August 2018 here

Relax laws on e-cigarettes, urge MPs

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DDN
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Regulations on the licensing, prescribing and advertising of e-cigarettes need to be relaxed, says a report from Parliament’s cross-party Science and Technology Committee. Despite being thought to be 95 per cent safer than conventional cigarettes (DDN, September 2015, page 4) e-cigarettes are ‘too often being overlooked as a stop-smoking tool by the NHS’, the document states.

The report found that e-cigarettes are not a significant ‘gateway’ into smoking for young people and do not pose a significant risk through second-hand inhalation. It recommends reconsidering the tax levels relating to the devices to encourage more people to switch from conventional cigarettes, and calls on the government to ‘consider risk-based regulation to allow more freedom to advertise e-cigarettes as the relatively less harmful option’.

There also needs to be a ‘wider debate’ on how e-cigarettes are dealt with in public places such as buses and trains to reach a solution that ‘at least starts from the evidence’ rather than misconceptions about health impacts, it adds, while NHS England should establish a policy of allowing people in mental health facilities to use the products ‘unless trusts can demonstrate evidence-based reasons for not doing so’.

The committee also wants to see the government, the Medicines and Healthcare products Regulatory Agency (MHRA) and e-cigarette manufacturers review how approval systems for stop-smoking therapies can be streamlined when products are put forward for medical licensing. However, a research programme into any long-term health impacts also needs to be established, it says, overseen by PHE and the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment. Currently around 2.9m people in the UK use the products.

‘Smoking remains a national health crisis and the government should be considering innovative ways of reducing the smoking rate,’ said Science and Technology Committee chair Norman Lamb. ‘E-cigarettes are less harmful than conventional cigarettes, but current policy and regulations do not sufficiently reflect this and businesses, transport providers and public places should stop viewing conventional and e-cigarettes as one and the same. There is no public health rationale for doing so. Concerns that e-cigarettes could be a gateway to conventional smoking, including for young non-smokers, have not materialised. If used correctly, e-cigarettes could be a key weapon in the NHS’s stop smoking arsenal.’

‘The UK has an effective regulatory model for e-cigarettes which we should be proud of,’ added ASH chief executive Deborah Arnott. ‘However, today’s call to improve the process to enable e-cigarettes to be licensed as medicines is extremely welcome. E-cigarettes have already helped many smokers to quit, but they could help many more. Licensed products could transform the public’s understanding of e-cigarettes and help many more smokers see vaping as a viable alternative to smoking.’

 E-cigarettes report here

Hep C deaths down 11 per cent in a year

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DDN
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Deaths from hepatitis C-related end-stage liver disease fell by 11 per cent last year compared to 2016, according to new figures from Public Health England (PHE).

The fall, which comes after a decade of continuous increases, is ‘most likely’ due to the growing use of new antiviral medications available on the NHS, says PHE. These ‘have the potential to cure the condition in most cases’ and also have fewer side effects than previously used medications such as interferon.

The number of people accessing treatment is also up by 19 per cent compared to the previous year, and by 125 per cent on pre-2015 levels. More than 200,000 people are thought to be infected with hepatitis C – with around half of them likely to be unaware of their infection – and there is still an average of 1,974 new end-stage liver disease and cancer diagnoses per year.

‘Substantially greater’ numbers of people need to be tested to meet NHS targets on hepatitis C

The NHS has a target of eliminating the virus by 2025 but a report by the All Party Parliamentary Group (APPG) on Liver Health earlier this year said that ‘substantially greater’ numbers of people would need to be tested, diagnosed and treated if this were to be achieved (DDN, April, page 4)

‘The fall in deaths from hepatitis C related advanced liver disease in the last year suggests that more people are accessing new, potentially curative treatments and shows we’re making positives steps towards reaching our overall goal of elimination of hepatitis C as a major public health threat,’ said PHE consultant epidemiologist, Dr Sema Mandal.

‘However, more needs to be done. We are urging anyone who has ever injected drugs, even once or a long time ago, had a tattoo or medical treatment overseas where proper hygiene procedures may not have been followed, or has had a blood transfusion before hepatitis C screening was in place, to get tested at their GP, community drug services or sexual health clinic. It could save your life.’

Hepatitis C in the UK: 2018 report here

See September’s DDN for an eight-page pull out on hepatitis C and health

 

Record drug deaths for England and Wales

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DDN
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England and Wales have once again recorded their highest ever number of drug-related deaths, according to the latest figures from the Office for National Statistics (ONS).

There were 3,756 deaths related to drug poisoning in 2017, a slight increase on 2016’s figure of 3,744 (DDN, September 2017, page 4) and the highest number since records began. However, while drug-related deaths rose by ‘a statistically significant amount’ each year between 2012 and 2015 – mainly driven by heroin-related fatalities – rates since 2015 have only increased slightly and remain ‘broadly stable’, says ONS.

Two-thirds of deaths were among men, and once again the North East had a ‘significantly higher’ death rate than any other region. While the figures relate to both illegal and legal drugs, almost 70 per cent were classed as the result of ‘drug misuse’, with the highest rate of these in the 40-49 age group.

Although deaths from ‘most opioids’ have remained steady, fentanyl-related deaths have continued to rise – to 75, from 58 in 2016 – while deaths related to cocaine have now increased for six consecutive years. There were 432 cocaine-related deaths in 2017, up from 371 the previous year. The number of deaths related to pregabalin, meanwhile, has risen from just four in 2009 to 136, although NPS-related deaths halved between 2016 – when the Psychoactive Substances Act was introduced – and 2017, down to 61 from 123.

Release said the death rates were a ‘national crisis’ requiring a coordinated public health response, and called for the establishment of consumption rooms, scaled-up access to naloxone, and central funding for heroin-assisted treatment.

Niamh Eastwood: The drug death rates are a national crisis

‘The government is driving this devastating public health crisis by punishing people for their drug use instead of implementing compassionate, evidence-based policies,’ said executive director Niamh Eastwood. ‘By criminalising people for drug possession, the government is dissuading people who want help from seeking it. This, in turn, is fuelling drug-related deaths.

‘To make matters worse, the government is actively blocking the opening of life-saving drug consumption rooms, despite calls for their introduction from treatment service users, health professionals, and even the Scottish Parliament. The government has also slashed funding to essential treatment services, leaving thousands of people at the mercy of a postcode lottery as to whether their local authorities will provide the support that they need.’

‘The continuing high rates of drug-related deaths and the emerging threat of overdoses associated with fentanyl points to a national need to improve the balance of harm reduction initiatives,’ added a spokesperson for Change Grow Live (CGL). ‘We know what effective harm reduction consists of: rapid access to effective substitute opioid prescription; supporting take-home naloxone programmes; robust identification systems for those most at-risk, as well as addressing existing health conditions wherever possible.

‘It is essential that harm reduction is prioritised as a core and essential element of treatment, giving people support to reduce the harms from drugs and achieve sufficient stability to keep themselves safe and alive.

Deaths relating to drug poisoning in England and Wales: 2017 registrations at www.ons.gov.uk

Cocaine and ecstasy driving increase in class A use

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DDN
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Around 1.1m adults took a class A drug in the last year, according to the latest Home Office figures, 3 per cent up on a decade ago. Class A use among 16 to 24-year-olds, meanwhile, has increased from 6.2 per cent to 8.4 per cent since 2011-12, says Drug misuse: findings from the 2017-18 crime survey for England and Wales, ‘mainly driven by an increase in powder cocaine and ecstasy use’.

Ecstasy use among young people has increased

Around 875,000 people had used powder cocaine in the previous year, more than 360,000 of them in the 16-24 age range. There has been a ‘statistically significant increase in powder cocaine use’ for both young people and all adults since 2011-12, says the report, with usage rates increasing from 2.1 to 2.6 per cent among 16 to 59-year-olds and 4.1 to 6 per cent among 16-24 year olds. Ecstasy use among young people has also increased from 3.3 per cent to 5.1 per cent over the same period, while use of LSD, ketamine, magic mushrooms and non-prescribed tranquilisers was also up across all adults.Around 9 per cent of 16 to 59-year-olds had taken any drug in the previous year – approximately 3m people – a figure largely unchanged for a decade, while the proportion rose to almost 20 per cent for 16 to 24-year-olds. Cannabis remains the most commonly used substance, with 7.2 per cent of adults having used it in the last year, with cocaine the second most commonly used drug.

There has been a ‘statistically significant increase in powder cocaine use’

Only around 2 per cent of adults were classed as ‘frequent’ drug users, however – defined as using an illicit substance more than once a month on average – rising to 4 per cent for 16 to 24-year-olds.

Meanwhile, the home secretary has announced that clinicians will be able to legally prescribe cannabis-based medicines ‘by the autumn’ following a two-part review commissioned in June (DDN, July/August, page 4). The Department for Health and Social Care (DHSC) and the Medicines and Health products Regulatory Agency (MHRA) will now develop a ‘clear definition’ of what constitutes a ‘cannabis-derived medicinal product’, says the government. ‘Other forms of cannabis will be kept under strict controls and will not be available on prescription,’ it states.

‘Recent cases involving sick children made it clear to me that our position on cannabis-related medicinal products was not satisfactory,’ said the home secretary, Sajid Javid. ‘That is why we launched a review and set up an expert panel to advise on licence applications in exceptional circumstances. Following advice from two sets of independent advisers, I have taken the decision to reschedule cannabis-derived medicinal products – meaning they will be available on prescription. This will help patients with an exceptional clinical need, but is in no way a first step to the legalisation of cannabis for recreational use.’

Crime survey statistics here

International Remembrance Day

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DDN
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Demonstrators gather outside Parliament to mark International Remembrance Day
Doves
Honouring lost family and friends

This year’s International Remembrance Day was marked by a demonstration outside Parliament that saw speeches from Professor John Strang and others. The annual event is designed to celebrate the lives of people who use drugs, and have died – often as the result of the ‘repressive and stigmatising conditions imposed by prohibition’.

This year once again saw Scotland record its highest ever number of drug-related deaths (DDN, July/August, page 4) and the country’s drug death rate remains the highest in the EU. While the latest statistics for England and Wales have yet to be released, last year’s figures saw 3,744 drug poisoning deaths – the highest since comparable records began – almost 70 per cent of which were classed as drug misuse deaths (DDN, September 2017, page 4).   

Although International Remembrance Day usually takes place on 21 July this year it was held a day early to coincide with the last day of Parliament before the summer recess. 

‘As we honour our family and friends, we want MPs to know the human cost of their decisions; that the policies they support inflict suffering upon tens of thousands of people across the country,’ said Release. ‘We know that many of our loved ones would still be here today if we had compassionate drug laws rooted in evidence.’

Coordinated effort needed to eliminate hepatitis C

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DDN
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An ‘urgent, coordinated’ effort is needed to increase testing and treatment for hepatitis C in order to ensure the elimination of the disease in time for NHS England’s 2025 target, says a new report from the Hepatitis C Coalition.

All parts of the ‘hepatitis C pathway’ need to work together to support the NHS in its target, says Signposting the way to elimination by 2025. The document builds on the work of the All Party Parliamentary Group on Liver Health’s Eliminating hepatitis C in England report (DDN, April, page 4) to set out the practical steps that organisations can now take.

The hepatitis C patient pathway is ‘complex’ and commissioning services can be fragmented, so efficient data gathering and sharing between agencies would ‘significantly reduce the number of patients losing touch with treatment services’, says the document. Finding the undiagnosed and reconnecting with people with a diagnosis but who remain untreated is ‘a key priority’ for achieving elimination, it adds, while health service leaders in every area also need to work together to ‘demystify and destigmatise’ the condition.

Steve Ryder: ‘Well within our capability to eliminate hepatitis C’

‘It is not often that we can say that it is possible to eliminate a disease as a public health threat, but this is well within our capability to achieve,’ said Professor Steve Ryder, chair of the Hepatitis C Coalition – a collection of clinicians, treatment providers, service user groups, charities and others.

‘We are at a vital moment in the fight against hepatitis C and now is the time to act,’ he said. ‘The different parts of the NHS and those involved in treating this little-known but deadly disease are now on the same page, and are working together to do our best to eliminate it by 2025.’ It was vital to raise awareness as widely as possible and get as many people as possible tested and into treatment, he stressed.

Meanwhile, the World Health Organization (WHO) marked World Hepatitis Day on 28 July by stressing the need for countries to ‘urgently increase hepatitis testing and treatment services’ in order to eliminate viral hepatitis as a public health threat by its target year of 2030. ‘We have a clear vision for elimination, and we have the tools to do it,’ said WHO director-general Dr Tedros Adhanom Ghebreyesus. ‘But we must accelerate progress to achieve our goal of eliminating hepatitis by 2030.’

‘Breaking down the stigma and informing people about the ease and ways to get tested are the first barrier we need to overcome,’ said Lord Victor Adebowale (above) as he attended Croydon Recovery Network for a dry-blood spot test for Hepatitis B, C and HIV to mark World Hepatitis Day. Around 90 per cent of cases of hep C in London occur in past of current intravenous drug users and the network, run by Turning Point, delivers a vital service through its specialist onsite hepatitis clinic.

Document at www.hepc-coalition.uk

DDN Conference 2023 on the day

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DDN
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Thank you to everyone who made the DDN Conference such a special day!

Pictures, feedback, presentations, and coverage coming soon!

 

 

 

 

 

 

 

 

The Conference Programme

THE DDN CONFERENCE 2023

‘Many Roads’

9.00–10.00am registration and refreshments, Foyer

10.00–11.30am Session one, Conference Hall
Welcome to the DDN Conference! Claire Brown, DDN editor

CHALLENGING STIGMA

The Anti Stigma Network, introduced by Karen Biggs, CEO of Phoenix Futures
This growing and diverse network aims to understand and challenge the stigma directed towards people who use drugs and alcohol, people experiencing addiction, and their families. We invite you to get involved in the network, bringing your experience to help us confront and challenge this discrimination.

Women and stigma, with April Wareham of Working with Everyone and Hannah Shead, CEO of Trevi. Looking at the specific challenges faced by women who use drugs and the need for more specialist support.

The stigma inside
Callie Davidson of the Safe Ground project talks about how they are working with serving prisoners to challenge this stigma and thrive. 

11.20–11.40pm Tea, coffee and refreshments
Exhibition Hall

11.40–1.00pm Session two, Conference Hall

PARTNERSHIP WORKING

Peer power – a story of co-production
Cranstoun’s team share their dynamic harm reduction initiatives. Alistair Bryant describes the PACKs peer team’s naloxone distribution and Luke O’Neil explains how they used innovative tech to create BuddyUp.

From policy to practice
Laura Pechey from the government’s Office for Health Improvement and Disparities (OHID), Lanre Babalola, and Ade Babalola of BUBIC discuss their shared determination to embed lived experience in the treatment system.

Community outreach
Marcus Johnson, Christiane Jenkins, Sanjeev Kumar and Karolina Sowinska from SUIT share innovative ways they’re engaging with the wider community, including challenging specific issues around stigma faced by people in Asian and East European communities.

1.00–2.00pm Delicious LUNCH, networking, and a chance to enjoy everything going on in the Exhibition Hall

 

2.15–3.45pm Session three (with tea/coffee available), Conference Hall

THE BIG CONVERSATION

Make sure you are part of this vital interactive session – your chance to contribute to the debate, let people know what’s working, what needs to be done and your ideas for how it should happen. 

Come and share your innovative work, thoughts and ideas with your peers!

We’ll be looking at a series of topics in turn:

Experiences of treatment
How do you challenge ‘one size fits all’ treatment?
What do you do if you’re not happy with the treatment you’re offered?

Peers save lives!
What are you doing in your area?
Which peer-led initiatives are really working?

Let’s talk about stigma
Has stigma ever stopped you from moving forward?
How have you tackled these barriers?
How can we all help to shape, inform and influence work to tackle stigma?

Me, myself, I… where do we go from here?
How can we organise, mobilise and influence – beyond today’s event?

You’ll have chance to speak out if you want to, discuss the topics in roundtable groups, and write down thoughts, suggestions and feedback. This promises to be a lively, collaborative and enjoyable session, which will be central to our write-up in DDN and vital to taking your key issues forward. All welcome – come and join in!

3.45pm – Closing remarks

Conference close – and you are warmly invited to enjoy free entry to the National Motorcycle Museum

We would like to thank all the amazing peers and volunteers who have fed into the programme consultation and are helping to stage and run the conference. We couldn’t do it without you.

Karen Biggs has been chief executive of Phoenix Futures since 2007. Her earlier career was in supported housing and homelessness. She believes in the charity sector and its role in supporting people that the state can’t or won’t help, and is equally passionate about ‘making lovely environments for people to do difficult stuff in’.

April Wareham is director at Working with Everyone, a collective of unique individuals who bring both lived experience and professional expertise. They are driven by the knowledge that the voices and experiences of marginalised and vulnerable people are crucial in improving outcomes. 

Hannah Shead is chief executive of Trevi, a nationally award-winning women’s and children’s charity based in South West England. Trevi provides safe and nurturing spaces for women in recovery to heal, grow and thrive.

Callie Davidson is programmes coordinator at Safe Ground, an award-winning national arts organisation delivering high quality, well-evidenced group work interventions to people in prison and community settings.

Alistair Bryant is media and harm reduction content creator at Cranstoun. He works with the Worcester peer harm reduction team, PACKS (peer-assisted community knowledge & support).

Luke O’Neil has over 15 years’ experience working in the third sector for charities that address and challenge health and social inequalities. He joined Cranstoun in 2017 and as assistant director for business development, he leads on income generation and innovation across Cranstoun services – including the development of new approaches informed by global practice. 

Laura Pechey is programme manager for alcohol and drug treatment and recovery at OHID, the government’s Office for Health Improvement and Disparities. Working in alcohol, drug and recovery service development, delivery and policy for over 15 years, she is passionate about changing the nation’s attitudes to and support for people who use alcohol and drugs. She currently works to improve best practice in drug and alcohol prevention, treatment and recovery through influencing and informing national policy. 

Lanre Babalola is chief executive of BUBIC – Bringing Unity Back Into the Community. He decided while he was in prison to seek help to change the course of his life after 12 years of drug use and began working with drug support services. He teamed up with a group of peers he met in one of the services to set up the award-winning charity BUBIC.

Marcus Johnson is a Project Worker at SUIT – the Service User Involvement Team in Wolverhampton. He is a Level 5 Qualified Integrative Therapist and studying to be a counsellor. 

Karolina Sowinska is a volunteer at SUIT.

