We could be about to see a big upsurge in crack use – but are we ready for it? How seriously should we treat the reappearance of ‘crack horror’ warnings? In this month’s cover story, Kevin Flemen suggests a pragmatic response.
With so many different drugs in circulation and symptoms to look out for, we’ve been developing our DDN ‘Wider Health’ series, beginning with a centre-pages pullout on alcohol. As Steve Brinksman points out in his latest Post-it, many patients present with health issues that are not obviously linked to drug or alcohol use. Our at-a-glance guide will help to understand conditions in which alcohol is a contributory factor and is designed with non-specialists in mind, to create better pathways across all branches of healthcare. Please pass it to colleagues where you can – the pdf is freely available on our website. We are very grateful for Alcohol Research UK for supporting us to develop this resource.
In creating advice pages, let’s not forget that most crucial part of the equation – service user involvement. When we started DDN nearly 14 years ago ‘Nothing about us without us’ was an essential theme. When Alan Joyce wrote his piece in 2006 (page 9) there was plenty to campaign for, but no suggestion of the patient voice being silenced. So Nick Goldstein’s questions on page 8 about the health of service user involvement deserve our full attention. We may need to consider a different model, but the need for a clear and challenging voice has never been greater.
The maximum stake that someone can gamble on Fixed Odds Betting Terminals (FOBTs) is to be cut from £100 to £2, the government has announced. The move is intended to ‘reduce the risk of gambling-related harm’.
MPs and campaigners have been calling for a reduction in the maximum permitted stake for years (DDN, September 2014, page 6), with the controversial terminals frequently referred to as the ‘crack cocaine of gambling’. The move relates to ‘category B2’ FOBT machines, which are mainly located in betting shops, and follows a consultation with the public and the gambling industry.
It is estimated that FOBTs account for around half of betting shop takings (DDN, September 2014, page 6) and the Association of British Bookmakers has said that it expects more than 4,000 shops to close, with the loss of 21,000 jobs. Digital, culture, media and sport secretary Matt Hancock, however, said the terminals were a ‘social blight’ that preyed on the vulnerable.
Public Health England will also carry out a review of the evidence around the public health harms of gambling, the government has announced, while the Gambling Commission is set to introduce stronger age verification rules for online betting.
Tracey Crouch: ‘Problem gambling can devastate lives’
‘Problem gambling can devastate individuals’ lives, families and communities,’ said sports minister Tracey Crouch. ‘It is right that we take decisive action now to ensure a responsible gambling industry that protects the most vulnerable in our society. By reducing FOBT stakes to £2 we can help stop extreme losses by those who can least afford it. We are increasing protections around online gambling, doing more on research, education and treatment of problem gambling and ensuring tighter rules around gambling advertising. We will work with the industry on the impact of these changes and are confident that this innovative sector will step up and help achieve this balance.’
A pilot project offering hepatitis C testing in pharmacies with needle exchange facilities has been hailed a success, with more than 50 per cent of those tested in the four-month scheme having hepatitis C antibodies. Almost 80 per cent of those who engaged with specialist services, meanwhile, had hep C viral particles in their blood.
A new report from the London Joint Working Group on Substance Use and Hepatitis C (LJWG) highlights the need for further awareness-raising, as 57 per cent of those taking part were unaware that medical advances meant the virus could be treated with oral tablets rather than painful interferon injections. The pilot – which was carried out at nine pharmacies across London – demonstrates the potential for offering treatment alongside testing, says LJWG, as 84 per cent of participants said they would be happy to receive treatment at their local pharmacy.
‘Innovative testing measures are essential’: Steve Brine MP with the LJWG
Innovative testing initiatives were essential in order to diagnose and treat everyone who has the virus, said public health minister Steve Brine, who added that the government was still working to eliminate hep C by 2025. It is thought that around half of the estimated 160,000 people in England living with the virus remain undiagnosed, and a recent report from the All Party Parliamentary Group on Liver Health stated that ‘significantly greater’ numbers of people would need to be tested, diagnosed and treated if it were to be successfully eliminated (DDN, April, page 4).
‘This project is another great example of how community pharmacists and their teams can support the health of their local communities and engage with people who may be reluctant to go to their GP,’ said chief executive of Kensington, Chelsea and Westminster Local Pharmaceutical Committee, Rekha Shah.
‘We now have the treatments to eliminate hepatitis C as a serious public health concern in the UK,’ added LJWG co-chair and consultant hepatologist at Chelsea and Westminster Hospital, Dr Suman Verma. ‘Offering free, accessible hepatitis C testing in community pharmacies is a more patient-centric way of engaging with a group of vulnerable, young people where hepatitis C prevalence and risk of transmission is high but, due to personal and social circumstances, engagement with community drugs services or healthcare services in general is poor and sporadic.
‘By offering hepatitis C testing in community pharmacies, we will transform and save lives as well as preventing further virus transmissions. This pilot project has the potential to be developed further to encompass the provision of hepatitis C antiviral treatment directly in the community pharmacies for this vulnerable, socially marginalised, at-risk population.’
Philipe Bonnet: ‘The work of the NNEF is more vital than ever.’
‘A 29-year-old kid dying of sepsis in 2018 in the UK’s second city.’ This was just one drug-related death of many, said National Needle Exchange Forum chair Philippe Bonnet, and reinforced why the focus on harm reduction must not waver and why the work of the NNEF was more vital than ever.
Back after a break in holding its annual event, the NNEF presented a packed conference programme that brought together speakers from health, criminal justice, drug treatment, legal services and policy.
With the first UK drug consumption rooms feeling like a distinct possibility and ever more influential voices and organisations joining the call for decriminalisation, the issues on the programme were bringing back an essential focus on harm reduction.
David Jamieson: ‘We need new dialogue and thinking.’
First speaker to the platform was West Midlands police and crime commissioner David Jamieson, who recently spoke out on the need for treatment over punishment (DDN, April, page 6).
‘We’ve got to move away from a polarised binary position – soft or hard on drugs,’ he said. ‘We need new dialogue and thinking.’ Was spending £1.4bn a year in the West Midlands on the ‘war on drugs’ a good use of resources, he asked. Jamieson had launched a strategy to divert people away from the courts and into treatment, through a series of recommendations that recognised drug dependence as a health issue over a criminal justice one.
As a former detective sergeant and undercover drugs operative, Neil Woods had developed an informed perspective of policing the illicit drug market. ‘Locking up nasty people’ was a ‘constant narrative for the public and press’, he said, but the market was so huge that this had a ‘tiny impact’ and ‘the process of policing drugs makes drug dealers more violent’. The growth of ‘county lines’ was involving children in gangs and causing more violence.
Neil Woods: ‘It’s the time to be drastic, the time to be brave.’
His experience had made him evaluate how police operations increased problems for many vulnerable people in society and conclude that the answer was harm reduction.
‘It’s the time to be drastic, the time to be brave,’ he said. ‘Criminalisation of drugs will be looked back on with as much disgust as criminalisation of homosexuality.’
Tony Mercer: ‘Ideology can get in the way of interventions,’
Public Health England’s drugs and alcohol manager, Tony Mercer, had been asked to comment on the arguments of harm reduction versus abstinence – a ‘polarised debate’ that worried him.
‘Ideology can get in the way of interventions,’ he said. ‘We need workers who are happy to provide whatever’s needed at the time.’ Spending energy on a debate that couldn’t be solved meant taking our eye off the ball, he added. ‘It’s a debate that can’t be resolved, so we need to reframe it.’
Referring to William White’s work on the need for different interventions, he said ‘The aim of everything should be to reach and engage people.’
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Effective engagement was a central theme for all of the speakers, with the prospect of the first UK drug consumption rooms. They would be a unique part of engaging people, though not a panacea, according to the Scottish Drugs Forum’s Kirsten Horsburgh. ‘We need a whole range of different things,’ she said. Looking at the situation in her Glasgow neighbourhood demonstrated very clearly the difference they would make.
Kirsten Horsburgh: ‘You don’t have to go very far to find discarded injecting equipment,’
‘You don’t have to go very far from the main shopping areas to find needle litter and discarded injecting equipment,’ she said. ‘We’re already providing sterile injecting equipment but not the rooms to use in.’ People needed to inject in public places – back alleys, toilets, or on the streets. In many cases they would be thrown out of hostels if they were caught injecting on the premises.
The constraints on where people could inject made them do it hurriedly – and the need for speed left them vulnerable to violence, stigma, and dangerous injecting practice, said Dr Magdalena Harris, associate professor at the London School of Hygiene and Tropical Medicine.
Urgent injecting led to venous damage and could easily transition to the groin as this was ‘quicker and easier in a low light’. She shared the experiences of two people involved in her research: Emma had told her about her transition to skin popping (injecting under the skin), which intensified the harms by causing infection. Gary had described injecting while blood was pouring out of his groin – and had seen this as the only viable option to being misunderstood and mistreated at hospital.