Christiane Jenkins is researching a PhD which will identify underdeveloped and disinvested individual and social factors surrounding problem drug and alcohol use. She has lived experience and believes that engaging community groups as co-producers of knowledge, enhances learning, creates impact, and benefits the wider community. She is currently working alongside the Service User Involvement Team (SUIT), Wolverhampton, to develop co-produced mutual aid and peer-led support.

The DDN Magazine and the DDN Conference are all about getting involved, making a noise and sharing your story. By working together we can make real change!

There are lots of ways to get involved on the day and in the magazine.

The Big Conversation (Afternoon session 2.00pm – 3.30pm)

Make sure you are part of this essential interactive session – your chance to contribute to the debate, let people know what’s working, what needs to be done and your ideas for how it should happen. We’ll be wanting your thoughts and ideas around peer-led working and outreach, prescribing options, tackling stigma, and effective peer networking. A lively, collaborative and enjoyable session that will be central to our write-up in DDN and vital to taking your key issues forward.

Naloxone training

Have you got your kit, if not why not! Thank you to Turning Point who are providing free training and naloxone to take away. Please visit their stand in the exhibition area.

Surveys

There are many organisations wanting to canvass your views and learn fro your experience including Anna Millington, April Wareham and Goldsmiths University. Please visit their stands at the back of the main hall to take part. You can even enter a draw to win free stuff!

Share it on social

Spread the word on twitter, insta, facebook, teams and even give it a go on threads! Please use #ddnconf and we can find all the messages and share them and use your contributions for the special issue.

Picture this

We need your help creating the DDN Special issue covering the event and sharing the content on our website. If you take any pictures or video you would like us to use please either share them on social media with #ddnconf or email them to conferences@cjwellings.com 

Have your say

If it is about something discussed at the conference or just a burning issue that you want to get off your chest, DDN is your magazine. Please use it! Please email your letters and comment to our editor claire@cjwellings.com

Sponsors and Supporters:

We are really grateful to the main sponsors of this year’s conference, without them it would not be possible to hold this annual event.

We would also like to thank all of the organisations in the exhibition area. We will be sharing more information about them online and in the special issue but please make sure you visit all of the stands today.

DDN is a free magazine and we would like to thank all of our ongoing advertisers, sponsors and partners, without their support we would not be able to provide a free to read publication.

Venue Information

Thank you to the National Motorcycle museum for hosting this year’s conference.

Museum visits: You can access the museum after the conference free of charge, please just say you have been attending the DDN event.

Wifi: Select the visitor wifi for free access with no login or password required.

Refreshments: Tea, coffee and refreshments will be served throughout the day including a full cooked lunch. Vegetarian, vegan and gluten free options are available but please ask the venue staff if you have any specific requests.

Facilities: There is a lift and full disabled access throughout and a free cloakroom is available to leave bags and coats. If you require taxi’s for the station or any other assistance please ask at reception by the main entrance.

 

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Social media creating unprecedented alcohol marketing opportunities

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DDN
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The explosion in social media use among young people has created ‘unprecedented’ opportunities for alcohol marketers, says a report from the University of Bath and the University of Birmingham. Platforms that are more interactive are especially useful for reaching under-25s, says All night long: social media marketing to young people by alcohol brands and venues.

Social Media

The report, which is funded by the charity formed from the merger of Alcohol Concern and Alcohol Research UK, is the first to study online marketing to young people by venues as well as brands, and found that regulation is ‘struggling to keep up’ with technology. Social media now plays a ‘central role’ for young people in both planning and documenting their drinking occasions, says the report, which follows another recent document from the two charities calling on the government to completely overhaul UK alcohol marketing regulation.  

Researchers found that drinks brands were more popular among younger social media users – including those under the legal drinking age – while 18 to 25-year-olds were more likely to follow local bars and clubs. Images associating alcohol ‘with social success, sexual attractiveness and intoxication’ – which go against self-regulation guidelines – were more common in venue marketing, while responsible drinking messages were included in just 2 per cent of posts by brands and were ‘completely absent’ from marketing by venues, researchers found.  

‘Whereas major brands are liable to have, or be signatories to, codes of conduct for marketing this is not the case for many venues, especially independents,’ says the report. ‘Venue marketing is also very short-term. The speed and volume of social media activity at the very local level poses serious challenges for regulation, especially in a “reactive” system whereby complaints are adjudicated over a number of weeks.’

‘We need to recognise that social media is markedly different to other forms of advertising – it is more focused in its targeting and more transient,’ said report co-author Professor Isabelle Szmigin. ‘The traditional form of reactive complaint process is no longer sufficient.’

Document at alcoholresearchuk.org

Government urged to overhaul drinks marketing regulation

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DDN
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The government needs to undertake a ‘thorough review’ of the way alcohol marketing is currently regulated, according to a report from the charity formed by the merger of Alcohol Concern and Alcohol Research UK.

Fit for purpose? An analysis of the role of the Portman Group in alcohol industry self regulation looks at the regulatory decisions made by the group’s complaints panel over the last 12 years and states that there is ‘inconsistent decision making, lack of scrutiny and an apparent failure to address how modern alcohol marketing works’.

The Portman Group lacks accountability, the report claims, with little or no means to amend or reverse decisions and no appeals body, and with decisions often appearing to be based on ‘opinion’ rather than evidence. The group’s inconsistent decision making means that ‘neither producers nor consumers’ can rely on it for guidance, the document says, while its purpose is ill defined and amounts to little more than a ‘vague statement’ about responsible marketing. ‘Its role in reducing alcohol-related harm is neither clear nor explicit’, the charity says.

The fragmented nature of marketing regulation also plays into the hands of the industry, the report adds, with bottles and cans regulated by the Portman Group, TV sponsorship monitored by Ofcom and adverts overseen by the Advertising Standards Authority (ASA). ‘The regulators look at them in isolation, meaning that none of them is seeing the full picture.’

Richard Piper: ‘We have the right to set boundaries’

‘With roughly one person in the UK dying as a result of alcohol every hour, alcohol is no ordinary commodity, and we as a society have the right to set boundaries on the ways in which it is promoted,’ said CEO Dr Richard Piper.

A statement from Portman Group CEO John Timothy refutes the report’s conclusions and states that the group is ‘open and transparent’ in the way it operates and regulates. ‘Analysing apparent inconsistencies in decisions on complaints ignores changes in the industry and wider society,’ it says, adding that the group updates its code rules every few years to reflect this, such as how immoderate consumption is measured following the shift in government drinking guidelines. ‘Despite what ideologues might say, we have a regulatory system that works. Let’s not waste time, effort and energy arguing about whether it needs to be put on a statutory footing.’

However, Richard Piper stated that the current regulatory system ‘doesn’t work’ and called on the government to launch an independent review. ‘The aim must be to make alcohol regulation fit for purpose, and ensure that regulators have a clearly defined remit and standards of evidence-based decision-making. Such a review offers the perfect opportunity to better integrate the various regulatory strands, so they can be brought together to create stronger protections for all consumers.’

Report at www.alcoholconcern.org.uk

Drugs behind ‘huge increase’ in prison violence

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DDN
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chief inspector of prisons, Peter Clarke.
Peter Clarke: Drugs are behind much of the violence

A ‘huge increase’ in violence across the prison estate has taken place in the last five years, according to the latest annual report from the chief inspector of prisons. As well as coinciding with substantial reductions in staff numbers, the ‘ready availability of drugs in too many of our prisons sits behind much of the violence’, says chief inspector of prisons, Peter Clarke. 

‘In our surveys of prisoners, we are regularly told how easy it is to get hold of illicit drugs in prisons, and of the shockingly high numbers who acquire a drug habit while they are detained,’ says Clarke. Thirteen per cent of adult male prisoners surveyed reported that they had developed a problem with illicit drugs since arriving in prison, with 11 per cent reporting that they had developed a problem misusing medication that had not been prescribed to them. 

The document reveals ‘some of the worst prison conditions ever seen’, with ‘violence, drugs, suicide and self-harm, squalor and poor access to education’ prominent themes. The conditions had no place in the prison system of ‘an advanced nation in the 21st century’, stated Clarke, with the report also detailing the ‘disappointing failure’ of many prisons to act on the inspectorate’s previous recommendations.

 

Much of the violence in the prison estate is driven by ‘widespread use of illicit substances and associated debt, bullying and self-harm’, says the report.

Although suicide rates had fallen, levels remained high, while levels of self-harm had increased by 11 per cent between 2016 and 2017 to 44,651 incidents, with mental health difficulties, drug use and debt again among the contributory factors.

The Howard League for Penal Reform’s director of campaigns, Andrew Neilson, said the ‘excoriating’ report was ‘yet another reminder of the scale of the chaos in overcrowded and under-resourced’ jails that were ‘failing everyone’.

‘No public service in England and Wales has deteriorated as rapidly and as profoundly in recent years as the prison system,’ he said. ‘The chief inspector’s warnings must not be allowed to fall on deaf ears, and what matters now is how the government responds.’

HM chief inspector of prisons for England and Wales annual report 2017–18 at www.gov.uk

 

Perfect partners

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DDN
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As competition for funding heats up it’s time for charities to form meaningful and creative partnerships with the private sector, says Eleanor Youdell.

Read this article in DDN

In May this year East Midlands-based drug and alcohol recovery charity Double Impact marked its 20th birthday with our Spirit of Recovery Awards – an awards ceremony that celebrates the transformative power of recovery and recognises service users, staff, volunteers, and partner organisations for their various achievements and support over the past 12 months.

The event received support and sponsorship from a wide range of private sector companies, including Nottingham’s Park Plaza hotel, which hosted and catered the 150-person event at no cost.

One of Double Impact’s wider goals as a charity – beyond the direct support it provides to those in recovery – is to help break down the societal stigma of addiction. Reaching out and making connections to businesses and employers is an important way of achieving this, as well as raising awareness outside of the third sector.

With public sector funding shrinking and competition for grants increasing, charities are being forced to focus on a wider range of potential funding sources, and we are no exception. Support from the private sector is more important than ever, but how do smaller organisations compete against the plethora of local and national charities with more popular and media-friendly causes than addiction – something that can still be perceived by many to be a lifestyle choice rather than a health issue.

Double Impact has responded to this challenge in a number of ways. Firstly we have embedded employer engagement into a number of our grant-funded projects, such as Recovery Recruitment, a Big Lottery funded initiative that has operated in Nottinghamshire for a number of years. The primary vehicle for this is free drug and alcohol awareness training for local employers, angled towards meeting their needs and addressing issues within their own workforce, and building in participation from volunteers in recovery. The volunteers are able to directly challenge preconceived ideas about ‘addicts’ or ‘alcoholics’ and deliver a powerful message that people in recovery can make as good – if not better – employees as anyone else.

Fruitful relationships have developed with Primark, HMRC, Cineworld, Games Workshop and most recently local confectioners The Treat Kitchen, and several employers have given their support through hosting mock interview sessions that help to prepare people in recovery to re-enter the workplace.

The charity has also raised its profile through our Café Sobar social enterprise, a high street café and alcohol-free venue that is always bustling with city centre shoppers and workers. Set up in 2014, again with the support of a Big Lottery Fund grant, this provides a safe social venue and space for business meetings, community and recovery-focused groups, as well as volunteering opportunities for people in recovery. While the challenge of creating and sustaining a successful business is not to be underestimated – especially for a smaller charity such as Double Impact – we believe it has reaped many benefits in terms of the charity’s ability to engage with the private sector.

Café Sobar literally acts as a shop window for the work of the charity. There is always a mix of people in the café and it’s never obvious who is in recovery and who isn’t, which in itself helps to challenge stereotypical ideas of what addiction looks like. The café provides a way for us to attract business people in a very low-key way, for example through hosting business breakfasts, offering affordable meeting room space or just providing a pleasant place for people to come to have a meeting over coffee or do some work. This means business people are exposed to our cause in a non-threatening and positive way, and can feel good about supporting us through the cost of their usual cup of coffee. Often this then leads on to us being offered other kinds of support.

There are several good examples of this – contact with The Treat Kitchen was initially made through the café, with both businesses planning and participating in a Halloween event together. After becoming aware of the positive impact we were having locally, the company expressed an interest in taking on some Recovery Recruitment participants as volunteers, and then took even greater strides in their support by naming Double Impact their charity of the year.

‘With the volume of collaboration we do with Café Sobar it seemed only natural to pick Double Impact as our chosen charity,’ says The Treat Kitchen’s owner Jess Barnett. ‘We admire what they do and would like to support it and the service users as much as we can. Offering placements within different parts of our business is a great way to do this.’

The relationship is now thriving with several volunteers having successfully gained work experience in various parts of their business. The employers also generously ran an open competition to design a Double Impact sweet, and the winning flavour (chilli and chocolate) is soon to hit the shelves, with all profits going back to the charity. Four of their staff are also raising money by running in the Robin Hood half marathon.

Similarly, a local business club that held an event in the café then invited our CEO to speak at its Christmas lunch – as well as the cash donations generated as a result, the real opportunity was in being able to reach out to so many business people at once, and so far it has resulted in several people committing to run in the Robin Hood marathon for us and sponsor our Spirit of Recovery Awards.

Our current 20th anniversary fundraising appeal has also provided a focal point for businesses to do something for the charity. Over the course of the anniversary year, CEO Graham Miller has been raising funds and awareness through undertaking to run 20 half-marathons in one year.

Combining a popular fundraising activity like running with a story that has caught the imagination of the local media has enabled us to attract support from many people in the private sector, who may have come into contact through the café or heard Graham speaking at a business lunch event. The appeal has also meant we’ve needed to brush up our social media skills, and having a longer-term appeal that generates regular news and updates has enabled us to connect into businesses’ social media networks in a meaningful way.

‘All this is common sense stuff really, but it still feels quite new for us, as it’s easy to shy away from this sort of fundraising due to the sense that it’s an “unsexy”’ cause – perhaps being guilty ourselves of succumbing to a kind of stigma,’ says Graham. ‘In fact, what this year has shown us is that there are many supporters out there, including forward thinking individuals within the business sector, who aren’t afraid to do something different and show their support. Often you find out that there is a personal connection to the cause – as we know, conservative estimates say that one in ten people experience addiction and that this in turn directly affects another seven – so there are plenty of people out there who are affected by this.’

How does all this reduce stigma? The increased willingness of employers to give people in recovery a chance has a huge impact on the individual, and can help to restore confidence and self-belief. Among those employers, HMRC has played a big part in helping service users to take that big leap into the job market by holding mock interview sessions.

‘My colleagues and I were impressed not only by the fortitude and resilience shown by the interviewees, in the face of what have clearly been very difficult circumstances for them, but also particularly by the enthusiasm and positive attitudes which they all demonstrated during the interviews,’ says Julian Bentley, who was involved in the process. ‘We hope that HMRC have been able to contribute, if only in a small way, to helping the interviewees obtain employment.’

‘I was fearful about interviews because the atmosphere is uncomfortable and the spotlight is on me,’ says Tom, one of the interviewees, who is now working full time as an administrator. ‘The mock interviews held at Double Impact with staff from HMRC were a great opportunity to practise being in that atmosphere, have a go at answering questions that I don’t usually get asked, and most importantly get feedback on how well I performed.

‘Interviews have been few and far between for me so I gained a lot from the mock interviews, and I felt more confident going into a real interview a few months later. The experience and tools helped me to secure employment earlier this year.’

‘It’s hard to measure something as intangible as a reduction in stigma, but we believe we’re contributing to a larger movement and the response we’re having locally is very encouraging,’ says Graham. ‘It’s great to have support from businesses that aren’t afraid to lead the way, do something different and make a statement about it – like most things in life, where one goes, another will follow. The willingness of the private sector to demonstrate support for recovery from addiction is worth so much more that any actual financial contribution.

‘It might not be normal yet for a big corporate to choose an addition charity as their charity of the year, but the response I’ve had from the general public and from the private sector to my running tells me that the tide is beginning to turn.’

Eleanor Youdell is business development manager at Double Impact

Puncturing the myths?

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DDN
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Acupuncture is commonly used as a complementary therapy in the substance use field. But how effective is it, asks Natalie Davies.

Read this article in DDN

A recent essay published by Drug and Alcohol Findings asked whether acupuncture can treat acute substance use problems and disorders or relieve symptoms of withdrawal, and included a healthy dose of scepticism about whether acupuncture ‘works’ at all. No doubt some readers thought it went too far in its criticism of acupuncture, and others that it had not gone far enough to distance the practice from accepted evidence-based treatments.

Building on that essay, I want to explore how language may be blurring the lines between alternative and conventional treatments, and why resistance to acupuncture may be more an issue of ethical resistance to placebos, making acupuncture a topical vehicle through which to debate their use.

Traditional acupuncture has been developed over 2,000 years in China, Japan, and other East Asian countries. A self-regulated profession in the UK, traditional acupuncture is delivered outside the NHS alongside other alternative and complementary therapies. Western medical acupuncture, on the other hand, is sometimes available on the NHS but most often paid for privately, and delivered by medical practitioners such as doctors, physiotherapists and nurses as an add-on to their conventional professional practice.

The NHS Choices website doesn’t equate acupuncture with conventional treatment, but does distinguish ‘Western medical acupuncture’ from ‘non-medical acupuncture’ or ‘traditional Chinese medicine acupuncture’ – the first at least sounding more like a conventional treatment. Allied with this is the medical language explaining how it works and the stipulation that Western medical acupuncture is used following a medical diagnosis.

Traditional acupuncture is based on the idea that problems with our health and wellbeing can surface when vital energy known as Qi (pronounced ‘chee’) is prevented from flowing freely throughout the body, and works by restoring the flow of this so-called ‘life force’. In contrast, Western medical acupuncture reincarnates acupuncture as a procedure that stimulates sensory nerves (as opposed to ‘energy’) under the skin and in muscles, causing the body to produce endorphins and other naturally-occurring chemicals.

Acupuncture adherents cite the benefits of treating the person not the condition, and claim in doing so that acupuncture can not only maintain good health and prevent bad health, but improve one’s overall sense of wellbeing. For people so inclined, the gentle insertion of hair-thin, flexible needles is reported to be relaxing, and at the site of the needles is sometimes associated with pain-free feelings of heaviness, aching, tingling and warmth.

For the NHS, acupuncture is currently only recommended for chronic tension-type headaches and migraines, but is also used to treat other types of pain. In the substance use field acupuncture has been a popular alternative treatment for people with cocaine use problems – though this may have had more to do with the lack of an accepted conventional treatment than the particular merits of acupuncture, and the need for acupuncture itself may be illusory as just about any psychosocial therapy helps some of these clients some of the time.