Magdalena Harris: Safe injecting spaces would be ‘a place for opportunistic care’
Safe injecting spaces would be ‘a place for opportunistic care’, said Harris – a place for food, healthcare, and a shared space for other support services such as benefits and housing. The facilities also made sound financial sense, as people were being hospitalised for preventable conditions such as sepsis and gangrene and not seeking treatment early enough.
‘Soft tissue infections exacerbate social exclusion,’ she added. ‘They give problems with mobility and have a massive impact on people’s lives.’
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Roger Nuttall: ‘Homelessness and addiction tend to rob people of their identity’
Getting the psychological approach right was equally important to tackling exclusion, and Roger Nuttall gave insight from his role as nurse coordinator at Hastings Homeless Service.
He talked about Paul, a 42-year-old man who had gone to his GP surgery with a wound from ‘skin popping’. He had disengaged too early from treatment, but since starting to attend the homeless service he had never missed an appointment.
So what had worked in engaging him? The holistic approach to building trust, using counselling skills, respect and empathy, was just as important as the wound care, said Nuttall. ‘Homelessness and addiction tend to rob people of their identity. By listening to their background and history you can help them rediscover who they are.’
Healthcare environments were often stressful, and raised stress levels (shown through levels of cortisol) had been shown to slow wound healing and impair immunity, he explained. So a little empathy and humility could go a long way in creating the right setting for the transition into treatment.
Kevin Ratcliffe: ‘Another dynamic environment for interaction is the pharmacy’
Another dynamic environment for interaction was the pharmacy, and Kevin Ratcliffe, CGL’s non-medical prescribing lead gave insight into initiatives in Birmingham. Needle and syringe programmes (NSP) were being run out of 88 pharmacies in the city, many with extended hours. Service users were actively involved in providing feedback on the quality of services and a mystery shopper exercise had identified things that the community pharmacies could be doing much better – including harm reduction advice.
The exercise also identified a weak link in the chain of Birmingham’s take-home naloxone programme – that clients had to be already engaged with a drug treatment service to receive kits. After a pilot phase (‘and a lot of learning!’) the kits were given out through pharmacies, ‘reaching people that services weren’t’.
The other valuable role of NSP-commissioned pharmacies was to refer people directly into treatment, and Ratcliffe announced that funding had been secured for hepatitis C testing in the Birmingham pharmacies, with results given within the hour. ‘In the city centre we want to get as many people through as possible and refer them into treatment there and then,’ he said.
Dr Ahmed Elsharkawy: ‘The UK needs to be far more proactive in finding people with hep C’
Dr Ahmed Elsharkawy, consultant hepatologist at the Queen Elizabeth Hospital in Birmingham, said that community treatment was critical to NHS England’s target of eliminating hepatitis C by 2025. There were no patients now waiting in Birmingham and ‘we’re running out of people to treat’, he said. But the UK needed to be far more proactive in finding people with hep C as there were still more people becoming infected than being cured.
NHS England now needed ‘to put their money where their mouth is and stop the rhetoric’ on eliminating hep C, he said – particularly as the highly effective new oral treatments represented a cure within eight weeks.
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Dr Prun Bijral: ‘Essential strand of overdose prevention was giving out take-home naloxone kits’
While the route map for hep C seemed clear, it was as important as ever for workers to stay informed of the latest drug trends. CGL’s medical director, Dr Prun Bijral, explained some important (yet still widely misunderstood) risks of fentanyl – that potency varied widely, leading to uncertainty around consistency and dosing. When pressed with a bulking agent, ‘hotspots’ could occur, with pills containing dangerous levels of this potent painkillers.
Improving access to medically assisted treatment (MAT) was vital to keeping people safe, in accordance with the Orange Guidelines, he said. The other essential strand of overdose prevention was giving out take-home naloxone kits, as ‘the whole community is at risk, not just those in treatment’.
Dr Loretta Ford: ‘Toxicology services had to constantly rise to the challenge of detecting new compounds.’
Dr Loretta Ford of the West Midlands Toxicology Laboratory added to the discussion of changing drug trends and explained that toxicology services had to constantly rise to the challenge of detecting new compounds. The ‘classic’ drugs of misuse had been joined by rising trends inNPS, prescription medication (notably pregabalin and gabapentin), steroids, and over-the-counter meds such as anti-histamines – drugs that had opened up a whole new world of varying potency and uncertainty for the user.
This uncertainty meant that the take-home naloxone programme had an invaluable place in reducing drug-related deaths. Zoe Carre, policy researcher at Release, said that while there had been a significant increase in areas providing naloxone, it was shocking that some local authorities were commissioning drug services without monitoring whether it was being distributed.
Zoe Carre: ‘We recommend that England implements a take-home naloxone programme as a matter of urgency,’
Coverage of kits was still not wide enough, and was not reaching the people who needed it. In many areas they were not provided to NSP clients, OST patients or to family, friends and carers of people considered to be at risk. Needless barriers included people having to be assessed or referred before getting a kit, or having to wait for training when the kit contained detailed instructions.
‘We recommend that England implements a take-home naloxone programme as a matter of urgency,’ she said, and Release was setting up a steering group to develop national guidelines to improve coverage and remove barriers. ‘All local authorities should be providing take-home naloxone and every person who uses opiates should be given at least one kit.’
‘Naloxone is only part of the solution, but a vital part of the puzzle,’ she added. ‘There needs to be adequate access to harm reduction advice and information.’
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Dr Judith Yates: ‘Stop wasting money on the drug war and stop treating people who use drugs as criminals.’
At the end of a full and informative day, it was Dr Judith Yates’ job to spell out ‘how to reduce harm and save money’. The clearest message was that ‘we should be ending the war on people who use drugs,’ she said. Decriminalisation was the only model that made sense, ‘and we should do this first’.
Secondly, the harm reduction measures that the conference had considered were highly cost effective: ‘DCRs don’t have to be posh expensive places – just a roof and a kettle,’ she said.
The take-home naloxone programme was proving to be extremely effective and was only challenged by stigma and ignorance: ‘There isn’t another drug that can save a life for £15 in a few minutes,’ she said.
Her work in recording drug-related deaths reinforced time and again that these deaths were preventable and showed that 78 per cent of people were not in treatment at the time of death.
‘There is huge scope for getting these people in treatment,’ she said, calling for an end to re-commissioning and funding cuts. ‘Stop wasting money on the drug war and stop treating people who use drugs as criminals.’
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‘I wish I could have bought an idiot’s guide to setting up a DCR.’
Kasey Elmore: ‘Pick your battles and build an external consultancy team’
Kasey Elmore visited the conference from Australia to share learning points from developing and building Australia’s second drug consumption room.
‘I wanted to design the best DCR in the world, with no risk. But lesson number one is to accept that this isn’t possible,’ she said. You had to acknowledge that the service that you want to run, and others in the sector want you to run – your clients, the government, the wider community – all look incredibly different.
‘Our model had to be located at our workplace and be medically supervised – an integrated model with nurses, doctors and registered drug and alcohol workers,’ she explained. ‘It’s in a residential area, located on a large public housing estate, and runs a needle and syringe programme giving out 90,000 syringes a month.’
Consulting with the client group was essential, but she felt there wasn’t enough time to do it properly. As they designed the layout of facilities, they came up with a three-stage model with zones for registration, injecting and aftercare, which seemed logical but already posed a problem – that people had to inject to get access to the aftercare services. So it became necessary to discuss a stage four, where people could access mental health services etc, if they didn’t inject.
There were also some conditions imposed by their licence that they had to adhere to, such as not allowing pregnant women or under-18s to use the facility.
An important part of design was to get the toilets right, with needle disposal, and their location in zones three and four. Would pets be allowed in a health facility, and could a dog get in the way of medical staff? Should there be secure pet parking on site so they were not stolen?
Liaising with key stakeholders on the project meant working with people who had never worked with this client group, so ‘pick your battles and build an external consultancy team’, Elmore advised, adding ‘we’re lucky we have an awesome police liaison officer’.
Clients were keen to know the ‘house rules’, such as the amount of drugs they could take in, and it was important to work out the protocol for supervision, the amount of people allowed in a booth, how to prevent people from stealing each other’s drugs, how to stop someone from operating a vehicle afterwards – and would staff be able to inject out of their working hours?
Do not underestimate the time and money needed for staffing, she advised. Finding the right people could be a ‘nightmare’ and ‘training costs a fortune’, but it was important to build a team that reacted in the right way to witnessing injecting and responding to an overdose, and weren’t bothered by a backlash from residents or the media.
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Kirstie Douse: ‘Let’s step back, take a breath and not get bogged down in the law’
The law in the UK was used as an excuse but there was no real barrier to DCRs, Release’s head of legal services Kirstie Douse told the conference.
Home Office statements on DCRs ignored public health elements, such as reducing blood-borne viruses and getting people into treatment, and focused on points of the law, such as possession being an offence.
‘But is this really insurmountable?’ she asked. The legal issues cited related to offences under the Misuse of Drugs Act 1971, other related criminal offences, and civil legal issues. However, she said, ‘there are things we’re already doing in relation to NSPs that we can do in relation to DCRs.’ The focus of the initiative would be on preventing crime and limiting harm.