A 2006 assessment from the respected Cochrane collaboration of whether acupuncture at sites on the ear has helped in the treatment of cocaine dependence found definitively that, ‘There is currently no evidence that auricular acupuncture is effective for the treatment of cocaine dependence’. As evidence was limited and from methodologically poor studies, the assessment stopped short of saying that acupuncture was ineffective. Across the spectrum and range of substance use issues, the same or similar conclusions apply.

It could be argued that offering something concrete like acupuncture which both clients and staff believe to be worthwhile might aid a person’s recovery by attracting them to services, and – as some studies have suggested – helping to retain them in treatment. However, the defence of acupuncture in the absence of evidence of effectiveness would then almost certainly take us into the territory of ‘placebos’ – inert procedures wrapped up as medical treatments that may exert an effect, but only to the extent that patients expect or believe they will have an effect.

Any of the perceived ethical ambiguity of placebos was stripped out by a commentary published in the American Journal of Bioethics by Dr Alain Braillon, an alcohol treatment specialist in France. Disputing their ‘benign’ connotations, Braillon argued that placebos fundamentally compromise the precious relationship between doctor and patient, ‘strengthen medical arrogance’, ‘infantilise people’, and ‘can delay the proper diagnosis of a serious medical condition’. As he saw it, placebos were ultimately a lie.

Not coming down so harshly on placebos, the NHS website at one time reminded readers in the context of alternative and complementary therapies that ‘for many health conditions, there are treatments that work better than placebos […and by choosing] a treatment that only provides a placebo effect, [the patient] will miss out on the benefit that a better treatment would provide’. However, it stated ‘improvement in a health condition due to the placebo effect is still improvement, and that is always welcome’. Interestingly, in the last few months these comments appear to have been removed.

Although acupuncture specifically has drawn protestations of ‘sham procedure’ and ‘theatrical placebo’, it has also been able to elicit a certain generosity of hope of the type that may be reserved for interventions of a transcendental nature. Furthermore, as it has fallen between the gaps of alternative and conventional therapies for treating health conditions, whether delivered in a high street clinic or mainstream healthcare space, patients absorbing the cues of the environment and culture may have found themselves yielding to something which at once seems a legitimate medical treatment and an ancient form of healing.

Shu-Ming Wang and colleagues wrote in Anesthesia and Analgesia that ‘Instead of criticizing [the] ancient art [of acupuncture] with arguments culled from modern medicine and science, physicians and scientists should try to integrate current knowledge into this ancient, yet ever-evolving practice so it may be used to treat conditions for which pharmaceutical interventions are ineffective and/or potentially dangerous’.

Perhaps instead of removing acupuncture from the ambit of science as this comment suggested, it could be incorporated within the ‘common factors’ framework as a vehicle for delivering the essence of an effective psychosocial therapy – a credible procedure which offers an explanation for the patient’s condition and a credible remedy that the patient believes in, delivered in a context which gives it the aura of a bona fide clinical treatment.

If there is not so much a ‘lie’ as a false impression at the heart of acupuncture, it may be that it is presented as a physical treatment rather than vehicle for the common factors found in psychosocial therapies. But without that sincerely held conviction, those common factors would be undermined and with them any benefit to be gained.

Natalie Davies is co-editor of Drug and Alcohol Findings

Read more in Findings on acupuncture here

A foot in the door

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DDN
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Seeking healthcare can be daunting for homeless people. DDN visits a practice in north London that takes every opportunity to engage.

Read this article in DDN

‘We haven’t touched the sides of the people sleeping on the streets around here. Everybody comes to Camden, they come to Euston train station, they come to Kings Cross, there are millions of tourists marching up and down Euston Road all the time. So if you want to beg, it’s a good place to be.’ Paul Daly is the practice manager at Camden Health Improvement Practice (CHIP), an NHS service run by Turning Point which provides health services to homeless people.

Walking from St Pancras and past Euston on the way to CHIP means navigating through people of all ages and nationalities, sitting on the street and in doorways. As a drop-in health practice, CHIP welcomes all of them without any need for ID. If you are homeless you can make your way to 108 Hampstead Road and join the morning queue.

At 9.20am doors open and the first nine patients are seen by the doctor. ‘That doesn’t sound like a lot, but they tend to be very complex,’ says Daly. If you have an emergency you can fill out a form and they will squeeze you in; otherwise you will need to turn up again the next day. Appointment slots are supposed to be 20 minutes per patient, but often run way beyond that. ‘We don’t restrict patients to one problem, but there’s a limit to what you can do,’ he says. ‘Some of the patients don’t present very often, so they’ve stored up a whole set of issues and we can’t manage them all.’ The practice has 800 patients at the moment – an increase of 25 per cent in the last two years.

Paul Daly: ‘You have to do everything while the patient is right there in front of you.’

An important routine for each new arrival is the comprehensive health check, lasting around 45 minutes, which includes tests for HIV and hepatitis B and C. This is seen as a golden opportunity to engage, explains Daly. ‘A lot of these patients don’t go to a GP at all – they let themselves get so ill they go straight to hospital and it’s an endless cycle. So at least if they’re coming in here and getting their primary care managed, they have a better chance of stopping that from happening.’

The small team has one and a half doctors and two full-time nurses. They feel very lucky to have the support of a volunteer GP who used to work at the practice and comes back twice a week to do medical reports. In common with everywhere else, budgets (and space) have been squeezed. There’s no longer room for the clothing store, apart from some socks and gloves. Strong partnerships with local hostels and drop-in centres have become more important than ever.

A doctor from CHIP goes out on his bike twice a week to visit the hostels and find ‘the really entrenched people’ who won’t come to the centre, maybe offering a prescription as an incentive to engage. Five or six years ago they were more of an outreach service, running a clinic at each hostel once a week. But it was an expensive way to run the service, needing double the staff and a lot more kit – and no guarantee that patients would be in the right place at the right time to see the clinicians.

The current model allows hostels to send their residents over to CHIP for treatment and holistic care – and the support works both ways. The area has built up a network of specialist support through its drop-ins and day centres, so there are places to refer young people, sex workers, and arrivals from other countries who might need all kinds of help. Peer support is also close at hand through the charity Groundswell, who will take people to appointments – invaluable help since funding is no longer available for the team’s in-house ‘navigator’ post.

Coming through the door at CHIP represents an opportunity. ‘A lot of the time we find you have to do everything while the patient is right there in front of you,’ says Daly. ‘The minute they go out the door, you lose them again.’ Seeing them regularly gives a chance to address longer-term health conditions – although he points out that, sadly, many patients living in the harsh environment of the streets don’t actually survive long enough to develop late middle-age conditions like diabetes and COPD.

But having them in front of you means prescribing what they need: ‘You want them to come back, and if you take a rigid approach to it they won’t come back at all. Then we can work on their other issues – it’s a different concept of medicine to a mainstream practice.’

It’s a ‘massive challenge’ for the clinicians, he adds, as making a judgement on what to do with complex cases can be really difficult. The team’s weekly meetings are a focal point for agreeing the way forward for each patient, bringing in the other services as needed, or attending multi-disciplinary meetings outside. Complex patients might need expertise from mental health, drug services, social services, police and safeguarding.

With the dialogue created around their healthcare comes access to many sources of help. A hepatology consultant visits every two weeks from the local sexual health clinic and is ‘bombarded’ with patients wanting the new hepatitis C treatment. At ‘£40,000 a throw’ triage has to operate, through assessment by a panel.

Patients also have the opportunity to see an HIV consultant who comes in every fortnight, and there is support available for mental health problems and personality disorders. Many patients are referred to the specialist alcohol service in Camden, and Daly comments that ‘getting people to engage with the alcohol service is much harder than the drug service’.

The Citizens Advice Bureau (CAB) worker comes in once a week to help with benefits and housing – and is even more in demand since the benefits system moved online. Another vital visitor is the tissue viability nurse, who comes in one a month to support the nurses and do the more complex dressings. ‘We have patients who have huge leg ulcers because they’ve been injecting for years,’ says Daly. They might come to CHIP for a while, especially if they have come out of prison, and the nurse will get the leg to a point where it’s in a good state. ‘Then they’ll disappear and turn up two months later with the same dressing on, and it’s all gone back to square one again. It looks like something from a war zone.’

Unsurprisingly, the team who run this service ‘go over and above quite a lot’, whether it’s paying for an asylum seeker’s life-saving medication while paperwork is sorted or calling in the crisis team to help a patient with a mental health issue that might take hours and ‘blow the clinic’s schedule apart’. Producing calm from chaos has become second nature to a team that focuses on stabilisation in all its contexts.

There is naturally cross-referral of patients with the drug service upstairs, but the commissioning structure does not make this as easy or logical as it could be with CHIP being commissioned by NHS England and the substance misuse service commissioned by public health.

But Daly is appreciative that the CCG and medicines management team understand the nature of a homeless practice. ‘You can pay £35 just for one dressing, so our dressings budget is through the ceiling. And our antibiotics budget is a lot larger because we have a lot of infections.’ Furthermore, there are no predictable attendance patterns from one day to the next, summer or winter.

If the service was on TripAdvisor, they might have five star ratings; an equivalent endorsement would be those who still come back long after they’ve moved away. ‘People don’t want to leave us, so there are patients that have been here for 20 years,’ says Daly.

Sadly this may need to change as NHS England have told London homeless practices that nobody can stay registered with them for more than 15 months.

‘The theory is that after 15 months with us they will be cured and ready to go back to society,’ he says, ‘so you have to move everybody on, which is totally unrealistic. It was obviously written by somebody who has never come to a practice.’

High stakes

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DDN
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While a harmless diversion for many, for some people gambling can mean losing everything – even their life. With treatment provision still sparse, Jody Lombardini and Danny Hames set out how one clinic has been providing much-needed help.

 

Read this article in DDN

Recent public debate regarding fixed odds betting terminals (FOBTs), the increasing density of betting shops – particularly in more deprived areas – and the prominence of gambling advertising on television has created a much needed spotlight on the blight of gambling for many of those affected.

The Gambling Commission’s 2017 report indicated that 0.7 per cent of those who gambled in the past 12 months identified as problem gamblers (compared to 0.5 per cent in 2015), with 5.5 per cent identified as at-risk gamblers, and around 430,000 having a serious habit.

How many of these are individuals who also experience problems with drugs and alcohol, and do we identify this in services – even if it is an unmet need that needs highlighting to our commissioners?

Gambling is an addiction, and the NHS Substance Misuse Provider Alliance  (NHSSMPA) hope that extra funding is provided to increase access to treatment for those affected. Why? Because we know it can be effective – one of the NHSSMPA members, Central and North West London NHS Foundation Trust (CNWL), has long been at the forefront of providing support to gamblers. Below, Jody Lombardini shares its story on the tenth anniversary of the CNWL National Problem Gambling Clinic (NPGC).

MAKING A DIFFERENCE

Thousands of patients have walked through the NPGC’s doors over the past decade. In that time its influence has been felt far and wide, and we are very proud of it – our internationally renowned facility is still the only NHS clinic designed to treat gambling disorders. We’re finding our services are required more than ever, with the numbers of people with gambling-associated problems having reached around half a million, while many millions more are impacted by the problems caused.

The clinic treats problem gamblers living in England and Wales aged 16 and over. It assesses not just their needs, but also those of their partners and family members and provides a variety of treatments. It has also served an essential function since its inception in training mental health professionals in the treatment of problem gambling.

The importance of our clinic was acknowledged by the government in June when health secretary Jeremy Hunt joined with a variety of guests in unveiling a plaque to mark its tenth anniversary. I was pleased to hear Mr Hunt acknowledge that the NHS needed to do more to help the types of patients we see, and pledge to work with Public Health England to carry out a review of services and the client group in order to inform action on how to prevent and treat this issue. I was struck by his words: ‘We want to remedy this.’

The clinic was founded by consultant psychiatrist Dr Henrietta Bowden-Jones at a time when knowledge of gambling addiction was limited and support was sparse. The basic ethos was that something was needed to help people in the grip of a gambling addiction – our chief executive, Claire Murdoch, bought into this vision and has supported it ever since.

That was then, and now we have a long-term vision and hope for an expansion of dedicated services modelled on the NPGC across the country, combined with increasing awareness of problem gambling. At the unveiling of the plaque, Dr Bowden-Jones said, ‘We are optimistic that the next decade will bring what we have wished for from the day we started. This country needs to acknowledge problem gambling as an illness, as an addiction just like any other. In doing so it needs to accept responsibility for the treatment of the half a million patients currently suffering from this disease.’

As CNWL’s head of addictions I thoroughly endorse this vision. I have read and heard too many stories of patients whose families have been destroyed by gambling and heard too much about the numbers who have come to us having considered self-harm, or considered or attempted suicide. These are the lucky ones, however. We’ve all read about those who committed suicide having lost everything through gambling and had seen no way out.

We offer hope and help – both to gamblers and to their families.

Those who come to us will typically have had:

  • A lengthy period of problem gambling, with little or no abstinence
  • Previous unsuccessful structured psychological support for problem gambling
  • Mental health difficulties
  • Substance misuse or other compulsive behaviours
  • Concerns about risk of harm to self or others
  • Serious physical health difficulties
  • Homelessness or unstable housing or chronic social isolation
  • Frequent involvement with the criminal justice system or history of serious offending
  • Developmental disorders such as attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD) or difficulties with cognitive or intellectual functioning
  • Adverse experiences in childhood.

To be treated at CNWL’s national problem gambling clinic, people can self-refer or be referred. If accepted for treatment, a proven and effective help is cognitive behavioural therapy (CBT), which is provided on an individual and group basis. Psychodynamic psychotherapy is another option and may be used with those who have failed to maintain abstinence using CBT methods, or for those who are clear that there are emotional reasons for their lapses.

With the emphasis also on the family, the clinic offers behavioural couples therapy, while another option is medication, specifically naltrexone to suppress cravings. What’s clear is the gratitude of patients helped by the clinic, who through our help have managed to rebuild their lives. To mark its work, the clinic is also holding a conference at the Wellcome Collection in Euston Road on 8 October from 10am to 4pm.

The NHSSMPA behaviour change conference also takes place at the Wellcome Collection, on 17 September where CNWL will be presenting its work to delegates. For more information, or for NHS providers to find out how to be part of the alliance visit www.nhs-substance-misuse-provider-alliance.org.uk.

Jody Lombardini is head of addictions at CNWL

Danny Hames is head of development at NHSSMPA

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ALL BETS ARE OFF

Are Britain’s betting problems getting out of hand?

Gambling made national headlines with the government’s recent move to cut the maximum stake on highly controversial FOBTs from £100 to £2 (DDN, June, page 4), but how big is the UK’s gambling problem? It’s certainly large enough for PHE to launch an evidence review into its public health harms, and according to the Gambling Commission 45 per cent of people will have gambled in the last four weeks (although this includes activities like taking part in National Lottery draws or buying scratchcards).

The industry’s marketing budget is also huge, with betting companies spending around £150m a year on TV advertising alone – research by the BBC last year found that around 95 per cent of advertising breaks during live UK football matches had at least one gambling advert.

Using the Problem Gambling Severity Index (PGSI), 3.9 per cent of adults are categorised as ‘at-risk’ gamblers, while 0.8 per cent per cent of people over the age of 16 now identify as problem gamblers – defined as gambling ‘to a degree that compromises, disrupts or damages family, personal or recreational pursuits’.

According to the Royal College of Psychiatrists’ 2014 report, Gambling: the hidden addiction, the harm doesn’t stop there. For every problem gambler there are between eight and ten other people who are ‘directly affected’ – children, friends, family members and spouses, some of whom will experience domestic violence. The same document pointed out that treatment services, funded ‘almost exclusively’ by the industry itself, remained largely ‘underdeveloped, geographically patchy, or simply nonexistent’.

The Gambling Commission identifies the British gambling market as ‘one of the most accessible’ in the world, with a proliferation of betting shops on the high street and the internet bringing opportunities to gamble into ‘virtually every home’. While gambling is clearly something that many people will enjoy as an occasional pastime – having ‘a flutter’ on the World Cup, for example – for a minority it can lead to loss of their relationship, family, job, home and even life.

Gambling participation in 2017: behaviour, awareness and attitudes at www.gamblingcommission.gov.uk

Gambling: the hidden addiction at www.rcpsych.ac.uk

High risk strategy

By
DDN
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Failure to provide naloxone at the point of release for most prisoners is putting lives at risk, says John Jolly.

Read this article in DDN

Those leaving prison having had an opiate problem are seriously at risk of having a life-threatening overdose or dying as a result of one. Both Public Health England (PHE) and the government have been clear in their recommendation that all local areas need to have appropriate naloxone provision in place. However, prisons have so far failed to implement provision at the point of release across much of the estate, and this is putting lives at risk.

 

Blenheim workers have found that it’s rare for any of our service users to be released from prison having been provided with naloxone, medication that is literally life-saving in the case of overdose. PHE’s strategy to reduce drug-related deaths identifies discharge from prison as the point of maximum risk of overdose and maintaining contact with treatment services as a key intervention to stem the rise in drug-related deaths.

The NHS is responsible for provision of treatment services in prison, including naloxone, but refuses to take a national view. At one point the NHS even argued that as the prisoner would use naloxone outside of the prison it was not their responsibility, and each local authority should arrange to fund, provide, and negotiate arrangements for the supply of naloxone at the point of release. To expect them to do this with more than 100 prisons is something that anyone can see is ludicrous, but currently the NHS says it is for local NHS areas to decide.

It has proved difficult to get NHS England to provide clarity about what is going on as they are reluctant, or unable, to do so when asked. Below are a couple of replies given to questions by Grahame Morris MP that will have been prepared by officials for the government’s response.

Question: To ask the secretary of state for health and social care, how many and what proportion of prisoners with a history of opioid misuse were provided with naloxone when released from prison in the latest year for which information is available; and from which prisons those prisoners were released.

Reply (May 2018): Information on how many prisoners are provided with naloxone when released from prison in England is not currently available. This data is due to be published in 2019.

Question: To ask the secretary of state for health and social care, if he will bring forward legislative proposals to make the supply of the opioid-overdose antidote naloxone to all at-risk prisoners upon their release a mandatory requirement for prisons.

Reply: Naloxone has a vital role in saving lives and the government is committed to widening its use in England. There is no national programme that mandates the supply of naloxone for at-risk prisoners on their release, and the government does not have any plans to bring forward legislation to make this a mandatory requirement for prisons. The commissioning of substance misuse treatment for prisoners is the responsibility of health and justice commissioning teams in ten of NHS England’s area teams, supported by a central health and justice team. The government expects commissioners and providers of substance misuse services in prisons and in the community to work together closely in respect to prisoners being released from custody to ensure seamless transfers of care.

So according to NHS England they have not got a clue about what is happening and their best estimate is they may know in six months time. Or, as I suspect, they are putting off releasing the information and will do so for the foreseeable future. How long does it take to ask prisons the following three questions:

1)  Are you providing naloxone at point of release?

2)  Are you providing naloxone and overdose training?

3)  How many naloxone kits have you given out?

Well let me try and help them out a bit. There are currently at least 36 prisons in England and Wales claiming to give out naloxone on release – a low percentage. There may also be others that I and my sources are unaware of, but just because someone at a prison says they are providing naloxone it doesn’t mean they are handing out many, or any, kits. In Scotland, where all prisons are supposed to be providing naloxone at the point of release, the position is depressing – in one prison in the last year only 24 kits had been provided, while in another none had been handed out. Operational difficulties are often cited as the reason for this, a common excuse that covers most prison failures.

On the NHS website it says that NHS England health and justice teams commission to the ‘principle of equivalence’ which means that the health needs of a population ‘constrained by their circumstances are not compromised’ and that they receive an equal level of service as that offered to the rest of the population. It goes on to say that NHS England health and justice commissioning supports effective links with CCGs and local authorities to support the delivery of social care within secure settings and the ‘continuity of care’ as individuals move in and out of them.

Failure to provide naloxone at point of release, along with the breakdown in continuity of care – documented in response after response to the ACMD in relation to custody-to-community transitions – demonstrate a clear failure to live up to these statements. I am starting to wonder how much stigma and prejudice underlies this – I am sure diabetics requiring insulin do not suffer in the same way.

So to recap, why does naloxone at the point of release matter? A recent large scale Norwegian study examined the deaths of all prisoners in the first six months of their release over a 15-year period – the sample comprised 92,663 prisoners released a total of 153,604 times, and the study found that overdose was the most common reason for death at every time period within the first six months post-release.

During the first week post-release, overdose deaths accounted for 85 per cent of all deaths, with accidents accounting for 6 per cent and suicide for 3 per cent. Overdose deaths peaked during the first days post-release, and thereafter declined gradually during the first month.

During the second week the total number of deaths approximately halved, with overdose deaths accounting for 68 per cent of all deaths. During weeks three to four and months two to six, overdose accounted for 62 per cent and 46 per cent of all deaths, respectively. For several years, Norway, like the UK, has been ranked as one of the European countries with the highest rates of overdose mortality, often explained by high rates of injecting drug use and an ageing poly-drug using population.

Recent UK research also found that the first week following prison release was the period of highest risk of mortality with drug-related deaths the main cause.

By now it will come as no surprise when I say we do not have an accurate figure of the number of drug-related deaths of recently released prisoners in England and Wales. Please NHS, help sort this out and start preventing these needless deaths.

John Jolly is chief executive of Blenheim CDP

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DEADLY DESIGN

The uneven provision of naloxone by prisons is representative of wider barriers to continuity of care from custody to community, says a new Blenheim report (see news, page 4). High death rates of opiate-dependent prisoners post-release and high dropout rates in community treatment are ‘symptomatic of critical failures in the system’, says Failure by design and disinvestment: the critical state of custody-community transitions, prepared by Russell Webster.

Funding cuts across the criminal justice system and changes to probation services mean that ‘quality, supported transitions’ are now the exception rather than the rule, the document states. One key area of concern is the depleted funding for the Drug Intervention Programme (DIP), which had provided the mechanism to ensure joined-up transitions, and the report urges the government to return to a ‘fully funded and sustainable case management approach’, along with naloxone provision for those at risk, in order to avoid further needless deaths.

Your shout!

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DDN
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DDN welcomes your Letters. Please email the editor or post them to DDN, CJ Wellings Ltd, Romney House, School Road, Ashford, Kent TN27 0LT. Letters may be edited for space or clarity.

Significant step

I write to congratulate the National Assembly for Wales on passing the Public Health (Minimum Price for Alcohol) (Wales) Bill on 19 June. The introduction of a minimum unit price for alcohol in Wales is a significant step towards helping people around the country who struggle with alcohol misuse.

Every day in Salvation Army churches and centres we witness first-hand the damage caused by alcohol dependency to society. Alcohol misuse can have a devastating effect on our sense of self-worth and physical, mental, emotional and spiritual health. It can damage our ability to form and maintain relationships, to hold down a job, and can often lead to financial hardship, isolation and loneliness.

Since the nineteenth century, The Salvation Army has worked with women and men with problematic substance abuse. Today our support services for people who misuse alcohol include preparation, detoxification and aftercare services along with psycho-social support, education and training.

We are a long-term supporter of the Welsh Government’s attempts to tackle the devastating effects of alcohol misuse on individuals and communities and have given evidence to the Health and Sports Committee about the need for a minimum unit price for alcohol.

The Salvation Army has also developed an addictions strategy for 2018-21 which sets out our clear commitment to continue to bolster the Welsh Government in its delivery of extensive social programmes helping individuals, families and communities to make positive choices about the role of alcohol in their lives.

Major Lynden Gibbs, territorial addictions officer, The Salvation Army UK and Northern Ireland Territory, London

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Don’t put us down

The ‘all or nothing’ article (DDN, April, page 12) appeared to slate people’s choices of going to NA or other fellowships etc, which account for the majority of people reaching abstinence through 12 steps. It’s the usual argument that people are vulnerable and new­comers preyed upon, which happens everywhere – churches, work places etc.

The 12 steps allow people who are addicts to recover the parts of themselves they have lost.

For the last 25 years abstinence has proved to be the only way for me, as someone who was a chaotic drug user and addict. Some people are just drug users, they are not addicts – there is a difference, and if they think they can successfully go and use after a period of abstinence then either they’ll be back or dead, or they were never addicts in the first place.

I have watched many people, including close friends, try controlled drinking, only to see them die or use for years and struggle because of the traits of an addict – shame, pride, etc – and refuse to ask for help, which is a sad reflection on society, never mind fellowships.

NA continues to save many lives and will do forever, as we are fully self-supporting and we don’t need outside money to function. No one will turn up and say your funding has come to an end, like lots of other services.

Going to a programme of complete abstinence is hard work if you still want to use, so people who don’t get it then blame the fellowship instead of looking at their own patterns of behaviour. Let’s keep encouraging people to find people they identify with at the level they need.

I hear these criticisms regularly but it’s hard to criticise the second largest fellowship in the world when so many people not only get clean, they work through a programme to feel clean inside as well. Dealing with things from the past and amending things is a wonder­ful way of making sure you don’t return.

Some people, and I include some of the resentful readers who emailed you, obviously have had bad experiences and, in my experience, it’s usually they who cause more damage in these places.

Where else offers phone numbers to use 24 hours a day, people who open rooms freely, turn up when the support is asked for, and don’t turn you away for being under the influence like lots of other services?

If anyone new read that article, it highlighted mostly negative aspects. When people see something working well they always want to bring it down. Why not try a meeting or two yourself as it’s open – no secrets and definitely not a cult who chant in rooms. So please stop putting that out there – we work in co-operating with all.

Allan Houston, by email

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On course?

What happened before treatment courses were available in prisons and specifically to ‘lifers’? My view is simple – lifers were released without interven­tions of any kind. If the historical perspective is to be believed, lifers as a released group reoffended in a minority of cases. This has continued to this day.

But we do not hear this view, do we? All I’m hearing is to complete this course, then this one. I’m writing to get my view challenged – did or did not lifers get released quicker before courses hit custody with a vengeance in the early ’90s. And if so, what ultimate use are the courses?

John Burns, HMP Frankland

Media Savvy

By
DDN
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The news,
and the skews,
in the national media

 

Whatever view of the cannabis issue is taken – and The Independent has always been open-minded and pragmatic in its belief – the medicinal use of cannabinoids is a narrower and more straightforward matter. Hospitals and GPs, by analogy, already make use of opioids, real and synthetic, both as painkillers and as heroin substitutes for certain addicts. It is something that is happening every day and, on balance, is something that has relieved human suffering. Even the most militantly conservative sections of opinion shouldn’t challenge those. Yet cannabis oil, a far less hazardous potion than the opioids, has provoked a moral panic as only the British are capable of.
Independent editorial, 18 June

The problem with these rancorous but sterile arguments for and against legalisation and decriminalisation is that they divert attention from what should and can be done: a sustained campaign to persuade people of all ages that cannabis can send them insane.
Patrick Cockburn, Independent, 25 June

Young people who take drugs at music festivals are only victims once they die. Until then they’re criminals, and know it… To change this, all we really need to do is care about drug users before they die, rather than only afterwards.
Hugo Rifkind, Times, 4 June

A smart government would decriminalise milder [cannabis] variants for those over 21, and make skunk a class A drug… While decriminalisation is the policy of the Liberal Democrats and the aptly named Greens, even Jeremy Corbyn, that doyen of Glastonbury, hasn’t adopted it for Labour. Legalisation will come eventually. The demographics of age make it inevitable. No one under 60 who isn’t a Tory MP believes that non-skunk cannabis is a serious menace. Already, a plurality of those polled favour its licensed sale. The margin will grow with natural wastage until the electoral maths make even the Mail’s opposition irrelevant.
Matthew Norman, Independent, 3 June

For a generation obsessed with all things ethical, isn’t it unethical to buy drugs when there’s so much baggage surrounding the trade?… with cocaine use on the rise in Britain – an estimated 3.6p per cent of millennials took the drug last year, well above the EU average – this is one area where young people clearly have a moral and ethical blind spot. As a millennial myself, I find my generation’s complicity hard to stomach.
Tomé Morrissy-Swan, Telegraph, 14 June

It is the thousands of selfish people, with more money than sense, who buy illegal drugs and sustain the whole great stinking heap of wickedness which they bring into being. They should be made to be ashamed of themselves, and to fear the law, made for the benefit of all, which they callously break.
Peter Hitchens, Mail on Sunday, 17 June

 

A fear of the new?

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DDN
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Consultation has been launched on online prescribing. Take the opportunity to contribute to better understanding, says Nicole Ridgwell.

The General Pharmaceutical Council (GPhC) has just launched a consultation on changes to their 2015 guidance for pharmacy services provided on the internet or at a distance. The consultation runs until 21 August 2018, and I strongly urge all such providers to contribute.

Significantly, the consultation’s tone is one of concern rather than collaboration. In the introduction, it states that GPhC ‘are increasingly concerned about the way some services appear to undermine the important safeguards that are in place to protect patients from accessing medicines that are not clinically appropriate for them’.

There is much of note within the consultation and providers must consider the detail to appreciate the potential consequences. For example, the consultation advises that ‘a good pharmacy service will verify the patient’s identity so that the medicines are right for the patient’ – within itself, wholly unarguable, but how to verify? I have seen a provider criticised for not contacting a service user’s NHS GP, where the service user had explicitly refused consent.

Also in the consultation, ‘We believe that there are certain categories of medicines that may not be suitable to be prescribed and supplied online unless further action is taken to make sure that they are clinically appropriate for the patient’. The list includes:

•  antibiotics

•  opiates and sedatives

•  medicines for mental health conditions

This would have a potentially huge (and hugely financially damaging) impact on the sector, if providers are not prepared. The consultation’s timing and sector scrutiny is unsurprising. A cursory Google search brings up numerous cases in which service users died or were seriously injured after taking inappropriately prescribed medication. Many involve individuals who, for whatever reason, did not divulge their full medical history to an online prescriber. This is of course a risk with prescribing in any environment, but regulators argue that there are greater inherent safeguards in the traditional face-to-face interaction with a GP.

Providers will highlight the safeguards that have already been built into online service provision and that current criticism is more a reflection of fear of ‘the new’ (and the financial impact on ‘the traditional’) than any legitimate concern. It will always be the case that new approaches encounter suspicion and scrutiny; it is to be expected. This is not the time for the sector to stick their fingers in their ears and merely hope that regulators will learn to trust them soon.

Providers should instead treat this consultation as an opportunity; to demonstrate their willingness to engage, to explain their safeguards, to demonstrate their procedural safety and their rationales. It is the absence of understanding which is more likely to engender fear and retaliation. I therefore urge providers – take this opportunity to allow the GPhC to understand you.

Nicole Ridgwell is solicitor at Ridouts Solicitors

 

DDN July/August 2018

By
DDN
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‘Partnerships have brought a culture change’

Tackling stigma is always a challenge, so we were interested to hear of Double Impact’s strategy to connect with business and employers (this month’s cover story). Looking at ways to raise funding, they worked hard to create productive partnerships with local businesses, which have not only opened up income streams but helped to bring about culture change. Their progress in creating meaningful employment opportunities and experience is heartening.

Changing culture is proving as difficult as ever at policy level. Why is naloxone not being provided to prisoners on release, when drug-related deaths are the main cause of mortality during the first week of release (page 14)? How can we be going round in circles on tackling drug-related deaths when this straightforward intervention could save so many lives? As John Jolly says, ‘please NHS, help sort this out’. We have the knowledge and the kit to act on this now.

One area where we need to build up knowledge quickly is around gambling addiction, and NHSSMPA’s article on page 12 shares the example of a clinic that provides much-needed help. And while we’re looking at different approaches to treatment, does acupuncture deserve a place in the treatment armoury? Natalie Davies examines its effectiveness on page 8.

We’ve been delighted with the response to our first Wider Health supplement on alcohol in last month’s issue, and our feature from visiting a clinic at a homeless practice on page 10 demonstrates frontline holistic healthcare at its most effective.

Claire Brown, editor

Read the latest issue as a PDF or online magazine

Keep in touch at www.drinkanddrugsnews.com and @DDNmagazine
Join us on Facebook!

Your letters and feedback are always welcome, along with suggestions for articles. Please email the editor here

Scotland records highest ever drug deaths  

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DDN
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Scotland has yet again recorded its highest ever number of drug-related deaths, at 934. The 2017 figure is 8 per cent up on the previous year (DDN, September 2017, page 4) and more than double the number from a decade ago. Scotland’s drug-death rate remains the highest of any EU country, and is around two and a half times that of the UK as a whole.

David Liddell: ‘Imagine drug strategy was based on the notion that people had the right to life’

Almost 40 per cent of the deaths were of people aged 35-44 and just under 30 per cent were in the 45-54 age group. Males accounted for 70 per cent of the deaths. As in previous years, the Greater Glasgow and Clyde NHS board area recorded the highest proportion, at 30 per cent. Opioids were implicated in ‘or potentially contributed to’ 87 per cent of the total number of deaths, with benzodiazepines implicated in or potentially contributing to 59 per cent.

The ‘sheer toll’ of drug-related deaths represented a ‘staggering weight carried by families and communities and the wider Scottish nation’, said Scottish Drugs Forum CEO David Liddell. ‘Just over 10,000 people have now died since these figures were first issued in 1996. That is the equivalent of the entire population of a Scottish town like Fort William or Stranraer or Methill or Haddington. Last year was a record high – and so was the year before and the year before that.’

Although Scots were now more than five times more likely to die from drugs than in traffic accidents the deaths were ‘entirely preventable’, he stated. ‘We know how to prevent drug-related deaths – and yet we don’t do all that we could to prevent them.’ It was vital that people had access to ‘high quality healthcare and support’, he stressed, as well as being removed from ‘the dangers of unregulated street drugs’.

‘A new Scottish drugs strategy is due to be announced – imagine it was based on the notion that people had the right to life,’ he said.

Although the vast majority of deaths were among men, the percentage increases between 2003-07 and 2013-17 were far higher for women – at more than 200 per cent – and a separate report suggests that reasons may include increasing rates of physical and mental health problems among women who use drugs, as well as factors such as abusive or coercive relationships, sex work and the impact of welfare reform.

‘It is unsurprising that mortality figures can be high in areas of deprivation especially at a time when drug-related deaths are rising nationally – when deprivation is often seen within an ageing cohort of drug users with increasingly complex health conditions,’ said Mike Pattinson, executive director at Change, Grow, Live (CGL). CGL staff were employing an assertive outreach approach, working directly with individuals who had been treated for a previous drug overdose.

Meanwhile, a new report from Blenheim says that uneven provision of naloxone is contributing to high rates of fatal overdose among prisoners in the period immediately after release, a situation CEO John Jolly described as ‘totally inexcusable’. ‘Too many people are falling through the gaps and too many people are dying,’ he said.

Drug-related deaths in Scotland in 2017 at www.nrscotland.gov.uk

Why are drug-related deaths among women increasing in Scotland? at www.gov.scot

Failure by design and disinvestment: the critical state of custody-community transitions at blenheimcdp.org.uk – read more on this report in our next issue, out on 9 July.

Opiates and cocaine ‘bigger global health threat than ever’

By
DDN
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Record-high production levels for opiates and cocaine, coupled with expanding drug markets, mean the drugs are now a ‘bigger global threat to public health and law enforcement than ever before’, according to UNODC’s latest World drug report.

Global opium production grew by 65 per cent between 2016 and 2017, the highest estimate ever recorded by UNODC, with production in Afghanistan increasing by a ‘profoundly alarming’ 87 per cent (DDN, December/January, page 4). Global cocaine manufacture, meanwhile, also reached its highest ever level in 2016, at an estimated 1,410 tons. The number of people worldwide who inject drugs now stands at around 10.6m, says the document, with more than half of them living with hepatitis C and one in eight living with HIV.

The world drug situation now presents ‘multiple challenges on multiple fronts’, says the agency, with pharmaceutically produced opioids accounting for 76 per cent of all non-medical prescription drug deaths. As well as the worsening problem with fentanyl in the US, tramadol is now becoming ‘a growing concern’ in parts of Asia and Africa, says the report. Global seizures of pharmaceutical opioids amounted to almost 90 tons in 2016, the vast majority in west, central and north Africa.

António Guterres: ‘Advance prevention and treatment’

UN secretary-general António Guterres urged countries to ‘advance prevention, treatment, rehabilitation and reintegration services; ensure access to controlled medicines while preventing diversion and abuse; promote alternatives to illicit drug cultivation, and stop trafficking and organised crime.’

Meanwhile, the latest figures from the Scottish Drug Misuse Database reinforce the narrative of an aging cohort of entrenched drug users, with the proportion of people assessed for specialist drug treatment who are over 35 increasing from under 30 per cent to more than 50 per cent in the ten years to 2016-17.