‘Let’s step back, take a breath and not get bogged down in the law, but remember that drug-related deaths are the highest since records began,’ she said. ‘These are not just statistics but real people, and we want to save lives.
‘It’s up to local areas to take a stand. The law is not as significant an obstacle as people would like you to believe.’
While numbers of crack users may be on the increase, the basics of providing an effective service for them haven’t changed, says Danny Hames.
Danny Hames is chair of the NHS Substance Misuse Providers Alliance (NHSSMPA)
I read the serious violence strategy recently produced by the Home Office (see news, page 4) with great interest. Leaving aside the debates in the media regarding police numbers and budgets, I was drawn to the growing concern regarding the increasing prevalence and purity of crack cocaine in UK markets, and its link to increasing levels of serious violence.
The report indicates that the East of England has seen an 18 per cent increase in the estimated number of users of opiates and/or crack cocaine, alongside a 21 per cent increase in the estimated number of crack cocaine users in the South East. Anecdotally, our operational colleagues in the East of England area are noticing a steady increase. As a practitioner in the noughties, both in London and Southampton, I saw the prevalence and damage caused by crack and it prompted me to reflect on what ensures a drug and alcohol treatment service meets the needs of these service users.
As NHS providers we have been at the forefront of operating services for those using crack cocaine and cocaine for many years, both in our drug and alcohol services but also alongside colleagues in mental and physical healthcare services and those in primary care. It seemed relevant at this point that we outline what NHSSMPA believes is good, solid practice when ensuring that we provide strong, effective and relevant services for crack cocaine users. Here are our five get-the-basics-right principles:
Make sure your service is accessible. When a crack cocaine user presents, really take the opportunity to engage and start building a relationship, as the window of opportunity will be small.
Have strong case management which is clearly shared and communicated with service users and steadily transitions responsibility for the plan from practitioner to service user. Provide stability and direction amidst the chaos.
Ensure that your staff, volunteers and peer mentors are well trained and supported to understand the impact of crack cocaine. This will help them to build a relationship with the service user.
Ensure your risk management is robust. It needs to be protective to all and also ensure that interventions can be provided effectively – quality psychosocial interventions in the right dose at the right time are vitally important. Close working with psychiatry and psychology is invaluable.
Build strong local relationships to ensure there is a broad range of recovery interventions available to those affected – both service users and their families.
If you would like to know more about NHSSMPA visit:
The widespread use of synthetic cannabinoids like ‘spice’ in UK prisons is risking the health of nurses and other staff, according to the Royal College of Nursing (RCN). The RCN has written to the head of HM Prison and Probation Service (HMPPS) asking for prison governors to do more to protect nurses and other health workers from the effects of the drugs.
RCN chief executive Janet Davies: ‘Spice poses a serious threat’
Nurses and healthcare assistants are often first on the scene when prisoners need emergency care, and current guidance means they are expected to enter cells before any smoke has cleared. The RCN says at least one nurse has been taken to A&E after being rendered unconscious by drug fumes, while other RCN members have reported feeling dizzy, nauseous or being unable to drive after their shift.
According to the royal college HMPPS guidance ‘conflates the chronic and longer term issues of exposure to second hand tobacco smoke with the serious and acute issue of exposure to psychoactive substances’, with the expectation on nursing staff to enter cells where smoke has not cleared running contrary to Resuscitation Council guidelines. According to those, emergency responders should ‘assess dangerous situations and ensure their own safety’ first before treating anyone.
‘Spice poses a serious threat to nurses, health care assistants and prison staff, whose safety and long-term health is being put at risk day in, day out,’ said RCN chief executive Janet Davies. ‘As dedicated health professionals, prison nursing staff are expected to offer high quality care, but they should not be expected to put their own wellbeing on the line to deliver it. I have heard some truly shocking stories of nursing staff passing out or being unable to drive after exposure to spice.
‘The scale of this problem demands swift and effective action from HM Prison and Probation Service. We would like to see an urgent review of the guidance that properly reflects the risks posed by this extremely dangerous drug.’
‘will CQC catch us out?’ With the proposed move by CQC to short-notice inspections coming into force this month, how much leniency will be allowed for one-off issues?
CQC’s intention to begin short-notice or unannounced inspections of substance misuse service providers will be a significant change for the sector, which has previously had notice of inspectors’ visits and been able to prepare.
It comes at a time when the sector is acutely aware that CQC is watching. In the November 2017 briefing ‘Substance misuse services: The quality and safety of residential detoxification’, CQC set out its significant concerns from the first inspection cycle under the new regime. The headline summary was that CQC took action to require 72 per cent of providers to make improvements due to breaching regulations and failing to meet fundamental standards of care.
Inspections are crucial to CQC’s understanding of the services it regulates. The less notice they provide, the less time providers have to prepare. This will understandably cause some nervousness and it may be tempting to request leniency during the period of adaptation.
Unfortunately, however, any such requests are likely to fall on deaf ears for two main reasons.
Firstly, short-notice and unannounced inspections have become increasingly common throughout the regulated sectors in the past few years. CQC gave no leniency to, for example, GP surgeries and dental practices when they introduced unannounced inspections and will feel no need to act differently with this sector.
Secondly, inspections are intended to capture an ‘on the day’ assessment of a service. Inspectors understand that the more notice given to prepare, the less likely that what they see is identical to normal practice. Short-notice inspections reduce the opportunities available to providers to ‘improve’ their service, and what the inspectors see is more likely to accurately reflect its normal running.
To expect inspectors to be more lenient because the provider does not have this extra notice period will be met with a less than positive response. That said, the rules of challenging the resulting draft inspection reports remain the same and it is just as important to challenge that which is not factually accurate.
We regularly view draft inspection reports which use isolated or one-off issues to improperly extrapolate a conclusion of systemic failure. This presents a false assessment of the service, and must be challenged through evidence that shows that a one-off issue is not representative of the wider service.
In summary, providers should not be asking for ‘leniency’, but should instead be demanding that CQC exercise reasonableness and proportionality when assessing those one-off issues. To do otherwise would be to publish a misleading report – something which is of no benefit to the public, the service or the reputation of the regulator.
Are alcohol services meeting the needs of adults with autism? Alcohol Concern and the University of Bath are working to improve support for this client group and want to hear the views of practitioners, as Andrew Misell explains.
Andrew Misell is Alcohol Concern’s Director for Wales
There are around 700,000 people in the UK on the autistic spectrum – around 1 per cent of the population. When you’re on the spectrum, social interaction and communication – with all their unwritten rules and conventions – can be tricky. Reading the thoughts, feelings and behaviours of others can be a minefield. When you’re unusually sensitive to sounds, touch, and light, our world of constant stimuli and chatter can be a challenge. And when you add it all up, everyday situations can feel overwhelming.
In the face of all this, retreat into safer spaces and activities is attractive. Indeed, many people with autism do respond to the busyness and bother of the world by avoiding risky or unpredictable situations. This has led in turn to something of an assumption that they are unlikely to misuse alcohol. The logic goes something like this: if someone likes to be clear about where they stand, why start using a substance that makes everything foggier?
Initial research by Alcohol Concern, however, suggests that this assumption doesn’t match the reality of many autistic people’s lives. Although solid evidence is thin on the ground, a recent review by the charity of the current literature – as well as consultations with academics and practitioners – has highlighted a number of issues that alcohol services may need to address, as well as the need for more thorough research into the topic.
Alcohol Concern’s investigation has revealed that although people on the autistic spectrum do not appear, necessarily, to drink more than anyone else, that’s not the whole story. As with many other stressful conditions, there is evidence that some people with autism self-medicate with alcohol. There is a growing genre of ‘autism autobiographies’ and several of these have included accounts of the use of alcohol as a stress-management tool. Alcohol use has been found by some to be a successful autism coping strategy in the short-term, enabling them to manage or conceal autism-related difficulties for years – until the alcohol use starts bringing on its own problems.
If people with autism do drink (because of their autism, or for any other reason) there is some evidence that they are likely to have greater difficulty managing their drinking behaviour, and be more prone towards harmful drinking and alcohol dependence. Further problems seem to be encountered at the point at which someone with autism is in need of support to manage their drinking.
The obvious initial obstacle is whether that person feels able to enter the treatment system. Substance misuse treatment centres can be quite chaotic environments, with a fairly constant flow of clients and their companions, some of whom may be disruptive and noisy. Even if a client with autism succeeds in making and attending an appointment, some alcohol treatment approaches – such as those relying on analogies, abstract thinking, or a sense of social self – are likely to be unsuitable for them. The need to be understood is often quite deep in people with autism, and if it becomes clear early on that a practitioner does not properly understand autism, the therapeutic relationship may stop before it starts.
Following from this initial research, Alcohol Concern is now working with the Centre for Applied Autism Research (CAAR) at the University of Bath to explore whether people with autism do access (or seek to access) alcohol treatment services; what happens when they do; and how alcohol services could be made more autism-friendly.