However, the numbers also point to declining heroin use overall – while heroin remains the most common substance for which people seek treatment, the percentage of those reporting it as their main drug has fallen from 64 per cent to 46 per cent over the same decade. Rates of injecting and needle/syringe sharing have also fallen, from 28 to 18 per cent and 12 to 6 per cent respectively.

World drug report 2018 at http://www.unodc.org

Scottish drug misuse database annual report at www.isdscotland.org

Campaigners call for urgent reform in sixth annual day of action

By
DDN
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The sixth Support. Don’t Punish global day of action is taking place on 26 June. Last year saw events in more than 200 cities across 93 countries, as people came to together to call for drug policies that are ‘anchored in public health and human rights’. ‘We are on course to break this record,’ say the organisers of this year’s activities.

As always, the events are timed to coincide with the UN’s International Day Against Drug Abuse and Illicit Trafficking, which is used by some governments to mark their contributions to the ‘war on drugs’ and can include beatings or even executions of drug offenders. The aim is that participants in the day of action can ‘reclaim the message’, says Support. Don’t Punish.

The campaign’s key aim is that future drug policy should focus on health and harm reduction. It wants to see an end to both the criminalisation of people who use drugs and the use of harsh or disproportionate punishments for people involved in the drugs trade at lower levels, particularly ‘those involved for reasons of subsistence or coercion’. Finally, the death penalty should never be imposed for drug offences, it states.

Find out more at supportdontpunish.org

‘I am a’ responses

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DDN
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Minimum pricing law passed in Wales

By
DDN
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The National Assembly for Wales has approved the introduction of minimum unit pricing (MUP) for alcohol. Approval of the Public Health (Minimum Price for Alcohol) (Wales) Bill, which was introduced late last year (DDN, November 2017, page 4) means that MUP will become law as soon as it has received Royal Assent.

Wales sees around 55,000 alcohol-related hospital admissions a year, at a cost to the NHS of more than £150m, and in 2016 there were more than 500 alcohol-related deaths. Minimum pricing became law in Scotland in May, following a five-year legal battle with the drinks industry, and there is now pressure on England to introduce similar legislation.

Vaughan Gething: ‘An opportunity for step change’

‘I’m very pleased the National Assembly has given its seal of approval to our landmark legislation,’ said health secretary Vaughan Gething. It would provide an opportunity for a ‘step change’, he said, taking ‘a sensible, targeted approach to a very real and evident problem’.

‘But it will be supported by a range of additional actions being taken forward to support those in need – forming part of the Welsh Government’s wider substance misuse strategy,’ he continued. ‘Wales, like so many other western countries, has a problem with cheap, strong, readily available alcohol. This legislation will make an important contribution to addressing this issue.’

A patient worth saving?

By
DDN
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We need to talk about service user involvement,
says Nick Goldstein.

Service user involvement, in one form or another, has been around a long time. An argument could be made that it’s been around since Hippocrates carved healing out of theology, superstition and belief to create modern medicine. He actually asked his patients to describe their symptoms and how their treatment was going and used their feedback to improve treatment, which sounds familiar.

Read the full article in June 2018 issue of DDN

Service user groups arrived in modern Britain with the forming of community health councils in 1974. Their stated aim was to allow the ‘public’ to participate in their own health and social care – and that public included service users.

The arrival of New Labour in 1997 marked the apogee of service user involvement in Britain. One of the government’s first acts was to legislate for greater public engagement in healthcare, so the NTA, PCTs et al all promoted, encouraged and even funded service user groups. But even at its peak, service user involvement often gave the impression of being an afterthought – something that had become a legislative obligation and hence tolerated by service providers, rather than a concept that was loved and appreciated.

A change of government in 2010 brought a change of agenda and the beginning of the decline of service user involvement. The adoption of the recovery agenda resulted in recovery-orientated services and recovery-focused service user groups, and their concentration on life post treatment meant that much of the emphasis on improving treatment and policy was lost. It also resulted in funding cuts, making it difficult to operate meaningful service user groups and furthering the disinterest in service user groups and what they had to say.

This is where service user involvement languishes at present – as an underfunded afterthought that only really exists to tick boxes. To be clear, service user involvement is gravely ill. The question is, is the patient worth saving?

The question alone will be heresy to some, but maybe the time has come to examine what service user involvement was supposed to be, what it actually became, and what it should be. Its initial aim was to empower users to improve their own health by involving them in partnerships with service providers, to improve and monitor services. That’s actually two subtly different aims – and that schism between the two aims is the root of the problem.

Firstly, there’s service user involvement as therapy for users. This could be sarcastically referred to as the service user involvement of pony riding trips and opera visits, but it would be short sighted or wilful blindness not to accept that it provides vital support and structure to many service users who are already marginalised.

It’s the second aim that’s the problem. Service user involvement has, and will, continue to be an abject failure in provid­ing user expertise in improving services and holding service providers to account.

The reasons for this failing range from the inclusive, democratic nature of the service user involvement model failing to provide the necessary level of expertise in its representatives; through to the reluctance of professional service providers to listen to amateur service users and the stigma that can be found in professional service providers’ reluctance to listen to a bunch of drug users.

Service user involvement in other areas of health and social care also suffers from this, although not to the same degree as substance misuse user groups. It seems that a service provider’s approach to it is directly proportionate to their preconcep­tions of their service users in general – which can be just as negative as those found in the general public. The blame for using such a flawed model can be spread around, but the bottom line is that service user involvement as a model fails to have an impact on treatment policy.

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 While writing this article I called several leading lights from service user involvement for research, and one question I asked them all was to name one national policy change that has been driven solely by service users. I’m still waiting for someone to come up with one – a silence that speaks volumes.

Substance misuse services are approaching major change – partly the result of changes to patterns of drug use, partly due to significant funding cuts – and it’s essential drug users engage with civil servants, politicians and treatment providers to ensure ‘best practice’ maximises resources and is as beneficial to drug users as possible. Service user involvement has repeatedly failed to provide a means of meaningful policy engagement and there’s no reason to believe this will change in the future. Consequently it’s imperative for all parties to find an alternative model.

This search for a functioning model doesn’t mean it’s the end of the road for service user engagement. Rather, what’s needed is an acceptance of the model’s limitations and a reappraisal of how to maximise its potential. Its sole aim needs to become a therapeutic tool for users on a local level, where its organic development can be supported by service providers. A meaningful service user group is always organic because it requires at least one service user, preferably with links to the local community, to manage and lead it. They cannot be artificially created or manufactured, but should rather be appreciated and supported whenever and wherever they flower.

I’ve been around substance misuse treatment long enough to see the pendulum swing back and forth, and in time the pendulum will swing back to favouring patient participation again. When it does, let’s be realistic regarding service user involvement’s role. What it does well should be supported – and for what it can’t do, we need to find another model.

Nick Goldstein is a service user

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Nothing about us…

In January 2006, Alan Joyce told DDN why effective service user involvement was so vital. This extract shows that his words are as relevant today as they were 12 years ago

There is overt hostility on the part of some practitioners to the very idea of ‘treating’ drug users, exemplified in the words of one GP to a patient for whom I advocated: ‘I am not here to provide you with free drugs. Come back when you are clean.’ Then there is the intimidating surgery receptionist who discusses the patient’s medical history or drug problem in front of other patients in the waiting room. The user feels so unwelcome at the practice that they leave and take their problem elsewhere.

If the user makes it beyond the surgery door to find a doctor who will treat them, they will still face continuing problems. One chronic problem is under prescribing – or more correctly, sub-therapeutic dosing. Many GPs prescribe methadone at levels way below government guidelines, refusing to consider a realistic dose. Understandably patients continue using on top, or relapse, and treatment is routinely associated with poor outcomes.

Another common problem is a punitive response to a user exhibiting symptoms of their condition. Opiate use is described as a chronic medical condition characterised by relapse. In no other branch of medical treatment would a patient exhibiting a classic symptom of their condition find their treatment withdrawn on ‘punitive’ grounds.

Overly rigid prescribing and dispensing practice can cause further problems. While it is understandable that supervised consumption may often be a necessary and appropriate measure to be taken when initiating, prescribing and stabilising the patient, it can all too often be applied in a dogmatic and inflexible manner that makes it very difficult for certain patients to remain in treatment.

Another common problem is a refusal by some GPs providing treatment to follow the science or evidence base – or even current guidelines. The right to exercise ‘independent clinical judgement’ is deployed as a fig leaf to cover what is, at best, down to poor training and ignorance – or at worst the doctor’s imposition of their own personal morality and belief system on the patient.

In some medical practitioners, this can give rise to a fixation on abstinence-based recovery. While for some users cessation of drug use is a laudable and achievable goal, for many others it is not. Other treatment options that focus on harm reduction and maintenance are denied to such patients. Sometimes this can have a drastic impact on treatment provision in a whole region, and we can identify such ‘problem’ areas by the number and type of cases we receive. Sadly, one can also identify such areas by high overdose and drug related mortality rates.

By listening to the patient’s voice, both drug user and treatment provider will cease to find themselves in an enforced embrace characterised by mutual misunderstanding, incomprehension, distrust and antagonism, and become equals in a therapeutic alliance.

Alan Joyce was senior advocate of the Alliance. He died in 2013 but his work is remembered by many. His article, Why do we need user advocates? was published in DDN, 16 January 2006, page 12.

Home secretary announces medicinal cannabis review

By
DDN
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The government is to undertake a review of the medicinal use of cannabis, home secretary Sajid Javid has announced. The move follows headline stories about the parents of two children with epilepsy – Alfie Dingley and Billy Caldwell – being unable to legally access cannabis oil-based medicines that can prevent seizures. In both cases emergency licences have since been issued.

Sajid Javid: ‘A pressing need for the review’

‘I have now come to the conclusion that it is time to review the scheduling of cannabis,’ Javid told the House of Commons. However, it was ‘absolutely clear’ that the move was ‘in no way a first step to the legalisation of cannabis for recreational use,’ he stated. ‘This government has absolutely no plans to legalise cannabis and the penalties for unauthorised supply and possession will remain unchanged.’

The review will take place in two parts, with part one – overseen by chief medical officer Professor Sally Davies – looking at the evidence for the medicinal and therapeutic benefits of cannabis-based medicines. The second part, to be carried out by the Advisory Council on the Misuse of Drugs (ACMD), will be an assessment of ‘what, if anything, should be rescheduled’, said Javid. If significant medical benefits were identified for certain cannabis-based medicines or ‘forms of cannabis’, however, then the government did ‘intend to reschedule’, he said. ‘We have seen in recent months that there is a pressing need to allow those who might benefit from cannabis-based products to access them.’

The announcement follows an article in the Telegraph by former Conservative leader William Hague that calls for a complete overhaul of the ‘failed’ policy on cannabis – including for recreational use – and stating that ‘any war has been comprehensively and irreversibly lost’ and that ‘official intransigence is now at odds with common sense’.

The drugs policy lead for the Police Federation of England and Wales has since also stated that drug legislation is ‘outdated’ and ‘ineffective’. ‘The proliferation of drugs in this country is unchecked and the current situation is fuelling an illicit trade in not only drugs but weapons and the violence that comes with it,’ said Simon Kempton. ‘Although the police service will continue to uphold the laws passed by Parliament – a public debate is needed on the future of drugs legislation, incorporating health, education and enforcement programmes.’

Crack Cocaine – Cracks in the mirror

By
DDN
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Kevin Flemen talks about crack cocaine
Kevin Flemen runs the drugs education and training initiative, KFx

Could a recent growth in crack cocaine use indicate its move to social acceptability – and how should we respond? Kevin Flemen examines the situation.

Read the full article in the June 2018 issue of DDN

Stigma-driven barriers between powder cocaine and crack may be breaking down. Increased availability of crack thanks to ‘county lines’, combined with increased demand and reduced stigma, could see a big upsurge in crack use. But are drug services ready for a growing population of dependent stimulant users?

‘They weren’t finding their coke use so rewarding anymore… so they’ve moved in to smoking crack.’

This observation by a participant in a recent stimulant training day echoed comments that have been coming up more frequently of late, and it made me very anxious. The users in question had been trades or construction workers in the Telford area. Historically this would have been a cohort who found powder cocaine highly acceptable but would have viewed crack cocaine less favourably. That they were migrating from cocaine powder to crack suggested not just changes in availability of crack, but also changes in attitude.

Crack cocaine has, generally, not enjoyed the same kudos and acceptance as cocaine powder. The stereotypes and assumptions – a highly addictive, ‘ghetto’ drug associated with crime, impoverishment and squalor – were on the one hand highly stigmatising. But on the other they acted as a buffer, as many people viewed cocaine powder as ‘acceptable’ but crack cocaine as a ‘dirty’, unacceptable drug.

Granted, there had always been those who didn’t subscribe to this simplistic view and there were a fair few North London types who used to drift in to Dalston to sample the dubious pleasures of a crack house before heading back to less edgy areas. There were numerous ‘Professionals Binge on Crack’ type stories in the media 20 years ago (The Guardian, 13 November 2000), but this didn’t translate to more widespread usage.

The drugs field too had more than a few of its own workers who believed that the demonisation of crack was unwarranted and that they were more than capable of handling crack or making their own freebase. Some fared OK, others less so.

These exceptions aside, the prevailing view of crack as a ‘bad’ drug would, once upon a time, have meant that the Telford trades workers mentioned earlier would generally not have gone near crack.

‘My brother works on a construction site and he’s in his forties. He’s just walked off a job because at the end of the day the rest of the crew are all sitting in the cabin smoking crack.’

On all recent courses I’ve been exploring the issue, and repeatedly, similar examples have emerged – established white working-class trades and construction workers who, finding powder cocaine less rewarding, are putting down the tube and picking up the pipe. But subsequent cases suggest that the issue is more widespread.

‘Some of my “friends” have been smoking rocks too. They were finding that their noses were hurting too much from cocaine, so switched to rocks.’

‘All the cool and edgy kids are doing it. They all go off to a room at the end of the evening or at parties and are smoking rocks. They’d been dipping cigarettes in cocaine and it moved from there.’

The first of these examples was a recently graduated social work student in Staffordshire, and the second related to the artist community in increasingly-gentrified Hackney Wick. They highlighted to me that the increased access and acceptability of crack was resulting in take-up across a range of different social settings.

Availability of crack has increased at least in part because of the ‘county lines’ phenomenon, and we are seeing crack markets emerging in areas where it had previously not been a significant issue. These markets had, however, often piggy-backed onto existing opiate markets – expanding market share by offering two-for-one deals or mixed ‘any five for £30’ offers, where the buyer could have four rocks and a bag of heroin for the comedown, or three bags of heroin for an opiate habit and two rocks as a ‘treat’.Crack Cocaine User

This expansion into existing heroin markets is, of course, in itself problematic. Experience says that the stability and health of heroin users often markedly deteriorates when they add crack to their repertoire. Treatment requirements change dramatically and engagement can be more difficult. But my tacit assumption was that the size of the market for crack was limited by the size of the heroin market it was latching on to. The stigma relating to crack in the past had offered a degree of protection.

What, then, if that stigma has been significantly eroded? What if even just 10-15 per cent of our existing cocaine users start to migrate to crack use? How big would that population be, and how well set up are services to identify and respond to it?

Stigma is of course a double-edged sword. It may well in the past have deterred people from using crack. But that stigma also reduced access to services. Some activists in the field, such as Mat Southwell, argued that ‘the demonisation of the drug and its users has fostered the belief that crack cannot be managed.’ Offer empowerment and tools for control and we could change behaviour went the argument: http://www.drugwise.org.uk/wp-content/uploads/More-than-a-pipe-dream.pdf

Others, such as Peter McDermott, writing around the same time challenged this model and the prospects of ‘managed’ crack use for the majority of users: http://www.drugwise.org.uk/wp-content/uploads/Crack-harm-reduction.pdf

So it will be interesting to see the extent to which the current cohort of asset-rich crack users, unencumbered by the mythos of crack as an unmanageable drug are, in fact, able to manage their crack use – or if it spirals out of control.

If, as I fear, we are starting to see an upsurge in crack use which sprawls beyond a core demographic, services are going to have to get ready and, fast. In 2003/4, when the government and the NTA saw growing levels of crack use as an issue, resources were put in place, regions and agencies were encouraged to develop stimulant strategies and some areas appointed lead workers to address the issue.

Although levels of crack use increased, the feared ‘crack epidemic’ never materialised as envisaged and these strategies gradually got subsumed by other agendas and strategies.

If, as I suspect, we are going to see a marked increase in crack presentations, the useful aspects of these strategies need to be exhumed and brought up to date. We also need to learn what didn’t work and not repeat these mistakes.

As there is currently no model of substitute prescribing for crack, some workers feel disempowered and people with crack dependencies may feel that there is little on offer for them. Services therefore need to ensure that through training and resources, staff are empowered to respond confidently to people presenting with crack dependency.

Regionally, outreach, GP liaison and arrest referral will be useful in determining the scale of the issue locally. As this nascent crack using population aren’t currently injecting or heroin-using, they won’t automatically have contact with drug services via, for example, needle exchange.

Harm reduction interventions, including resources to address the needs of crack smokers, polydrug users (including crack and alcohol, use of opiates or benzos as comedown drugs) and crack injectors need to be in place. Drug-related deaths strategies should also address responses to critical incidents involving crack, including the need for rapid ambulance attendance and CPR.

Services need to ensure that they have the capacity to deliver a rapidly accessible service to clients in chaos, who may need numerous brief interventions over a short period of time. Structured, evidence-based day programmes, craving management interventions, and healthcare to address physical and mental health problems stemming from crack use, need to be in place sooner rather than later.

It’s always risky pressing the button marked ‘crack problem’, as it’s been pushed too often. But I’m probably more anxious about crack this time around than I have ever been working in the field. I hope I’m wrong.

Read more on crack cocaine

Drawing on experience

By
DDN
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Does continuing professional development (CPD) have a purpose for volunteers and people without professional qualifications? Absolutely, says Kate Halliday, who explains how to get started.

Read the full article in June 2018 issue of DDN

What is CPD?
Continuing professional development (CPD) describes the process of documenting the skills, knowledge and experience that we gain as we work, and how we apply this learning. This can include formal learning (a training course for example) and informal learning (observing a colleague or taking part in a meeting). The important aspect of CPD is that the learning is recorded somehow. For many this may be a physical folder of evidence, though increasingly CPD is recorded electronically.