The ultimate aim is to work with services to make the necessary adjustments to promote equality of access for people with autism to alcohol support when they need it. Indeed, one of the most positive things that has already come out of this project is the idea that it may be possible for services to adapt their approaches to play to the strengths of autistic clients, i.e. to engage with them in ways that make the most of their traits.
As part of the project, Alcohol Concern and the research team at Bath are inviting anyone working in substance misuse services to complete a short questionnaire. Whatever your experiences have been – even if you’re not sure whether you’ve encountered clients with autism or how you’d recognise the condition – they’d like to hear your views. The questionnaire shouldn’t take more than 15 minutes to complete, and is on the Alcohol Concern website: www.alcoholconcern.org.uk/autism
All information you provide will be anonymous, confidential and securely stored.
For many people whose autism is undiagnosed, alcohol can act as a successful coping strategy – until the alcohol becomes a problem in itself. Matt Tinsley shares his story.
‘The chief aspect of my autism which resulted in extremely heavy use of alcohol to cope was a near constant sense of anxiety. I also was socially awkward and discovered alcohol turned me into a much more relaxed person. Of course, I was unaware of my autism at the time and it’s only in retrospect that I can understand why it worked so well.’
Alcohol also helped Matt to function in the workplace and develop and maintain relationships. It meant he was less affected by sensory stressors and so helped manage his anxiety.
‘Sensory problems which I have now such as loud noises and certain textured clothes being very uncomfortable were numbed to a certain extent by drink. Being overwhelmed with information when being given instructions was also not a problem when drinking, as I felt able to retain the information. This may sound like the opposite to the way alcohol would affect NTs [neurologically typical – people not on the autism spectrum], but I think that is the key to its success for me, until it became life-threatening – it made me feel and act in a much more neurotypical way.
‘Alcohol enabled me to do jobs where anxiety might have been crippling – working in an environment with constant contact with the public. Instead, despite being technically drunk, I was very efficient at my jobs and was able to cope doing such jobs for 17 years.’
However the point comes when the level of alcohol required for functioning becomes unsustainable and serious health issues occur. For Matt, that was severe liver damage, collapse and certain death if he continued to drink.
Some services have a requirement that clients be ‘dry’ before they are accepted for treatment. However for some – possibly undiagnosed – autistic people, for whom alcohol may be their coping strategy against extreme anxiety, it may be the case that they cannot access support as the removal of the alcohol may make them incapable of leaving the house. More awareness of the potential of autism to result in problem drinking is needed in alcohol support services, and there also needs to be recognition of what to look out for.
‘The signs to look for that a person with an alcohol problem might also be autistic could be unusual eye-contact, special interests (is there a certain level of ‘nerdiness’ in what interests the drinker, or do they have one subject at which they are expert at?). Is their use of language (grammar and syntax) unusual in any way, does their conversation sound odd or pedantic? Also, they may just present themselves, as I did, with the conviction that they are autistic and have just discovered why they are like they are. This should definitely be paid attention to, and not dismissed.’
For support on all aspects of living with autism visit www.autism.org.uk
The history of prohibition proves it fuels gangsterism and forces up potency, from moonshine replacing beer and wine almost a century ago in the United States through to skunk ousting milder cannabis on British streets. Stronger products mean smaller quantities for smuggling, bigger profits and more turf fights… When will Westminster accept its lethal failure on this battlefront? We have the highest rates of heroin use and almost one in three of the overdose deaths in Europe. Our mortality rate is ten times that of Portugal, where addiction is treated as a health issue, not a crime. It slashed heroin abuse after decriminalising drugs. British politicians are acting with criminal incompetence as other countries start to end this stupid war and focus on harm reduction.
Ian Birrell, Times, 18 April
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There are drug injection facilities in almost 70 cities around the world, but not one in the UK. That is because of outdated laws that the UK government must either change or devolve to Scotland. There were 867 drug-related deaths in Scotland last year and countless other lives were devastated. How many of those people would still be alive if they were in a safe environment, using clean equipment and with medical professionals on hand?
Aileen Campbell, Herald, 9 April
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Obviously, it’s far more harmful to drink heavily. However, the part of the [Lancet] study relating to moderate drinking appears to be mainly middle-class territory – the ‘one (or two) glasses of red a night won’t do me any harm and probably quite a bit of good’ self-delusion desperados, who seem to think their alcohol can’t hurt them because they bought it from Waitrose… It could be a pricey bottle or a dented can from the budget bin of the supermarket, but drink too much of it, at the right strength, and it will affect your health.
Barbara Ellen, Observer, 15 April
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Shouty headlines on Friday morning proclaimed: ‘Couple of glasses a night shortens life by two years! Much more than four bottles a week can lop off five years!’ By that count, I should have died four years ago… I have always wondered about the veracity of these scare stories, thinking, well, what if your wine glasses are really small? And I cannot help wondering why everyone wants to prolong a life that will inevitably be joyless, as if this were our only ambition.
I was impressed by Alex Boyt’s thoughtful and intelligent article regarding 12-step programmes (DDN, April, page 12). I wanted to explore the current wisdom of encouraging people who approach drug services struggling with addiction to attend 12-step meetings.
It may be that my experience is particularly shaped by the culture in Bristol where there are an awful lot of people, predominantly men, who have to attend meetings as a condition of living in a ‘dry house’. Anyway, unless you are an attractive woman going to a meeting currently using, if you don’t have any friends in the fellowship will get you treated like a leper. Imagine someone’s state of mind who perhaps through hard struggle has abstained from crack and heroin when on a methadone script and then seeks support at NA only to be made to feel unwelcome. Workers should bear this in mind before encouraging clients to attend.
Some sort of pre-briefing of the rituals at these meetings (hand holding and chanting) would also be wise, as it can seem pretty weird to a newcomer. I’m including these thoughts as notes of caution as I have friends who have gone on to live drug-free lives after using 12-step support.
Richie, Bristol, by email
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WHATEVER WORKS
Brilliant read. I did 12-step abstinence for six years, but never felt I was being true to myself and witnessed so much judgement within fellowships. It’s 14 years in July since I took my last methadone or any other class A, following nearly 18 years of chaotic addiction and lifestyle. The six-year abstinence was definitely a good foundation for my recovery but once I realised I had a great support network within my life outside of NA I made a choice to get on with my life. So for eight years now I’ve not questioned myself – if I want a drink with friends I have one. I even went to Amsterdam on a girly trip and had a puff on a joint, didn’t beat myself up, no one judged me and guess what… I’m still living and loving a productive life!
I thank the 12 steps for giving me some great principles to apply within my life but I too disagree with the ‘powerless forever’ statement! If 12 steps forever are what works for you then I’m happy for you, but for me it was the bridge to normal living and the biggest factor in my recovery is definitely my support, acceptance, love and laughter from friends and family. Do what works for you but don’t beat yourself up if things don’t always go to plan, especially if it’s someone else’s plan!
Tara, via www.drinkanddrugsnews.com
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TO THINE OWN SELF BE TRUE
What am amazing well-written paper. You have raised some valuable points, that I for one have just been discussing with a friend. I am a person in long-term recovery, and have been working on myself for many years. I have always believed that those who commit suicide or relapse either cannot maintain the ‘all or nothing’ concept or the self-development which I believe is needed to continue in recovery.
I stopped attending the rooms because I changed, as simple as that. I didn’t pick up nor do I want to pick up, even after losing a son and more recently the death of my mother. I didn’t want to use because I knew that would not be the answer – I do believe that NA is not the answer to everyone’s drug problems. I believe we all have a unique guidance system and our soul knows the way. I have worked in drug and alcohol serves and I am now a qualified, integrative therapist in my final month of a BA honours degree. I have wonderful choices now, that I would not change for anyone. Thank you for your article – being my true authentic self has always been my goal.
Anonymous, via www.drinkanddrugsnews.com
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RUINOUS READING
Reading this has ruined my day and I was upset it had been even brought anywhere near me. I think you are a clever person who could help a lot of people change – why bother to get bogged down with an unnecessary debate?
Ellie, via www.drinkanddrugsnews.com
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GET SMART
It didn’t/doesn’t work for me personally. Things didn’t really click for me until I found Smart Recovery. That’s not to say I didn’t find a lot of value in some of the 12 steps approach, I just couldn’t get totally comfortable with it – for many reasons. At the end of the day though, it’s whatever works for you. Any positive steps.
National judo champion Stuart Pascoe thought his sports career was over as his alcohol use spiralled. But with help from Addaction the 46-year-old has gone on to beat competitors half his age, as well as volunteering with the charity to help people experiencing similar problems.
I started drinking excessively after my divorce. I tried to run away from what was happening and travelled around working, living out of a suitcase. But I should’ve stayed and dealt with things. I’ve always been a reward drinker, so throwing myself into work and achieving gave me the perfect opportunity to drink every night. But that gradually became drinking in the morning and going home at lunchtime to drink.
All those years ago I didn’t realise that places like Addaction existed. I can remember my mum coming with me to my first meeting because I was shaking with nerves. Looking around the room I realised this illness doesn’t discriminate – there were people from all walks of life, and of all ages. I never imagined meeting a group of like-minded, supportive people I would go on to call friends.
I went to Addaction Chy, the charity’s rehabilitation centre in Truro, but I wasn’t ready and got very complacent. I thought I was fixed after five months and that I could jump back into my old life. I told myself I could manage it, that the old me was back and I was where I wanted to be. I was so wrong. It went downhill in months and within a year I was out of work. The loneliness started creeping in, I stopped seeing family or doing judo, and I isolated myself with nowhere to go.
At the worst point I was drinking about 1.5 litres of vodka a day and not leaving the room I was staying in. I’d send a taxi to the shop to get a bottle and lock myself away all day. I didn’t eat when I was drinking, I was so alone, and nobody saw me for about six months.
I was up and down all the time, crying one minute, laughing the next, hallucinating and having vivid dreams. My body was failing and I was being sick all the time. Friends and family can only do so much, and I had pushed them all away so many times.
My wake-up call was a visit from the doctor who told me I would be dead in six to eight weeks and wouldn’t see Christmas if I carried on. I knew this was it, but if I was going to change I didn’t have time to wait around. So I did a detox in hospital and luckily Addaction Chy was able to get me in quickly.
This time I stayed 12 weeks in the main house and then did three months in the move-on flats, rather than jumping back into the community. I focused on getting things back in my life that were healthy and not worrying about work. Judo had been part of my life for 40 years and I wanted to get back into it. I’d won a couple of national championships before, but retired in 2003. I decided to set myself the goal of winning the British championships and started training that September.
Stuart at Addaction Chy with manager Ross Dunstan
Nine weeks later I won the open-age category, competing against people half my age – the guy on the silver podium said his dad was younger than me. It was the first competitive judo I’d done in 14 years and it put me among the oldest champions ever. I’d had aspirations to go back into it before, but the alcohol got in the way.
Now I’m eligible to train with the national squad and the British masters squad. The rest of the time I train locally at Redruth Judo Club where people have been really supportive, and sometimes at Helston and Plymouth. Next I’m planning to compete in the British Judo Council open nationals.
Volunteering with Addaction and judo are my life now. I run some of the charity’s mutual aid groups, prep for treatment groups and am a mentor to new clients. I’m also volunteering at Chy, running the introductions group for people who are in their first four weeks of rehab.
My life is a dream now. This afternoon I will go and mentor clients before going to work tonight, then my weekend will be filled with catching up with friends and watching some judo. It’s been a hard journey, but thanks to Addaction I made it to the other side and now I want to spend my time helping others do the same.
A study of people who used heroin in prison gives vital clues on reaching out to this significant and vulnerable cohort. Lana Durjava shares her findings.
Lana Durjava has a background in forensic psychology and works at HMP Pentonville
Recent reports on drug use in prison have highlighted the increased use of new psychoactive substances; however heroin is still a significant concern and tends to be used for longer periods than other drugs such as cocaine and amphetamine. Additionally, prisoners often present with dual diagnosis and polysubstance addiction, which amplify problems associated with their wellbeing and raise concerns for staff and prison security.
Heroin use carries multiple health, legal and social implications, such as increased risk of blood-borne viruses, infections, injecting-related complications, poor health, risk of overdose, social isolation and engagement in criminal activities. In a prison setting it carries additional challenges, with individuals often engaging in riskier behaviour due to contextual factors such as unsafe environment, limited availability of harm reduction services and a climate in which they have to hide their drug use to avoid punishment for failing mandatory drug testing.
Incarceration has an overwhelming impact on everyday life. It brings multiple losses, some of which are irretrievable – loss of liberty, relationships, opportunities, time, and control over one’s own life – and heroin use is one of the means of coping with these losses. The prison environment, with its climate of hostility, suspicion and unpredictability, means regular exposure to feelings of isolation and threats of violence.
Incarceration has an overwhelming impact on everyday life.
The prison population in England and Wales has doubled in the last 25 years due to increases in custodial sentencing and sentence lengths. This has resulted in a population comprising many more prisoners with mental health problems, substance use disorders and histories of self-harm and suicide attempts.
‘Heroin made me bulletproof’
A qualitative study was conducted with former prisoners who had experienced heroin addiction while inside. The aim was to gain better understanding of psychological and social aspects of the phenomenon, and to explore how to support people in this situation to achieve recovery most effectively.
Compulsive heroin use is generally the result of a number contributing factors; however all participants in the study said that one of the main purposes of their heroin use was to regulate overwhelming emotions. Heroin use was an attempt at self-regulation and management of difficult emotional states, with the ever-present theme being an attempt to disconnect from reality and achieve a state of numbness.
‘It kept my emotions stable. Constantly when I was on gear, I’d feel composed, I don’t get angry, I don’t get upset, I just deal with stuff, I feel pretty much invincible when I am on it…
‘It’s not always easy sitting in prison and thinking who’s my missus sleeping with now, who’s trying to play dad to my daughter, what does my daughter think of me, who’s driving my car… Cos you know you lose everything every time you go to prison. You don’t get a chance to sort your stuff out, you just lose everything.’ (Ben)
The conceptualisation of heroin use as an emotion regulator and coping mechanism, which people resort to because they have failed to develop adaptive responses to stress and negative emotional states, is not something new. It matches the self-medication hypothesis, which argues that a person who is more sensitive to emotional distress and who has a lower ability to self-regulate is at greater risk of progressing from experimental to dependent drug use as a means to cope. Indeed, the results of this study showed that participants used heroin to self-medicate.
Ability to self-soothe in times of distress is essential for healthy emotional functioning and to prevent the person from becoming emotionally overwhelmed. Being unable to do this is commonly connected with the problem of internalisation – not learning how to regulate emotions from a primary caregiver at an early stage, which would have allowed someone to practise effective self-care. People who are addicted to heroin have often been described as having disturbed global ego function, turning to the drug to self-regulate.
Generally speaking, a person’s choice of a particular drug is not accidental and different drugs are chosen to cope with different forms of emotional distress. With its characteristic ability to kill physical and emotional pain, heroin appears to be a magic drug, ideal for coping with the pain and loss associated with imprisonment.
‘It helped me deal with emotions I guess, I mean it helped me suppress them. It made me feel numb and that was what I needed at the time cos life was overwhelming otherwise. I felt depressed and all, but then I took heroin and did not feel anything at all. I could forget the mess I was in, I mean I lost my kids and all and I didn’t really care or feel anything about it when I was on heroin.’ (Mark)
‘It’s my obsession’
This study also aimed to explored participants’ relationship with heroin – a relationship that was characterised by obsession and ambivalence and was prioritised above individuals’ interpersonal relationships. Participants manifested a strong attachment to the drug, which was experienced as a secure base and safe haven. They perceived it as an attachment figure, gravitated towards it in times of distress and used it as a source of comfort and safety.
‘…I felt I had no control or power over it and it was running me – my missus once said to me that she had a dream I was having an affair and that affair was with drugs, and that was true. I did not understand that back then but it makes sense today.’ (Simon)
This tallies with previous research on attachment and heroin addiction, which argued that due to its neuro-biological properties, the drug was used to compensate for the absence of satisfying relationships. It was previously shown that heroin is chosen to serve specific emotional and social needs; so one possibility is that people who experience problems in forming close and trusting relationships gravitate towards heroin use. Later on, their heroin use can complicate interpersonal relations and so limit their potential for forming trusting relationships.
The findings suggested that heroin use has a significant impact on object relations – the need for contact with others. Relationships were made based on drugs, disproportionate power dynamics emerged between heroin users and suppliers, a climate of mistrust was created, and the participants tended to isolate themselves and maintain distance from any meaningful interpersonal contact. Prisoners with drug problems often oscillated between feelings of empowerment and disempowerment, based on their level of addiction and drug accessibility.
‘[With the other inmates] it was very basic, there was no friendship or relationship there really, it was just focused on getting and using the drugs, that was as far as it went. You were just talking about what’s happening and who has the money and who has the gear and who will score and where to use it and stuff like that.’(Adam)
The disparity involved in the power dynamics between heroin users and dealers became particularly evident during withdrawal, when biopsychosocial discomfort induced fear and isolation. Sizeable debts could also build up among prisoners, creating additional complications – often compounded by prisoners’ mental health problems. Certainly the participants in this study reported mistrust of both the authorities and other prisoners, where heroin had the dual purpose of being both ‘a blessing and a curse’.
‘You’ve gotta deal with people who you’re buying it off and they obviously use it as an element of power… Then the obvious violence that goes with it as well, cos things don’t always run smoothly… People rob other people, nick their stuff, people don’t pay people, so it’s kinda like, yeah, looking back I don’t know how I had the energy to do it.’ (Ben)
The study aimed to contribute to the existing knowledge about the psychological and social experience of heroin addiction in prison – an experience that could be summarised as a life of lonely compulsion in a mundane and ruthless environment. While the findings cannot be generalised to the wider prison population, they nevertheless offer a fair indication of the everyday reality of people who experience heroin addiction during incarceration.