What is the point of CPD?
Recording what you learn, how you learn it, and how you apply it, can help you develop as a practitioner and improve your skills and knowledge, providing a better service for clients. This in turn helps you develop your career, and it helps your employer deliver services.

What is the difference between CPD and training?
The terms ‘training’ and ‘CPD’ are often used interchangeably, but they are different. On the whole, training describes a linear and formal process with the aim of learning a specific skill or area of knowledge. Development is often informal and describes the ability to move from basic ‘know how’ to more advanced and complex application of skills and knowledge. So you may receive training on how to complete an assessment. You can evidence development when you complete a complex assessment, perhaps with the support of a colleague.

Is CPD only important for people with professional qualifications?
No! It is true that many professional bodies (such as the Health and Care Professional Council) require their members to have completed a specified number of hours of CPD to remain a member or become accredited. But there is great value in non-qualified practitioners, including volunteers, keeping a log of their CPD. There are a number of ways this can help:

  • You can begin to identify the areas you have knowledge, skills and experience in, and identify the areas you need to learn more about. If you are a volunteer who is interested in getting employment in the field, then this can be especially useful in helping gain the experience and learning you need to get a job. I have seen people use their CPD record effectively in the interview process by letting employers know that they record and reflect on their learning, and are aware of both their strengths and the areas in which they would like to develop.
  • It can help with confidence: setting goals and achieving them feels good! And it can help us get to where we want to go.
  • It can help us understand how we learn; we all have different learning styles. Some of us need a bit of time away from the workplace to read and reflect, and others like discussions and learning on the job. If you understand the best way for you to learn, you may be able to tailor future learning goals to your style.
  • It can help us become reflective practitioners. Sometimes making mistakes can be a great way of learning (even if it is painful at the time!). It is good to be able to process both things that have gone well, and also things that have not worked.
  • CPD makes us better practitioners, providing a better service to our clients.

How do I start?
Many professionals will have a format that they will follow as part of their membership of a professional body. Some workplaces will also have templates that can support recording of CPD. But you do not have to have a formal template to get started. As long as you follow these steps you can begin your CPD record:

1          Record your learning
Think about any learning experiences you have had in the last year, and provide a written record that reviews and reflects upon their impact, including what and how you learned from them. This could include formal training, or informal learning which may be gained from:

  • observing or discussing cases with colleagues
  • attending team meetings
  • reading articles, books, or blogs
  • learning that has taken place in supervision or mentoring
  • learning that has taken place if you have taken up a new role or activity
  • learning from a situation that has not gone according to plan

2          Record where you would like to be
Think about the direction you would like to take over the next one, three and five years. This could be about gaining employment if you are a volunteer, getting a promotion, developing a specialism, or deepening a skill in your current role.

3          Record what you have to do to get there
This may be taking on some formal training, or gaining more experience at work in a specific area. Or it may be as simple as discussing the next steps in supervision.

4          Review your progress
Set a date for when you will review the goals you have set yourself. This could be every month, three months, six months or every year. It will often depend upon what stage you are at in your working life.

Summary: Key features of CPD

  • driven by you (self directed) and not your employer
  • recorded – electronically and/or in a paper folder
  • include learning gained from formal training and from informal experiences
  • be reflective – not simply a list of training courses you have completed/ meetings you have attended, but describe what you have learned, and how you will apply it in the future
  • focus on the learning process and not simply the knowledge, skills and experience that you have
  • identify gaps in your skills, knowledge and experience
  • identify future goals and how you could achieve them
  • include reviews of your goals

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case study
‘My learning log landed me a new job’

Documenting experience makes you a serious bet for employers, says Jenny

Having been in recovery for a while, I began to volunteer at my local services. I started by welcoming people in the waiting area and signposting them to what services were around, depending on what they wanted, and generally encouraging them into recovery and giving them support. After a few months I began to get involved in delivering groups – nerve wracking at first but I loved it.

My supervisor and mentor always encouraged me to keep a log of what I had learned – whether it was from a training course or learning from others (or from my own mistakes!). During supervision I talked about how I wanted to become a drug and alcohol recovery worker, and my supervisor encouraged me to put this in my learning log as a goal and to take some basic qualifications (maths and English) to make me more employable. And they also began to give me a bit more responsibility at work. I got training, shadowed people and began to deliver needle exchange.

When a recovery worker job came up in another service nearby, my log of learning really helped me fill in the application form – not just my qualifications and training, but also my personal statement, my skills, knowledge and experience and what I still wanted to learn. If I had not been keeping a log I don’t know how I would have begun to fill in the application form! I was really pleased to get an interview. I took my learning log along to the interview and talked about it and showed it to the panel.

I can’t tell you how pleased I was to get the job and the feedback I got was that my learning log had helped – they could see that I had goals and I was meeting them, and I wanted to give the best service I could to the clients. I have been a recovery worker for a year now and am still keeping a learning log. My next goal is to get a promotion – although I think I still have a lot of learning to do before this happens!

I would encourage anyone to log your learning – whether you are a volun­teer or working in a service. It helps you improve your work with clients, making you better at what you do. It helps you meet your goals – and it helps show that you are serious about your role, making you a good bet for employers if you want to work in recovery services or get a promotion.

Kate Halliday is FDAP/SMMGP interim executive director

Surviving and thriving: Kaleidoscope at 50

By
DDN
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‘It’s down to you guys that people get a chance of a new life.’ Eleanor Conway pauses for a serious moment during a ‘stand-up’ routine that entertained guests at Kaleidoscope Project’s 50-year anniversary celebration.

‘I have huge respect for the organisation – for its values as well as its evidence-based approach,’ added Annette Dale-Perera, in her speech. ‘You have to keep trying, and that’s what Kaleidoscope keep demonstrating. She spoke of her first visit to Kingston, where the charity was pioneering harm reduction through its needle exchange and methadone dispensing service. It was ‘chaotic, busy and noisy’ and ‘a fantastic example of harm reduction and recovery-orientated services’. Most importantly it was a ‘place of sanctuary’ and ‘served a population in need when others had rigid rules to exclude them.’

‘Kaleidoscope has always challenged orthodoxy and provided evidence-based practice, even when this hasn’t been the prevailing zeitgeist,’ she said. ‘You guys have made a difference to thousands of people’s lives.’

‘We haven’t just survived, we’ve grown and flourished – but our commitment to harm reduction hasn’t changed,’ said the charity’s chair Chris Freegard, while CEO Martin Blakebrough thanked the many guests who had supported them in their mission. Surviving and thriving also meant proactively working with police and crime commissioners: ‘Criminal justice is as an important partner for change,’ he said.

Dying with their rights on?

By
DDN
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Should we be doing more to protect people from harmful drinking, asks Mike Ward.

Read the full article in June 2018 issue of DDN

Some people are so chronically damaged by alcohol, particularly through cognitive impairment, that they are no longer able to look after themselves or control their behaviour, and so pose a risk to themselves or other people. In the UK, people whose mental illness places them in a position where they can no longer live safely without harm to self or others can be detained under the Mental Health Act. This is not to punish them, but rather for protection, assessment and – hopefully – positive treatment to improve their lives.

But these powers are not easily extended to people whose problems arise mainly from heavy drinking, despite their facing many of the same challenges, and needing intensive support. Without these powers in place these people often do not receive the help they need. As a result, many end up in the criminal justice system, which does not provide them with the correct protection and treatment. This also consumes a huge amount of police time.

In too many instances these people are never adequately supported, leading to tragic outcomes – for example in the case of Angela Wrightson from Hartlepool, who was severely incapacitated by alcohol and unable to look after herself. In the end she was killed in her own home by two teenage girls, and is now the subject of an adult safeguarding death review (https://bit.ly/2kLjObe).

How did we end up in this position? Since 1983 our mental health legislation has sought to separate problems due to alcohol misuse from those due to mental illness, with chronic alcohol problems seen as a matter of lifestyle choice. It can be argued that people are free to drink, even to the point of extreme harm and death, if they choose to do so.

But modern Britain is unusual in this. Many other economically developed countries have powers that allow for the protective and rehabilitative detention of people with chronic alcohol problems. This is true of Holland, Switzerland, France, Germany and many states in the USA and Canada. Protective detention is allowed in the European Convention on Human Rights, Article 5 (e). The language is now outdated, but the intention is clear.

These powers are not simply archaic legislation that has lingered on the statute books. A good example of this kind of legislation in action is the Swedish Care of Alcoholics, Drug Abusers and Abusers of Volatile Solvents Act (1988).

Sweden’s Care of Alcoholics, Drug Abusers and Abusers of Volatile Solvents Act (1988)

The Act’s aims are to ‘immediately stop a destructive way of life; motivate patients to seek further treatment, if such a process is required; and to overcome addiction and hence achieve a better lifestyle.’ Under the Act, social workers must take a person into treatment if they match the four criteria set by the Swedish government:

»          If the individual is risking his/her psychological health on purpose or by helplessness

»          If the individual is destroying the prospect of his/her future due to substance misuse

»          If the individual is risking the security of him/herself or intimate associates

»          Necessary intervention is not possible on a voluntary basis

 

Probably the best evidence of the positive impact of such powers comes from New South Wales, Australia. In her YouTube presentation, clinician Glenys Dore sets out the positive impact of their relatively new (2007) legislation. She describes how patients are admitted to dedicated units, with 60 per cent abstinent or improved as a result of these positive interventions.

On entry to these units all patients are screened for cognitive impairment. The average score shows that they are operating at the level of someone with Alzheimer’s and some even lower. However, after four weeks in a unit their score is moving much closer to the normal range. Chronic drinking often moves beyond a matter of choice to an impaired mental state where people need outside help to break them free. At this point, they can begin once again to make choices for themselves.

The development of compulsory powers is not an easy option. It would require solid criteria and safeguarding, reinvestment in inpatient units and the development of a workforce trained to manage such clients. However, doing nothing is not a cost-free option; the current cost to the police and other emergency services, to communities and to individual lives, is immense.

People have the right to drink, even when it is doing them harm. But for some, is this a free choice? In reality, is society is doing far too little and allowing people to – in the words of Glenys Dore – ‘die with their rights on’?

Mike Ward is senior consultant for the charity formed by the merger of Alcohol Concern and Alcohol Research UK, www.alcoholresearchuk.org

In his next article, he will discuss the problems with the legislation currently used to meet the needs of heavy drinkers who cannot look after themselves: a patchwork of the Mental Health Act, Mental Capacity Act and the Care Act.

Commissioners call for joined-up approach to opioid use disorder decision-making

By
DDN
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Expert Faculty on Commissioning confirms speakers for ‘EXCO’, the first joint congress on excellence in commissioning for opioid use disorder.

Excellence in Commissioning for Opioid Use Disorders

The Expert Faculty on Commissioning will hold the first integrated meeting for commissioners and other experts focused on opioid use disorder (OUD) care. The event on 22 June 2018 is entitled ‘Excellence in Commissioning for Opioid Use Disorder’ and includes 75 experts from across England who will debate the future of addiction care for people with serious drug problems.

Senior experts including Rosanna O’Connor (director of alcohol, drugs and tobacco, Public Health England), Prof Rod Thomson (director of public health, Shropshire) and Mark Moody (chief executive, Change, Grow, Live) will lead the discussions in the meeting with commissioners responsible for designing and overseeing drug treatment services.

Terry Pearson, responsible for commissioning drug and alcohol services for Northamptonshire Country Council and joint lead for the Expert Faculty, commented: ‘There is significant innovation in the treatment of opioid use disorder – commissioners must act to ensure that we make the most appropriate use of new treatments and technologies avoiding unnecessary delays.’

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Expert Faculty on Commissioning (EXCO)

2018 Congress, 22 June, Manchester

Programme: 

Plenary sessions

Rosanna O’Connor, director of alcohol, drugs and tobacco, Public Health England; Rod Thomson, director of public health, Shropshire Council; Mark Moody, chief executive, Change, Grow, Live; Stewart Atkinson, Office of Police and Crime Commissioner for Humberside; Terry Pearson, commissioning manager, Northamptonshire County Council; Jayne Randall, drug and alcohol strategic commissioner, Shropshire Council; Mark Gilman, Discovering Health, former PHE recovery lead; Anthony Bullock, senior commissioning manager, Staffordshire County Council; Paul Musgrave, senior manager, public health, Cumbria County Council; Annemarie Ward, CEO of FAVOR; Kerrie Hudson, operational lead, The Well Communities  

Workshop sessions

Collaboration and innovation: building a modern approach to commissioning OUD Service. Tony Mercer, health improvement manager (alcohol and other drugs), Public Health England; Will Haydock, senior health programme advisor, Public Health Dorset; Chris Lee, public health specialist: behaviour change, Lancashire County Council; Mark Webster, head of development in ACT Peer Recovery; Dave Vaughan, service manager, Recovery Works Ltd; Paula Harriott, Prison Reform Trust

Decision-making, evidence and outcomes: planning for key choices in commissioned services using data. Rosie Winyard, public health commissioning lead, Worcestershire County Council; Karen Cassidy, public health specialist, Blackburn; Clive Hallam, substance misuse commissioning manager at Wandsworth and Richmond Borough Councils; Annette Dale-Perera, chair of the recovery committee, Advisory Council on the Misuse of Drugs (ACMD); John Bucknall, commissioner, Halton Borough Council, Helen Phillips-Jackson, strategic commissioning manager – substance misuse, Sheffield City Council, Mark Knight, substance misuse lead, Greater Manchester Combined Authority.

All interested in the future of innovation in OUD care and the evolving role of commissioning are strongly recommended to join this event. Registration is free for those working in the field.

Please find more information and register at: www.expertfaculty.org/exco

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Insights

Jayne Randall (drugs and alcohol strategic commissioner, Shropshire)

The ‘new’ Drug Strategy 2017 defines the goals and scope of OUD care in England and identifies the future challenge: ‘Progress has been made in supporting people to recover from their dependence on drugs, but we need to go further.’ The 2017 ‘Orange Book’ or Drug misuse and dependence UK guidelines, Public Health England (PHE) and the Advisory Council on the Misuse of Drugs (ACMD) inform the debate on best practice in OUD care.

It is noted that ‘despite successes with falling numbers of young people currently developing heroin dependence, the morbidity, mortality and long-term needs of an ageing cohort of patients with long-term heroin dependence problems means that treatment is increasingly complex…’

The environment is not static – there is important change in progress and commission­ers of drug treatment services must ensure the decisions they make reflect the new options innova­tion can deliver. For example, depot forms of medication, which do not have the inherent risks of oral treatments, may be approved in England. Commissioners in each of the local authority public health departments can now work together in the expert faculty for the first time. This collabor­ation will be key in the future; I encourage all commissioners and others involved in decision-making for drug treat­ment services to participate in the expert faculty.

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Development in the last 20 years led to a treatment system for OUD that achieved important successes, saving many lives and avoiding public health crises.

Mark Gilman (expert faculty participant, former PHE recovery lead)

Some now observe the approach to treatment today has remained unchanged for many years and there is a need for innovation to address some of the problems experienced by those using the treatment system

Problems with treatment reported include that many people are not in care, and some in treatment face worsening health and find it hard to get optimal care. Others may still be using on top or be involved in diversion of medications. Treatment is still associated with problems including the risk of domestic exposure and harm to others.

Important questions are in focus:

Why do so many people not use treatment services at all? Do the individuals in care get a service that is flexible and targeted to their needs? Do we do everything to minimise risks?

Considering the approach we have today, is the burden of treatment too great? Does the regimen of daily treatment and obligations around collection of medications make treatment too much of a burden for some?

At the highest level, what is the treatment system for? Does the legacy system we work within deliver the results for the people we aim to service today?  With innovation on the way – including new digital tools for online help, new medications with weekly or monthly dosing and better use of integrated data systems to join up care – does the structure of the treatment system make it possible to achieve the best possible results for the 300,000 people with very important needs?

There is now an opportunity to review all the assumptions we make about OUD care and ask, with open eyes, ‘What does good care really look like?’, address the gaps in the current treatment system and decide how to improve outcomes for people with OUD.

The expert faculty works to challenge assumptions and, with the responsibilities of its members, ensure that commissioning is a key lever in the ongoing evolution of treatment services. It is time to act.

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About EXCo

The Expert Faculty on Commissioning is an independent group of experts, formed in 2016, that aims to support commissioners by sharing experience and insights on best practice, with the overall goal of improving outcomes for people with OUD.

The Expert Faculty is independent and participants do not receive payment. Specific programmes are funded individually.

The faculty works on a project basis with resources from all types of organisations and businesses. Organisations providing resources do not influence the thinking nor work of the faculty. Camurus AB, a company developing new medications for OUD, has provided funds for the logistics of the faculty annual congress.

More information at: www.expertfaculty.org

 

Step Into Summer

By
DDN
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Steps Together Rehab
Steps together rehab is a modern 17 bedroom fully residential, private treatment centre

Steps together rehab is a modern 17 bedroom fully residential, private treatment centre, offering detox, rehab and aftercare.

In our quiet secluded residential setting in Nottinghamshire, our world class team consists, of psychiatrists, nurses and therapists.

At Steps Together Rehab, our drug rehabilitation techniques balance a relaxing and tranquil atmosphere with the dynamic energy of learning and recovery. We focus on stress reduction techniques that involve therapy and exercise.

Steps Together CEO Darren Rolfe
‘I’m truly passionate about recovery and working with clients and their family offering hope and a solution for a better way of living.’ Darren Rolfe, CEO

As part of your drug or alcohol detox programme, it is important that you are relaxed and feel healthy. We believe in creating the best atmosphere possible, so meals are served to our clients and staff together, creating a relaxed and comfortable ambience. Our chef prepares high, quality healthy meals in keeping with our programme and will accommodate all types of dietary requirements and tastes.

We offer a wide range of therapies , including –

  • Cognitive behavioural therapy
  • 12 step recovery
  • Group therapy
  • Holistic therapies – including acupuncture, massage and mindfulness
  • Educational workshops
  • Physical activity, including gym and swimming (off-site gym)
  • Family workshops
  • Aftercare

All the bed-rooms are en-suite, and include a ground floor room with wheel-chair access.

Call our admission team today to start your journey to recovery, in our beautiful tranquil setting.

Call 0800 038 5585 Email: info@stepstogether.rehab

www.stepstogether.rehabSteps Together Rehab

Back to reality – treating ARBD

By
DDN
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Getting the right treatment can reverse effects of alcohol-related brain damage, says Alyson Smith.