British prisons are in a state of perpetual crisis, with endemic drug use, bullying and violence being fundamental parts of daily reality. The prison system currently appears to be mostly about containment and risk management and is characterised by limited resources, staff shortages, lack of meaningful activities and support services that are inadequate in responding to prisoners’ needs.
It is hoped that, with time, an holistic approach will be more consistently adopted that addresses the multiple health, social and psychological needs of the prison population, despite all the contextual pressures and factors that hinder recovery from compulsive drug use and offending. Furthermore, it is hoped that the prison service will employ less punitive strategies in the detection and punishment of illicit drug users – and that custodial sentencing will incarcerate violent offenders, rather than those who are vulnerable, with complex needs, and deemed ‘petty’ criminals.
The guiding principles are oriented around growing as much of our own produce as possible
Phoenix Futures we have been working with people with substance misuse issues for over 47 years, offering specialist services across community, prison and residential settings. Our fundamental belief is that every person who is dependent on drugs and alcohol has the potential to rebuild their life.
It is only by focusing on an individual’s wider recovery, however, that lives can be rebuilt and individuals can stay on track. So in addition to our core recovery services we also offer a number of personal development programmes that help service users gain skills, confidence, motivation, employment and reintegrate into their communities. The longest running and most successful of these programmes is Recovery through Nature (RtN).
‘Purple Camels’ is a holistic approach to developing sustainable recovery. The guiding principles are oriented around growing as much of our own produce as possible in our gardens and allotments, to be used in our kitchens. We source local produce, if and where cheaper (including environmentally preferable purchasing), and have developed a culture of recycling and being aware of the way we use and save water and the energy for heating and lighting. We look at the use of renewable resources across the spectrum and are aware of pollution.
We called the project ‘Purple Camels’ because camels are able to adapt and survive in challenging environments, and purple is Phoenix Futures’ colour. The programme is part of the organisation’s Recovery through Nature programme – a highly effective therapeutic intervention that engages teams of service users recovering from substance addiction in practical conservation projects, and uses that experience to support their rehabilitation and recovery.
There are two fundamental guiding principles to ‘Purple Camels’. Firstly, the idea must be incorporated into the therapeutic community (TC) process as part of a ‘right living’ ethos, and be service user-led and orientated. It links into the proven, underpinned benefits of eco-therapy, horticultural therapy and our own Recovery through Nature programme and becomes integral to our TC process. Secondly, as an organisation, we are making a conscious effort to reduce our costs in such straitened times, so the intention is that it will save money in the long term and make our approach unique.
Working in partnership with Lane End Farm Trust (LEFT) at Phoenix Futures’ Sheffield residential service brings together our expertise to develop the desired sustainable concept. Our aim is to collaborate on a sustainable food cycle programme by developing the large, walled, Victorian garden at its Storth Oaks site into a kitchen garden of raised growing beds. The intention is to create a vegetable and fruit growing garden that can supply seasonal organic produce for the kitchen at the residential service, and any surplus produce can be sold into the local food community working with the Lane End Farm Trust (LEFT) existing customer network. In addition to the raised beds, we intend to have a poly tunnel on site to extend the growing season and provide better growing conditions to produce a wider variety of produce for more months of the year.
The victorian garden at Phoenix Storth Oaks site
Service users from both PF and LEFT will have access to working in the garden across all stages of the growing season, and trained staff with horticulture and therapeutic horticulture experience will provide guidance and training for service users. As the project develops, we intend to provide basic qualifications for service users who wish to engage in that part of the programme. Other users may simply benefit from the chance to be involved in a real work environment and gain empowerment through the therapeutic benefits of horticulture.
The benefit to the wider community, including local residents, volunteers and support workers, is access to high quality ethically produced food at fair prices that is grown and harvested by our service users. This ultimately improves community cohesion through inclusive outreach across the local area.
Work began to transform the gardens with raised beds on 16 April. It was discovered that the quality of the soil was excellent and the decision was made to move the programme forward rapidly, so service users planted the first crop of potatoes on 24 April – potatoes being chosen as the first crop so the soil may be thoroughly worked over when they are harvested.
‘It’s a mismatch between prison and
complex needs’
We need a new dialogue and thinking, says police and crime commissioner David Jamieson, talking about his recommendations to divert people away from the courts and into treatment (page 8). ‘Criminalisation of drugs will be looked back on with as much disgust as criminalisation of homosexuality,’ adds former detective sergeant Neil Woods, speaking at the same NNEF event.
We have long heard the call to stop wasting money on the drug war from healthcare workers – those at the sharp end of human suffering and misery. But when the pieces of the jigsaw join with those from the criminal justice, policy and treatment sectors, there is surely enough to complete the picture that health must come first – and that it is politicians’ duty to take account of the evidence.
The prison population has expanded rapidly and institutions are bursting at the seams. Lana Durjava’s study of people who used heroin in prison (page 6) shines a light on the mismatch between incarceration and complex needs. The motivation is to self-medicate, to shut down responses and deaden the pain – summarised as ‘a life of lonely compulsion in a mundane and ruthless environment’. If they are lucky enough to receive treatment, they are still vulnerable to leaving prison without the support, the right medication, or even a take-home naloxone kit to keep them alive.
So where does this ineffectual policy leave us? In the meantime, our prisoner is trying to block out each day more than the last.
A cycle of disinvestment coupled with reduced capacity and staffing levels means that the alcohol treatment sector in England is in crisis, according to a new report. The situation is putting ‘hundreds of thousands of people at risk’, says The hardest hit: addressing the crisis in alcohol treatment services, which is published by the charity formed from the merger of Alcohol Concern and Alcohol Research UK.
Rapid re-tendering cycles, lack of political support, loss of qualified staff and funding cuts are having a severe impact, the document warns, with the end of ring-fenced public health funding in 2020 likely to worsen the situation further and pose ‘additional risk to the areas of highest need’. It is estimated that there are almost 600,000 people in England who are alcohol-dependent and in need of specialist treatment.
The report highlights a real danger of alcohol services being seen as non essential.
The report is based on the views of more than 150 respondents including service providers, GPs, nurses and others, who reported funding cuts of between 10 and 58 per cent. Almost 90 per cent felt that resources in their area were insufficient, with nearly 60 per cent saying the situation had worsened in the last three years. Community detox and residential rehab were felt to be particularly at risk, and more than 60 per cent of respondents stated that appropriate care for people with both an alcohol and mental health problem was unavailable in their area.
In an era of consistently squeezed public finances there is a ‘real danger’ that alcohol services could come to be viewed as non-essential, the report warns, which risks both ‘creating a false economy’ and damaging ‘the lives of countless individuals, families and communities’.
The report, which was published on the day minimum pricing was implemented in Scotland, calls on the government to develop and implement a national alcohol strategy, and ‘urgently plug the gap’ in treatment funding. It also calls for a national review of staffing to identify the levels of expertise needed at each point in the system. While the use of peer mentors was widely welcomed, there was concern that many were being employed ‘without sufficient training and for economic reasons rather than to improve provision’, the report adds.
Dr Richard Piper: Government must develop a national alcohol strategy.
‘Around 595,000 people in the UK are dependent on alcohol,’ said the charity’s CEO, Dr Richard Piper. ‘It’s clear that the government must develop a national alcohol strategy to address the harm they and their families face, and include treatment at its heart to reduce the suffering of the four in every five who currently do not access the services they need. This report shows very clearly what action is needed and we urge policy makers, practitioners and service providers to join together to implement these recommendations to help the hundreds of thousands of people who are in desperate need of support.’
Meanwhile, people on higher incomes are more likely to drink regularly, according to statistics from two new reports. Almost 80 per cent of those earning £40,000 or above reported drinking alcohol in the previous week, compared to 58 per cent of all adults. For people earning under £10,000 per year the figure was 47 per cent. The total percentage of adults who reported having consumed alcohol in the previous week was largely unchanged from the previous year but almost 10 per cent lower than a decade ago, say Adult drinking habits in Great Britain: 2017 and Statistics on alcohol, England 2018.
In what is being seen as a landmark move, the Royal College of Physicians (RCP) has issued a statement backing drug decriminalisation. After a meeting of its council the RCP has signalled its formal support for the Royal Society of Public Health’s Taking a new line on drugs report from two years ago (DDN, July/August 2016, page 4) and the ‘evidence-based recommendations’ it advocates.
Among the recommendations were for the personal possession of all illegal drugs to be decriminalised, and for a transfer of responsibility for drug policy from the Home Office to the Department of Health. ‘The RCP strongly supports the view that drug addiction must be considered a health issue first and foremost’ the statement reads, adding that the organisation had been ‘alarmed’ by the rising rates of drug-related deaths seen in recent years (DDN, September 2017, page 4), as well as increasing numbers of drug poisonings and hospital admissions with a primary or secondary diagnosis of drug-related mental and behavioural disorders (DDN, March, page 5).
The statistics ‘demonstrate a clear need for physical, psychological and social support and care for people addicted to drugs’, says RCP, adding that diminishing resources in the field were ‘of critical concern’. The royal college ‘seeks urgent action to prioritise and increase investment in public health services and workforce in order to meet rising population need’ it states. The RCP, which has a membership almost 35,000, is the most high profile medical body so far to back drug law reform.
Shirley Cramer: This shows how far the debate has moved forward.
‘We are delighted that the Royal College of Physicians has voted to endorse our position on drug policy reform,’ said RSPH chief executive Shirley Cramer. ‘That such an influential medical body has put its weight behind a public health and harm reduction approach to drugs, including the decriminalisation of personal possession and use, goes to show just how far the debate on this issue has moved forward – and how far behind the curve many politicians in the UK still are.’
There was now a growing consensus that ‘criminal justice approaches’ to drug harm had failed, she added. ‘It is critical that the health community speaks with a united voice on this issue in order to drive meaningful policy change, and so we hope other medical colleges will soon follow the lead of the RCP.’
The government has pledged to increase support for children living with alcohol-dependent parents. The plans include faster identification of at-risk children – including those having to undertake ‘inappropriate care responsibilities’ – and are backed by £6m funding from the Department of Health and Social Care (DHSC) and Department for Work and Pensions (DWP).
Among other measures announced are increased outreach provision to help improve take-up of alcohol treatment, faster access to mental health and other support services for children of dependent drinkers, and early intervention programmes to reduce the number of children taken into care. Priority for the latter will be given to areas where more young people are affected, says the government, with progress monitored by Public Health England (PHE).
The funding package also includes £1m for ‘national capacity building’ by NGOs, and a £4.5m ‘innovation fund’ for local authorities to improve outcomes for the children affected. Public health minister Steve Brine has also been named as a dedicated minister with specific responsibility for the issue.
It’s estimated that there are around 200,000 children living with alcohol-dependent parents in England alone, while in 2017 the NSPCC revealed that its helpline had received 25,000 contacts raising concerns around substance use near children in the previous three years – an average of nearly one per hour (DDN, March 2017, page 5). The agency also made more than 20,000 referrals to external agencies such as children’s services and the police over the same period.
‘All children deserve to feel safe – and it is a cruel reality that those growing up with alcoholic parents are robbed of this basic need,’ said Brine. ‘Exposure to their parent’s harmful drinking leaves children vulnerable to a host of problems both in childhood and later in life – and it is right that we put a stop to it once and for all. I look forward to working with local authorities and charities to strengthen the services that make a real difference to young people and their families.’
‘The consequences of alcohol abuse are devastating for those in the grip of an addiction – but for too long, the children of alcoholic parents have been the silent victims,’ added health and social care secretary Jeremy Hunt. ‘This is not right, nor fair. These measures will ensure thousands of children affected by their parent’s alcohol dependency have access to the support they need and deserve.’
‘Today’s announcement, committing £6 million to support children of alcohol dependent parents, is both welcome and vital,’ commented Dr Richard Piper, chief executive of the charity formed by the merger of Alcohol Concern and Alcohol Research UK. ‘This very positive initiative would have even greater impact in the context of an over-arching national alcohol strategy.
‘Such a strategy would embed this initiative within a comprehensive approach: preventing people from sliding into harmful drinking, tackling the causes of problem drinking and helping those affected by dependency to beat their addiction and live their lives again. If linked to a comprehensive alcohol strategy, this initiative would be a turning point, improving the lives of thousands of children and adults in need of support.’
Educational institutions are failing to protect their students from the ‘potential harms of drugs’, according to a report from the National Union of Students (NUS) and Release. The document is based on a review of the institutional support available at more than 150 universities and colleges, as well as a survey of over 2,800 UK students.
Forty per cent of students said they would not feel comfortable disclosing information about their drug use because of fear of punishment – this acts as a barrier to getting appropriate support, the document states. In the 2016-17 academic year there were more than 500 incidents of students being reported to the police for possession of drugs, with 21 people permanently excluded for possession for personal use. ‘Policy responses that focus solely on disciplining students fail to recognise the complex reasons that lead people to use drugs,’ says the report, and risk adding to the marginalisation of certain groups.
Almost 60 per cent of respondents reported either using drugs currently or having done so in the past, with most saying they do so only occasionally. More than 30 per cent of those who have used drugs said they did so to deal with stress, and more than 20 per cent to self-medicate for mental health issues.
Institutions should make sure that a range of appropriate support – including harm reduction advice – is made available to students, the document stresses, and students should not be ‘disciplined for drug-related behaviour that does not constitute a criminal offence’. Any institutions that wish to apply a more punitive approach should do so through a ‘formal warning’ system, it adds, and students should not be ‘reported to the police or permanently excluded from their studies for simply possessing a drug’.
‘We are deeply concerned about the punitive approach taken towards student drug use in some institutions and the appropriateness of support that is offered around drugs in most cases,’ said policy researcher at Release, Zoe Carre.
Zoe Carre: Deeply concerned about punitive approach
‘The fact that at least 21 students were permanently excluded from their studies for simply possessing a drug, and one in four students caught with drugs for their own personal use were reported to the police, is archaic and harmful – this type of approach prevents people from seeking support if they need it. The reality is that students take drugs and educational institutions must have policies and procedures in place that protect the student population. This can only be done by providing vital harm reduction information, so that they can make more informed choices and be as safe as possible.’
The 12-step fellowships are a life-saver for some – but for others, the concept of total surrender can do more harm than good. Alex Boyt makes the case from his own experience.
I was first arrested for drugs in 1973, did my first three rehabs by 1987, and having been told early on I had a progressive and terminal disease that needed a permanent 12-step solution, I did about 3,000 Narcotics Anonymous meetings over the next 28 years. Though twice in my life it had played a central part in pulling me out of extreme injecting drug use, I was never convinced by the requirement to surrender and admit powerlessness.
photo by Nigel Brunsdon
The notion that I would always be an addict because I once had a problem felt very limiting to me. The relentless echo chamber of the fellowship however had me trapped, afraid that to question the need for a 12-step remedy would lead me back to jails, institutions and death.
The continuous references to God and prayer had always been an irritant, but what really began to grate on me was the requirement to swallow and regurgitate the ‘fact’ of suffering from an endless incurable illness that meant eternal vigilance. The sense of belonging was undeniably valuable, but it was conditional on acknowledging the 12-step programme as a God-given gift for which one must be grateful.
Within the 12-step environment you cannot have conversations about healthy ways to disengage, since leaving is the first step to relapse. Stories of people doing well without NA meetings were rarely mentioned and then dismissed as rare exceptions, or otherwise as people who had never really had ‘the problem’ in the first place.
‘I began to discover that endless
disease was not seen by all as
the optimum route to wellbeing.’
When I started to work in the addictions field in 2005 however, I began to experience a wider world of addiction and recovery and to discover that endless disease was not seen by all as the optimum route to wellbeing. I came across research papers and data, witnessed the tensions between harm reductionists and abstentionists, and began to build a picture of reality that made more sense to me.
I found support groups for people trying to leave 12-step fellowships, heard of counsellors who specialised in helping de-programme people from the fellowship mindset and I caught up with people I knew from Narcotics Anonymous in the ’80s and ’90s – many of whom had long given up meetings and were doing fine, abstinent or not.
I embarked on the process of disengaging myself, though the years of exposure to fellowship mantras had me wondering if, somehow, I was being deceived by a mind I had been taught I could not trust. When I met fellowship people, there was often a look of concern in their eyes and I found myself being defensive and feeling a little uneasy… I thank my therapist for supporting me through the transition.
Nonetheless, as I continued my journey it became clearer that the 12-step model, sold to me as the one true route out of addiction – though it suited some – did not hold up so well to closer inspection. Although you can, of course, find numbers and evidence to support any stance, I found the large American NESARC study that showed most people with a drink problem recovered without any intervention (12-step or otherwise) and many without abstinence.
I started to look at success rates which could be measured in different ways; many of the headline numbers put AA success rates at around 10 per cent, though better for those that stuck around longer.
‘The 12-step environment is no magic
bullet… recovery in its various
forms takes place elsewhere.’
The peer support, collective direction and structure of 12-step fellowships are a perfect combination for some. But it could be argued that for the population as a whole, 12-step intervention is little better than doing nothing. What is clear is the 12-step environment is no magic bullet and that significant amounts – if not more – recovery in its various forms takes place elsewhere.
Another piece of research that resonated with my experience was the Miller et al study, showing that when you want to find the main predictor of relapse, belief in the disease model is a significant factor. The ‘all or nothing’ measure of success and failure within the total abstinence framework is a two-edged sword. If you convince someone that any use is a calamity and that any attempt at self-control is futile, it can be a dangerous combination. A beer on a sunny afternoon will wipe all the clean time and status within the support group and bring the shame of failure bearing down, so there is very little more to be lost in returning to problematic use.
Now someone who has never come across the disease concept would very likely, well, just have a beer. The powerlessness message may help those who are totally abstinent, but is more likely to harm those who are not.