Read the full article in June 2018 issue of DDN

Alcohol-related brain damage (ARBD) refers to the damaging effects of long term alcohol consumption on the brain. Alcohol toxicity, vitamin deficiencies and disrupted blood supply to the brain can result in a range of serious conditions, including Wernicke’s Encepalopathy, Korsakoff’s Syndrome, alcohol-related dementia and alcohol amnestic syndrome.

It has been suggested that these disorders are best regarded as occurring on a spectrum (Jacques and Stephenson 2000). It is not the same thing as age-related dementia; ARBD occurs when a person is deficient in thiamine (vitamin B1) and if untreated can lead to memory problems and frontal lobe dysfunction (Chiang, 2002).

The impact of ARBD ranges from mild to very severe. The good news is that this need not necessarily be progressive if people can engage in cognitive rehabilitation, abstain from alcohol and maintain a good diet. While intellectual functioning appears to remain intact, memory and social functioning can be improved through targeted rehabilitation. Smith and Hillman (1999) suggest that 75 per cent of clients can expect some level of recovery, with 25 per cent making full recovery.

 

Cognitive and memory problems

  • Confusion regarding time and place
  • Impaired attention and concentration
  • Difficulty processing new information
  • Inability to screen out irrelevant information
  • Confabulation – filling gaps with irrelevant information
  • Apathy – loss of motivation, spontaneity and initiative
  • Depression and irritability
 Physical problems

  • Ataxia – poor balance, disordered gait
  • Damage to liver, stomach, and pancreas
  • Possibility of traumatic brain injury
  • Peripheral neuropathy – numbness, pins and needles in hands, feet, or legs
  • Nystagmus and opthalmoplegia – involuntary eye movement

It is very difficult to obtain accurate prevalence figures for ARBD. However, a service for those under 65 years of age in Cheshire and the Wirral reportedly receives three new referrals per month, suggesting an annual incidence of 13.9/100,000 in those aged under 65 (Wilson quoted in Smith and Emmerson, 2015).

Research (Wilson, 2014) suggests that the experiences of people with ARBD within the healthcare system are very poor. They include a lack of diagnostic expertise, general ignorance of psychiatric, medical and nursing staff, lack of care pathways and resources and stigma. Patients can fall between services and have higher rates of morbidity and mortality.

A report from Public Health Wales (Emmerson and Smith, 2015) suggested that given the estimated prevalence of ARBD, residential rehabilitation required for this group is inadequate. In 2014, a task and finish group was set up at Brynawel Rehab to address this gap in service provision locally.

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The Brynawel approach

A six-month programme was developed at Brynawel which focuses upon both neuropsychological rehabilitation as well as problematic alcohol use. Admission criteria are shown in the table below.

Clients are admitted to Brynawel following initial diagnosis and physical stabilisation (detox). Each client undertakes formal psychiatric and neuropsychological assessment at the beginning, middle and towards the end of their stay. Alongside qualitative daily observations, the results of these assessments are used to inform their individual rehabilitation plan during their stay and make any recommendations for their ongoing support needs upon discharge. Clients are supported by a dedicated ARBD team throughout their stay, with a support ratio of three to one, with the option to ‘step this up to one-to-one support’ if needed.

The assessment phase is an opportunity for clients to settle into a calm stable environment. During this time, a holistic approach is taken to supporting clients with abstinence (including thiamine), nutrition, regular sleep, and other aspects of lifestyle. Psychosocial support is introduced very early on, and engagement of family/significant others is encouraged. Individual progress is assessment via daily observations and neuropsychological and psychiatric assessments. This data informs the care plan and is used to determine readiness to enter the treatment stage.

The aims of treatment are to develop personal autonomy and promote functional recovery. The focus is on supporting clients to improve their orientation and memory, managing their alcohol consumption and developing good relationships. The programme also focuses on working with managing impulses and behaviours, apathy and motivation.

The programme is structured around a timetable which is designed to help clients to familiarise themselves with the routines and activities of daily living. The physical environment is set up to facilitate understanding (through signs, colour coding and whiteboards) and an appropriate level of stimulation (eg noise management). Assistive technology, such as memory apps on an iPad, is used where this will be helpful.

Interventions are primarily based upon the behavioural model and include diary keeping, activity scheduling, graded tasking, problem solving and memory cueing. The ‘errorless learning’ approach is also used, so that clients do not make errors while learning new information.

It can take two to three years for clients to reach their full potential, and therefore resettlement and recovery in the community need to be carefully planned and psychologically informed. The individual’s support needs will need to be thoroughly assessed, and a longer-term plan will need to be made to support relapse prevention and develop an appropriate level of independence and structured activities.

Admission criteria for ARBD programme
Patients will:

  • have a diagnosis of ARBD made by a suitably qualified clinician using modified Oslin criteria. For more information see https://bit.ly/2Hm4TwV
  • have a standard assessment document as part of the referral, including attached baseline scores
  • have undergone physical stabilisation, ie detoxed and currently abstinent from alcohol. Be on oral thiamine supplements
  • be in phase two or early phase three of Royal College of Psychiatry/ Wilson et al five-phase recovery model – for more information see https://bit.ly/2xT5vuq
  • be thought to be able to engage in the components of the treatment package (eg diary keeping)

Exclusion criteriaPatients will:

  • still be in the acute confusional stage of the natural history of ARBD (and therefore still requiring medical management)
  • be in late phase three, phase four or phase five (signpost to appropriate services)
  • have significant physical health comorbidity where medical stabilisation is required

 

*****

Case study
Back to independence

Brynawel’s ARBD programme transformed Kate’s prospects

Fifty-year-old ‘Kate’ was referred to Brynawel Rehab in August 2016, following a diagnosis of ARBD from her consultant psychiatrist. She had been admitted to hospital in November 2015 with a range of symptoms caused by heavy alcohol use and malnutrition resulting in seizures, ataxia and problems with articulation and swallowing reflex. Kate had trained as a nurse and worked in the NHS before and after having her family, and had been very highly regarded by her colleagues.

The results of her first neuropsychological assessment on admission to Brynawel suggested that she had difficulty planning tasks. This was evident from Kate’s inability to maintain her room to a manageable standard or to plan basic self-care tasks such as showering and personal care. Initial findings from the assessment highlighted a variety of problems with her immediate memory, her visuospatial ability and her delayed memory, which was extremely low.

Her results were supportive of a diagnosis of Korsakoff’s with additional complications. She underwent follow-up psychological and psychiatric assessments in November and then again for the final time in January 2017, using different versions of a battery of tests.

Kate had been very emotional on arrival, with periods of intense crying. Her sleeping and eating were quick to settle, but by week two she was noticed to have incontinence, diagnosed by a GP as anxiety-related. By the end of the first month she had begun to engage more in activities but was still noted to be unable to spontaneously initiate tasks such as keeping her room clean, although she had been able to use memory aids.

Staff were able to report an improvement in her engagement and socialisation, it was apparent by the second month that she still had problems initiating communication or tasks and decision-making. Although she had managed memory tasks in sessions, her recall of these tasks later on was poor. Her symptoms of depression had lessened over the 26 weeks and her levels of anxiety were lower than when first admitted.

Kate’s daughter acknowledged a marked improvement in her mother’s functioning, following her admission to Brynawel. Within weeks Kate had been able to recall the daytime activities she had been engaging in and, following small prompts, she could continue an accurate conversation about what had been happening. This had been ‘the first time we had noticed such a change in our mother’… ‘We felt like we had our mother back!’

They were aware that Kate could not initiate memories, but she was now able to recollect things quite well with a prompt. She seemed happier and had been able to make friends with other residents. Staff from Brynawel continued to support Kate in the community for six weeks, providing support with her cognitive rehabilitation, offering assistance with memory aids and adaptations in her own home and continuing to support her reintegration into the community using a graded approach to her discharge.

A year on, Kate has maintained abstinence and lives independently. The alternative option, which was suggested before her admission onto Brynawel Rehab’s ARBD Programme, was placement in a care home for the frail elderly, at 50 years of age.

Dr Alyson Smith is consultant clinical psychologist at Brynawel Rehab

An ever-decreasing share?

By
DDN
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Allowing shared care to dwindle is putting patients’ all-round physical and mental health at risk, says Dr Steve Brinksman.

One of the things I am most proud of in the 27 years I have been a GP is the way many working in primary care responded to the challenges posed by treating substance misuse and dependency, with the resultant growth in shared care services. In Birmingham, where I am based, the number of practices providing OST rose from 8 per cent to over 65 per cent in a decade. I now fear that all this progress is under threat from multiple directions and if lost, all that experience and enthusiasm will be very difficult to replace.

The years of austerity have been hard for many, but the move of public health into local authorities has opened up drug and alcohol treatment services to far more financial constraints than if they had remained inside health budgets. Retendering and enforced cuts in existing contracts have left providers with no option but to make significant changes. Some have been forced to merge, and despite what is supposed to be a culture of ‘localism providing tailored local solutions’, the number of options has dwindled. It is hard to see services being awarded to small local third sector organisations in this climate.

Where providers have to make cut-backs, the cost of providing services from multiple primary care settings can seem expensive compared to operating out of one or two hubs with central prescribers and workers. ‘Payment by results’ targets, based on numbers completing and being discharged from OST, can also work against shared care with a perception that fewer complete treatment in primary care.

Given this, why am I so passionate that shared care should continue? Most of the people I see who are on OST are incredibly complex – not so much from their drug use but as an ageing cohort with an array of physical and mental health problems. Many of these such as COPD, coronary heart disease, hepatitis C, renal failure, depression, anxiety and PTSD are chronic conditions that need long term support and management in a primary care setting. Engagement with treatment for these conditions can be erratic and by silo-ing off the OST into a specialist service, I worry that our ability to treat these people will be severely compromised.

If our aim is to provide holistic care and improve the lives of those affected by substance use then we need to commission services that deliver health, OST and recovery as a single package. Until then having an option for shared care treatment built into local provision at least gives the opportunity to some. It would be a sad day for me if, at the end of my career in general practice, shared care for people who use drugs had dwindled back to the minority interest it was when I first started out.

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

Bang for your buck

By
DDN
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The launch of the ‘Decency, safety, security’ strategy for prisons was greeted with mixed reactions by the Drugs, Alcohol, and Justice Cross-Party Parliamentary Group. DDN reports.

Read the full article in June 2018 issue of DDN here

The new prisons strategy promised a ‘back to basics’ crackdown on drugs and mobile phones, while also intending to ‘keep prisoners busy’ by tasking them with cleaning up yards and picking up rubbish, explained prison minister Rory Stewart. It would be piloted across ten prisons, and rolled out across the rest of the prison estate if successful.

Joe Simpson: ‘Not enough people to enforce the legislation.’

Joe Simpson, assistant general secretary of the Prison Officers Association, praised the strategy’s intentions but questioned if there would be the resources to back it up. He mentioned the importance of stopping drugs ‘at the wall and the gate’ but said there were not enough officers to do this. ‘There is lots of legislation, but not enough people to enforce it’, he said.

Prison officers had been calling for mobile phone blocking since 2007, he said, and while the technology was available it wasn’t being used, which he claimed was down to cost. Tools available to prison officers to tackle drug use such as mandatory drug testing (MDT) and random cell searches had unintended consequences, and could lead to changes in drug using behaviour and increased bullying, as inmates were intimidated into holding drugs for dealers.

‘All we are doing is warehousing prisoners, then breathing a sigh of relief if we get them out alive,’ said Simpson. ‘As a prison officer you see the misery caused by drug use’, he added, and emphasised the need for an integrated approach that looked at the reasons people use drugs and associated psychosocial issues. But doing this ‘needs proper resourcing’.

This theme was echoed by Majella Pearce, deputy head of healthcare for HM Inspectorate of Prisons. She highlighted that ‘substance misuse doesn’t happen in isolation’; that very good substance misuse services in prison were not enough, and that there was an urgent need for wraparound services.

Of 39 prisons that had been inspected, only a third met the required standard, 28 per cent of prisoners had reported a problem with drugs and 14 per cent with alcohol. Changing drug use within prisons was a big issue, with diverted medication and NPS being the key concerns. The use of drug testing was driving this as prisoners moved away from cannabis to drugs that leave the system quicker and are harder to detect.

Dedicated drug recovery wings were not the only answer and varied in their effectiveness – but when done well could be very effective, she said. This was especially the case when there was integrated mental health care and drug treatment: prisoners were more likely to engage as they perceived less stigma around mental health issues.

Louise Scherdel, project manager at Addaction, told the group about Addaction’s approach to working in jails in Lincolnshire. On reception, every prisoner was offered a chemical assessment, then seen again the next morning and offered specific harm reduction advice relating to the drugs most commonly reported in the prison. Scherdel said that NPS users were less likely to engage than traditional drug users, but initiatives using music and art therapy had been shown to be effective. While lack of resources meant that they were currently unable to implement a full recovery wing – but ran a programme on a landing – anecdotal evidence pointed to an 89 per cent completion rate.

The charity worked with prisoners on release with its ‘through the gateway’ programme, linking prisoners with treatment services in the area and family support teams, and providing harm reduction services such as take-home naloxone on release.

‘There is a focus on enforcement and reducing supply,’ commented Alex Boyt, as discussion opened up to the group. ‘But a lot of drug use is linked to depression – if you are banged up 23 hours a day and under threat of violence from other prisoners, you are more likely to self-medicate. It creates a vicious downward spiral.’

Letters to the editor – June issue

By
DDN
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Downward spiral

I applaud Ms Durjava’s sensitive and respectful study of heroin users in prison (DDN, May, page 6). Government drug strategies invariably talk negatively about drug use and base their strategies accordingly – on the  crude assumption that, given plenty of stick and a bit of carrot, all users want to stop. It is refreshing to read heroin use interpreted rationally for once, as a solution rather than a problem.

The UK prison system is in free fall and heading for the very bottom, as we all well know, and in spite of all the warnings successive governments have failed to take responsibility.

There are oases of good practice here and there, but overall successive governments have been utterly failing the disadvantaged, maligned, and ever increasing population shoved out of sight behind bars. As a result, the article explains, prisons are in perpetual crisis. It is hardly surprising that their residents like taking heroin, or anything else that might help to obliterate their misery.

It does not have to be like this. In search of humane and effective alternatives, the Dutch government has been closing prisons since 2009, sometimes renting them out for use by offenders from Norway and Belgium. Our government too has looked across the water for inspiration. Their preference though has been for American business models that drive down costs and do almost nothing for resources.

Why we would want to copy models from a country with the highest number of prisoners (more than 2m) and an insatiable appetite for locking up ethnic minorities is baffling. It’s a recipe for ongoing failure, and signals just how divorced from reality have become the ministers and civil servants propelling us down this miserable road.

The mandarins who peer down the wrong end of a telescope from their ivory towers before making up some new policy or other are, quite simply, clueless. Think of former justice secretary Grayling’s tenure, for example, and his aim to restrict prisoners’ access to books, or to sell prison training to Saudi Arabia. Thus many prisoner governors, staff, and indeed prisoners desperate for change, find themselves endlessly thwarted instead of supported by government.

Meanwhile life in prisons grinds on, at the mercy of ministers who have little or no idea what they’re dealing with. Take so called drug-free wings, offering privileges to people who agree to random drug testing. As cannabis may be detectable for a month or more while opiate traces are gone in more like 24 hours, policy has created another scenario where taking heroin is the rational choice.

What hope this Brexit-obsessed government will ever get a grip?

Paul Taylor, by email

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

Capital crisis

In response to Alex Boyt’s piece in the April edition of DDN (page 12), one cannot help but recognise the absence of distinction between what can perhaps be classified as ‘addiction’ with a small ‘a’ to indicate a behaviour that includes the habitual use of psychoactive substances for recreational reasons which might have some social and personal consequences, in contradistinction to ‘Addiction’ with a capital ‘A’ to indicate chronic substance misuse that has reached a life-threatening level after following a chaotic path of personal loss and degradation that impacts family, friends and society at large.

Alex is clearly referring to ‘addiction’ with a small ‘a’ when suggesting someone in recovery being able to imbibe a beer on a warm day while neglecting to take into consideration the neuroscience of Addiction with a capital ‘A’ that has ascertained the fundamental requirement of a corridor of abstinence for the metabolism to realign itself towards overall stability. This, for those suffering chronic life-threatening Addiction with a capital ‘A, affords an opportunity to achieve homeostatic neurochemical balance that includes the ability to keep addiction with a capital ‘A’ in remission by the observance of abstinence on a daily basis.

Alex also struggles with the word ‘powerless’ within the 12-step framework; yet this terminology is simply a paradox that proves the truth so to speak, in that once one has been able to accept their ‘powerlessness’ over Addiction with a capital ‘A’ one immediately gains the ‘power’ to do something about it, given that such admittance brings one out of denial which has been the unconscious dynamic driving the Addiction.

Of course Alex is being true to himself exploring his own preferences and prejudices while questioning the integrity of the 12-step programme – the efficacy of which is predicated on abstinence – although one wonders why he has to do this in a magazine of wide circulation that is read by individuals who may be in early recovery and have achieved ‘power’ over Addiction with a capital ‘A’ by means of the abstinence-based 12-step programme? What is the gain in casting doubt?

One wishes Alex well on his own journey, while perhaps suggesting he might demonstrate an attitude of acceptance for others who might not be as articulate as he is, but who nevertheless have an attitude of simple faith that abstinence-based recovery supported by the 12-step programme works as an enduringly life-saving intervention for each person individually.

John Graham, therapeutic counsellor (retired), by email

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Just be happy

There’s lots of great things about the fellowship (DDN, April, page 12) that I have benefited from and it certainly guided me from a selfish crazy drug addict child to the decent adult that I am now. I learnt how to laugh and judge and meet entirely the wrong men.

I liked God for a bit but wanted my power back – the one I own to make choices based on my own critical thinking. I agree that it has inherent flaws for me, but it played a valuable part.

But it was just a part. We did it so we are entitled (after a life of beating ourselves up for being flawed) to think and feel whatever we want. And to be happy. We are awesome.

Jo Rollason, via www.drinkanddrugsnews.com

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

Slight diversion

Diverting addicts from courts to treatment. This sounds pretty good. Until we ask: ‘What treatment? Where is the treatment? What is the goal of treatment?’

The current goal established for the Department of Health by psychiatric Professor Sir John Strang’s ‘Orange Book’ and his National Addiction Centre is merely to move addicts from usage of illicit drugs to continuing daily usage for life of prescription pharmaceutical drugs.

That‘s not ‘treatment’. It’s a clever profitable takeover by the psycho-pharm fraternity of clients created by drug barons and their pushers!

Or is ‘treatment’ persuading addicts to move themselves into 12-step AA, NA or CA groups in the hope that their dedication will deliver a few more ‘clean’ former addicts back into society at no cost to the government?

The truth is that ‘treatment’ is the wrong approach, because little of it delivers a lasting return to the natural state of relaxed abstinence which every addict needs, wants and deserves.

What does work is addiction recovery self-help training which gives an addict the knowledge he or she needs, plus the necessary revival of responsibility which together puts the former addict back in control of their life – for life.

But because the ‘Orange Book’ and the National Institute for Health and Care Excellence have recently downgraded all residential rehabs as ineffective, and because addiction recovery self-help training is necessarily also residential, every approach to addiction handling which is not based on some form of non-residential substitution therapy has now been effectively negated in the minds of the ministers and officials who make government drugs policy.

Above all else, what every addict needs is true and honest knowledge and a resurrection of personal responsibility in order to get themselves back in control of their lives, and availability of these vital factors should not be deprived of government support just because their delivery happens to be residential.

E Kenneth Eckersley, CEO Addiction Recovery Training Services (ARTS)

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Your letters are always welcome! 

Email the editor here Write to: The Editor, DDN, Romney House, School Road, Ashford, Kent TN27 0LT

 

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Media Savvy

By
DDN
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The news, and the skews, in the national media

When law enforcement officers call for drugs to be legalised, we have to listen. So too when doctors speak up. Last month the Royal College of Physicians took the important step of coming out in favour of decriminalisation, joining the BMA, the Faculty of Public Health, and the Royal Society of Public Health in supporting drug policy reform… The BMJ is firmly behind efforts to legalise, regulate, and tax the sale of drugs for recreational and medicinal use. This is an issue on which doctors can and should make their voices heard.
BMJ editorial, 10 May

Legalising drugs would halve the number of prisoners, lead to fewer murders and overdoses, and result in safer inner cities. Only one question remains: when will a politician muster the courage and admit that legalisation would work?
Jack Powell, Telegraph, 11 May

We’re hooked on a big lie. How can the stupid concept of ‘addiction’ survive, if people such as the Relate organisation can seriously suggest that anyone is ‘addicted’ to sex? People pursue pleasures at the expense of others, because they enjoy them. Why do doctors, and the criminal justice system, too, help them to do this?
Peter Hitchens, Mail on Sunday, 6 May

Nothing fires up we Scots quite like someone threatening to lengthen our life expectancy. And now, thanks to legislation that puts a floor on the price of alcohol, many of us have a reason to get upset… Yet there remains an elusive force at play in the public conversation about alcohol. Namely, the fact that so many of us who drink too much are either unaware of it or are in some form of denial. We tend to downplay or underestimate both how much we drink and the impact it has on our finances and mental health – which is why facts are useful when creating policies that are designed to tackle the issue.
Darren McGarvey, Guardian, 3 May

By some malign alchemy the problem has been reconceived in recent years as harm done not by drugs but by the law. So there’s been an ever-more explicit push to decriminalise all drugs, coming not just from legalisation charities but from an establishment which is increasingly in their pocket… To double down on calls for policy changes that will increase the number of drug users still farther is not to promote reform. It is a social death wish. Melanie Phillips, Times, 29 May

Strength in numbers

By
DDN
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Could the problem of recruiting and retaining good nurses be solved by better networking opportunities? Ishbel Straker makes the case.

In the last couple of months, I have attended some really interesting conferences on addiction. I have had the privilege of spending time with colleagues in the field – consultants, doctors, psychologists, pharmacists, and a smattering of nurses.  I came away from these learning and networking opportunities questioning where are all the nurses?

Some weeks before these dates, I met with a nurse whose light had started to fade. They had come to me because they felt a dwindling lack of passion for their vocation and hoped for it to be reignited. We spent time together, but whatever came from our meeting feels slightly irrelevant if we as nurses are not taking care of our passion and giving ourselves the time and space to allow it to continue to burn.

I really do feel a step towards this is networking and seizing opportunities to meet with colleagues in the field. So the question I’ve been asking myself is why aren’t nurses attending these functions – and my two guesses are workload and organisational opportunities.

If nurses are carrying huge caseloads of complex clients then I appreciate it may not feel like a priority to travel across the country to attend a conference – but I would say that it needs to be made a priority. I also understand that there are certain staff that naturally attend conferences, and I would suggest that organisations need to look at this and alter the focus so others get the chance.

I cannot stress enough the need for nurses to expand on their learning, meet other nurses with a passion for the field, and feel valued by their employer. I guarantee that when services make a point of doing this for their nurses they will see a cultural change within the workforce, including better retention.

Not only is it inspiring to talk to others who are going through the same issues as you, but it encourages best practice and gives an opportunity to shout about it.

So, I challenge nurses and organisations over the next six months to encourage attendance at addiction conferences and be inspired! I hope to see you there!

Ishbel Straker is a clinical director, registered mental health nurse, independent nurse prescriber and board member of IntNSA

A Winner’s Tale

By
DDN
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Last year Kelly’s Story won the Recovery Street Film Festival. In 2015, Kelly Judge was sleeping rough on the streets of London with no support network. Her children had been taken into care and she was unsure how long she would survive.
Interview by Chris Franks from CGL

Read the full article in June 2018 issue of DDN

What were you feeling at this point in your life?

‘I was at the end of a very long, treacherous road. I was beaten down and I was alone. I had no family around me, I had no friends around me. I was completely isolated, a shell of a person. I couldn’t see a way out of it. I knew there was something that needed to be done but I didn’t know how to get the help and I didn’t know if I could actually do it after 16 years of using drugs. Everything in my life was a question mark.’

Tell us about your experience of making the winning film for the 2017 festival, Kelly’s Story (produced by Jeremiah Quinn).

‘My biggest motivator was to let people know that if I can do it, then so can they. Part of the process of being in recovery is giving back to others in recovery. I was really nervous when I was told I was going to meet this guy at Trafalgar Square so he could film where I used to be, and then come back to the service for the main part of the interview. I was nervous about what he was going to ask me and what was expect­ed of me. I met Jeremiah, who was making the film, and he put me at ease completely. I just told my story to him and didn’t think about anyone seeing it. I never thought so many people would see it and come up to me and say, “I saw your film, it was amazing.”

‘The biggest thing I learnt from the experience was that I have the ability to get a message across, just by being myself. I’m just telling my story. I’ve lived it, and that’s all I’m talking about. When someone gets impacted by that it makes me feel like I’ve accomplished something – knowing that it can reach someone, knowing that someone can hear my story and it be similar to theirs and they can recognise that change is possible.’

How did you feel when you found out the film had won?

‘When I got told I had won, I was going through a difficult time. It was like a silver lining. I thought, how wonderful, someone’s thought that much of the film to give it first place. It made what was happening a little easier.’

What will you be looking for, as a judge of this year’s film festival?

‘As a judge for the festival this year I will be looking for authenticity, simple as that. I don’t need to see loads of bells and whistles and clever effects. I just want to see someone telling their story, making it real. When something is simple you get less distracted and can pay attention to the story you’re being told.’

What advice would you give to someone who is thinking about making a film for the festival?

‘You’ve got the chance of not only changing your life, but someone else’s too. Even if it’s one in a million, it’s worth it. Seeing your video might be that lightbulb moment they need.’

You can watch Kelly’s Story on the Recovery Street Film Festival YouTube channel, and the submission window for the 2018 Recovery Street Film Festival is now open. Visit rsff.co.uk for more information and to submit your film.

 

The price of a drink

By
DDN
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Alcohol misuse is causing huge damage to the nation’s health and its finances. With minimum pricing finally a reality in Scotland, what does the future look like for the rest of the country? DDN reports.

Read the full article in the June 2018 issue of DDN

According to the most recent figures from the Office for National Statistics (ONS), the number of ‘alcohol-specific’ deaths in the UK stands at more than 7,300 (DDN, December/January, page 5). While the death rate does appear to have plateaued in recent years, it’s still higher than at the turn of the century and ONS stresses that the narrow definition of ‘alcohol-specific’ means those numbers will be a conservative estimate.

Much has been made of the fact that fewer young people seem to be drinking, but those that are, are drinking a lot. Death rates among older people, meanwhile, are rising steeply – by around 50 per cent since 2001 among men aged 70-74, for example. As this issue’s Alcohol and Health supplement points out, it can be decades before the damage done to a liver by heavy drinking manifests any symptoms, and often when it’s too late.

Clearly, then, there’s no cause for complacency, and while calls for better labelling (DDN, February, page 5) have yet to show results, the battle to introduce minimum unit pricing (MUP) has finally been won, albeit after a five-year fight (DDN, December/January, page 4). MUP became law in Scotland last month, and Wales is also moving to introduce it (DDN, November 2017, page 4). So are we likely to see it in England?

‘We will have to wait and see,’ director of policy at Alcohol Research UK and Alcohol Concern, Dr James Nicholls, tells DDN. ‘I think it’s unlikely in the short term, not least because the government is tied up with Brexit. They have announced that a new alcohol strategy will be developed, but as regards MUP it sounds like that will only involve a review of the evidence. They are also waiting to see what the outcome is in Scotland, where we now have the opportunity to see how the policy plays out in the real world.’

James Nicholls: ‘Everyone is looking to see how it plays out.’

All eyes will be looking north of the border, not least because up to now everyone has had to rely on modelling predictions for MUP, Nicholls points out. ‘That modelling is detailed and extensive, but wasn’t a crystal ball. Now that the policy is in place, everyone is looking to see how it plays out.’ One very interested party, of course, is the drinks industry. Its battle with the Scottish Government went to the European Court of Justice and the Supreme Court, but it still lost, which means it’s unlikely to mount any legal challenges to Welsh or English plans. ‘The legal process leading up to the Supreme Court decision was lengthy and thorough, so I think the legal questions are largely resolved,’ he says.

The fact that it was so lengthy has led to criticism that the 50p level set is now too low, with the Scottish Lib Dems arguing 60p would better reflect the impact of inflation (DDN, March, page 5). Is that fair comment? ‘There is a very extensive evaluation taking place in Scotland, which will look at the impact of the 50p price on different types of drinkers, on retail practices, and on health outcomes,’ Nicholls states. ‘That’s a good thing – policies should be evaluated, and we should be prepared to adapt our view of them in line with what we find. The most important thing, at this stage, is to try and ensure the evaluation is robust and impartial – we can then develop our views on the future of MUP in the light of that understanding.’

While MUP may be a positive development, for those struggling with an alcohol problem it clearly isn’t a silver bullet. Access to effective help is vital, and the recent report The hardest hit spelled out that the treatment system is at crisis point (DDN, May, page 4). One of the reasons identified was lack of political support – is that simply down to competing local priorities for limited funds, or is it a fundamental failure to see the bigger picture?

‘I think it’s very hard to make the case for better investment in substance use treatment generally, and alcohol treatment in particular,’ says Nicholls. ‘It’s not really a popular cause, and there is often still the sense that this is government spending money on people who have brought problems on themselves. However, aside from the ethical responsibility to support people struggling to overcome dependency, disinvestment is clearly a false economy. If people can’t get the support they need that doesn’t mean their problems disappear – often those same people will end up as repeat visitors to A&E or to other social services, all of which has enormous cost implications. We are calling for concerted government action to tackle the crisis in alcohol treatment both because it is the right thing to do and because disinvestment in the system leads to enormous costs further down the line.’

As the government does finally seem to have committed to delivering a new alcohol strategy, what should be in it? Alongside action on marketing regulation and pricing his organisation wants to see a ‘commitment to meaningful action on helping vulnerable people – not just those needing help with problem drinking, but the families and communities affected by that,’ he says. ‘That not only means more money for treatment, but support for better skills development and commissioning.

‘For that reason, we are asking the government to look at the introduction of a levy on alcohol to plug the funding gap – we want better support for the range of services who encounter alcohol issues in their daily work, improved pathways into treatment, and more effective use of brief interventions.’

UK among biggest consumers in ‘buoyant’ cocaine market

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DDN
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Cocaine purity levels in Europe are at their highest for a decade, according to the latest EMCDDA annual report, with a ‘buoyant’ market and increased availability of the drug in a number of countries.

Coca cultivation and cocaine production in Latin America are increasing, says European drug report 2018: trends and developments, with wastewater analysis showing increased cocaine residues in 26 out of 31 European cities. Those with the highest traces were in Spain, the UK, Belgium and the Netherlands. Cocaine is the most commonly used illicit stimulant across the continent, with around 2.3m 15 to 34-year-olds using it in the last year. The number of first-time treatment admissions for cocaine use also increased by more than a fifth between 2014 to 2016, the document states, to more than 30,000.

New psychoactive substances (NPS) also remain a ‘considerable policy and public health challenge’, says the agency, with more than 50 reported to the EU’s early warning system for the first time in 2017. The EMCDDA is now monitoring more than 670 NPS, almost double the number from five years ago. ‘Highly potent’ new synthetic opioids, particularly those derived from fentanyl, are increasingly being detected, it adds. There were more than 9,000 overdose deaths – mainly related to heroin and other opioids – in Europe in 2016.

Alexis Goosdeel: ‘We must be concerned about the health implications’

 ‘The findings from our new report indicate that Europe is now experiencing the consequences of increased cocaine production in Latin America,’ said EMCDDA director Alexis Goosdeel. ‘Early warnings from wastewater analysis about rising cocaine availability are now supported by other data suggesting growing supply, including increases in purity and in the number and quantity of cocaine seizures. We must be concerned about the health implications of cocaine use as we are beginning to see some worrying developments in this area, including a larger number of people entering treatment for the first time for cocaine problems. These changes underline the growing importance of providing effective prevention, treatment and harm-reduction interventions for cocaine users’.

WHY MUMMY DRINKS – The diary of an exhausted mum

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DDN
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Book review by Mark Reid.

WHY MUMMY DRINKS – The diary of an exhausted mum.
By Gill Sims
ISBN: 9780008237493
HarperCollins £14.99

I spent much of this book wondering if the answer to the title is ‘because she is an alcoholic’. Has Ellen, 39-year-old mum of two, lost the ability to control her drinking? Mummy is at the stage when, increas­ingly, everything she has to do is better with alcohol – afterwards, and then, during: ‘stashing a large bottle of Pimm’s in my bag… made the intermin­able hell of sport’s day pass much faster’.

Mummy says she drinks because other people are too much. Especially her young children, Peter and Jane. Like when Jane picks a paperclip off a hospital floor, and it later gets stuck between her teeth. So it’s back to the hospital to have it removed. This leaves mummy ‘beyond the aid of mere wine and having to resort to gin’.

Then there are other people’s mummies; the ‘Bloody Perfect Coven’ and their obligatory middle-class extra-curricular activities: ‘take children to swimming/music/tennis/dance/Jiu Jitsu’. ‘So much to do, there is never enough time to do anything’. ‘It’s a wonder I don’t drink more’ listening to ‘Perfect Lucy Atkinson’s Perfect Mummy’ say things such as ‘you still eat quinoa? You should give Camargue red rice a try’. ‘3.45pm: ‘wonder how soon I can have wine?’.

These resent­ments are among many unhelpful ways in which Ellen thinks. She doesn’t come across as being sustainably comfortable in herself or nice to be around – except to her friends, Hannah and Sam, when they are drinking. Together they sneer at the dysfunctional relationships of other adults; split-up couples arguing about money or who sees the kids when.

Gill Sims
Author Gill Sims

Mummy is prone to doing other people’s thinking and fuelling her self-doubt by comparing herself unfavour­ably to everyone else. She sits on the top deck of buses, peering into people’s homes. ‘What I see through all those windows are the good stories. Do people think the same when they pass my house? A nice house, a woman who has everything she could want, two beautiful children and a husband who loves her?’

In fact Ellen thinks she is ‘a terrible parent’ and all aspects of parenting are an ordeal. An afternoon at a soft play centre is an event for which ‘there is not enough wine in the world to ease the pain’.

Her thinking jumps to conclusions, crystal-ball gazes or strives for perfection. She expects too much from everything – so a firework display, which might be exciting, is just ‘being jostled in a muddy park’.

The alcohol, on almost every page, is a symptom of Mummy’s sedation of all this over-thinking. What she idealises is control: ‘7.40 pm: enjoy a civilised gin and tonic with my loving husband as we discuss each other’s days and make supportive remarks’.

This is never the reality and Ellen’s conclusion is that she’s ‘a bored borderline alcoholic trying to pass herself off as a semi-functioning adult’.

So is the sequel going to be ‘Why Mummy Goes To AA’? It’s much more likely to be ‘Why Mummy Swears’, which she does – a lot.

Regulated cannabis market would generate ‘£1bn’ in tax

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DDN
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Introducing a legalised, regulated cannabis market in the UK would generate ‘at least £1bn in tax income, if not more’, according to a report from the Health Poverty Action NGO. The money could then be ring-fenced to support the NHS as well as education and harm reduction programmes, it says.

Legalisation ‘is an idea whose time has come’

With the Canadian senate about to vote on legalising cannabis for recreational use, regulation and legalisation is ‘an idea whose time has come’, says the report, adding that a legal market ‘could’ also reduce alcohol consumption among some groups. Other benefits would include better labelling and consumer choice, safer and less potent products and more effective harm reduction.

While the report accepts the ‘possibility’ that a legal market may mean increased levels of use, this would be balanced by the levels of revenue generated and by ‘decimating’ the criminal market. The NGO wants to see the government shift primary responsibility for drug policy to the Department of Health (DH) and the Department for International Development (DFID), as well as establish a panel of experts to develop an effective model for a regulated market. A Cannabis Regulatory Authority should then be set up to implement their recommendations, it says.

‘It is time to accept that prohibition is not only ineffective and expensive, but that regulation could – if it is done well – protect vulnerable groups and promote public health,’ the report states. ‘It would also generate both taxes (at least £1bn annually, but potentially more) and savings, which taken together would mean more resources for health, harm reduction and other public services. It is time for the UK government to catch up with the global shift and take the responsible approach by bringing in a regulated, legal market for cannabis.’

Meanwhile, a separate report from the Taxpayers’ Alliance says that legalisation could mean potential savings to the public purse of at least £891m a year. ‘The prohibition of cannabis places a significant burden on public finances,’ says the document, which claims legalisation would result in savings of £50m for the prison system, £21m for the CPS, £26m for the courts and £141m for the probation service, as well as significant gains for the police and NHS.

Cannabis: Regulate it. Tax it. Support the NHS. Promote public health at www.healthpovertyaction.org

Potential savings from the legalisation of cannabis at www.taxpayersalliance.com

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