If we throw into the mix people who have been persuaded off their psychiatric meds by well-meaning amateurs in the name of being ‘clean’, then risks begin to increase. If you function well and are happy with total abstinence of the purest kind, then great, and hats off to you. But it is rarely right to tell someone with a whole personalised set of trauma and resources to follow your path.
Those on methadone may not be ‘clean’ in some people’s eyes, but it is the number one evidenced intervention in reducing drug-related deaths, which are at an all-time high. Those on medications are often being kept safe by them, but all too often are subject to stigma within the 12-step environment, and pressure mounts to stop taking them.
‘Telling someone with problematic drug
use to get clean can be like telling
a homeless beggar to get a job.’
Some say that addiction is an equal opportunities affliction, but that is demonstrably false. The data shows that deprived communities have the highest rates of addiction, and the privileged have better rates of recovery. Too often I hear celebrities extolling the virtues of 12-step recovery – and that is all very well If you are successful, with significant internal and external resources. But telling someone with problematic drug use to get clean can be like telling a homeless beggar to get a job.
Last time I wrote an article discussing the merits of the 12-step environment the letters pages were hot for months, attacking and defending me, and I was reluctant to take the flak again. Nonetheless I write this for two reasons.
Firstly, I say to those for whom it works well: be gentle with others. The chances are that they may well find a way to recover without the fellowships, so go easy on the ‘all or nothing’ rhetoric. You may mean well, but it does not help everyone.
Secondly, for those who do not feel the fellowship environment is right for them, either initially or after some time, there is nothing wrong with exploring other options. If my son had a problem, the 12-step solution would not be my first choice.
I was thinking about those I know with drug histories who have died too early – either accidentally or who have killed themselves – and you know what? It’s the ones who have been told they are powerless and have failed without abstinence that make up the majority who have gone. I don’t hold this up as evidence; just an observation from my experience.
The six 12-step rehabs I went through were sometimes a godsend and at other times served only to reinforce my sense of failure. The fellowships have been a great resource for me at critical times, and the weird cult-like structures have been useful to turn things round. But the premise of endless disease has not felt healthy for me in the long run.
I know many people who consider the 12-step model a life saver for which they are very grateful. I know others who used it for a while and then happily moved on. But I also know too many who have felt diminished by their experience.
I will end with a word of caution. A support structure is a big deal; if you leave one, don’t do it without putting something else in place. And if you choose a beer on a sunny afternoon after a period of 12-step abstinence, the sense of failure is more likely to do the damage than the thing you consume.
Whatever you choose, I wish you well.
Alex Boyt has worked until recently as a service user coordinator in London and is still actively involved in drug policy debate
The UK’s comparatively low threshold for recommended safe drinking levels has been supported by a major new study.
As international low-risk drinking guidelines vary substantially, Risk thresholds for alcohol consumption– published in the Lancet – studied almost 600,000 people without previous cardiovascular disease across 19 countries, to attempt to define ‘thresholds associated with lowest risk for all-cause mortality and cardiovascular disease’.
The ‘minimum mortality risk’ was found to be around, or below, 100g of alcohol per week – or 12.5 units, as one UK unit is defined as 8g. Drinking above that level was found to increase the risk of heart failure, stroke, fatal hypertensive disease and fatal aortic aneurysm.
In the US, an upper limit of almost 200g per week is recommended for men – roughly twice the UK level – while guidelines in Italy, Portugal and Spain are almost 50 per higher still. Many national guidelines, however, recognise that drinkers are willing to accept some level of risk.
‘These data support limits for alcohol consumption that are lower than those recommended in most current guidelines,’ the study states. ‘Exploratory analyses suggested that drinkers of beer or spirits, as well as binge drinkers, had the highest risk for all-cause mortality.’
People drinking at the current UK guideline levels – which were revised just over two years ago to 14 units per week for both men and women (DDN, February 2016, page 4) – would face little increased risk. However, drinking above two units a day means the ‘death rates steadily climb’, according to Winton Professor for the Public Understanding of Risk at Cambridge University, Prof David Spiegelhalter. ‘This is a massive and very impressive study,’ he said. ‘The paper estimates a 40-year-old drinking four units a day above the guidelines has roughly two years lower life expectancy, which is around a twentieth of their remaining life. This works out at about an hour per day. So it’s as if each unit above guidelines is taking, on average, about 15 minutes of life, about the same as a cigarette.’
The widely reported study – which acknowledges that ‘self-reported alcohol consumption data are prone to bias’ – has led to headlines such as ‘Glass of wine a day could shave years off your life’ (Independent) and ‘Deadly cost of that extra drink’ (Mail).
‘This research adds to a growing number of studies supporting current UK guidelines for lower risk drinking,’ said Dr Tony Rao of the Institute of Psychiatry, Psychology and Neuroscience at King’s College, London. ‘It also highlights the need to reduce alcohol-related harm in baby boomers, an age group currently at highest risk of rising alcohol misuse.’
It used to be that senior police, like politicians, would only speak out on drug policy from the safety of retirement. These days, however, serving PCCs are taking an increasingly leading role in the call for change, as DDN reports.
A few short years ago most people would probably not have predicted that it would soon be the police who – as Release recently said – were ‘leading the way in the debate for drug policy reform’ (DDN, March, page 5). But that’s exactly what seems to be happening.
The charity was responding to the latest call by a police and crime commissioner (PCC) to implement radical measures to cut drug-related death and crime rates – in this case West Midlands PCC David Jamieson and his plans for prescribed heroin, diverting people from the courts into treatment, and ‘considering the benefits’ of consumption rooms.
‘Despite the good work being done by many, collectively our approach to drugs is failing,’ said Jamieson, whose region sees half of all burglary, robberies and shoplifting committed by people with drug problems, at huge cost to the public purse. He intends to have as many of his plans as possible in place before he leaves office in 2020, plans that also include training and equipping the police with naloxone and implementing safety-testing of drugs in the region’s night-time economy.
His call had the backing of the PCCs’ membership body, the Association of Police and Crime Commissioners (APPC), and follows similar announcements from North Wales PCC Arfon Jones – whose annual report included plans for a consumption room pilot and to look at decriminalisation as most drug use ‘is recreational and causes no harm’ (DDN, October 2017, page 5) – and Derbyshire PCC Alan Charles. The first PCC to put his head above the parapet, however, was Durham’s Ron Hogg.
Arfon Jones: ‘There’s no difference between addiction to lawful or unlawful substances – what makes a criminal is the law.’
It’s now over a year since Hogg announced that he’d asked local public health departments to look at options for introducing heroin-assisted treatment to allow people to ‘stabilise their addiction in a controlled environment’ (DDN, March 2017, page 4), although he’d been a vocal critic of government drug policy as far back as 2014.
Initiatives such as consumption rooms, heroin-assisted treatment and drug testing in nightclubs are no longer just backed by campaigning organisations like Release and Transform, but by august bodies such as the Royal Society for Public Health (DDN, March, page 4 and July/August 2017, page 4) who see them as part of a logical move towards a more evidence-based policy. But why is it that increasing numbers of PCCs are calling for radical reform? The obvious answer is that it’s they and their officers who are witnessing the failure of current approaches on the frontline, so it’s little surprise that they might want to try something new.
This mood was very much in evidence at last month’s meeting of the Drugs, Alcohol and Justice Cross-Party Parliamentary Group, which heard from Hogg, Jamieson and Jones as well as Derbyshire PCC Hardyal Dhindsa – who also serves as the APPC’s alcohol and drugs lead – in a roundtable discussion on ‘advancing an evidence-based approach to drug policy’.
Ron Hogg: ‘We cannot continue with prohibition, we’re just putting millions of pounds into the pockets of organised crime.’
‘It’s time for us all to show some leadership on this – it’s about us doing the right thing,’ Hogg told the group. ‘We cannot continue with prohibition, we’re just putting millions of pounds into the pockets of organised crime. It’s a crazy waste of money – policy has failed.’
In his 30 years as a drugs officer he’d seen only worsening problems, he said, and the background of constantly shrinking budgets meant that it was ever-more vital that money was spent as wisely as possible. While it was his call for heroin-assisted treatment that had unsurprisingly made the headlines, this was only ‘one small aspect’ of what needed to be done, he said – and one that would also help to cut out a ‘pot of money’ going to organised crime. ‘We must not criminalise addicts, but those who deal,’ he told the meeting. ‘We need to treat drug users in a different way to how we do at the moment.’
His Towards a safer drug policy document from July last year advocates a fundamental review of the Misuse of Drugs Act, and of UK drug policy in general. The Act’s effectiveness has never been formally evaluated, it argues, ‘despite overwhelming indications of failure’, while the current legal framework is both confusing for the public and fails to ‘correlate with evidence-based assessment of relative drug harm’. Any review should also ‘consider all international experiences in order to ascertain a more effective way forward’, it adds.
David Jamieson: ‘Despite the good work being done by many, collectively our approach to drugs is failing.’
David Jamieson’s report from earlier this year, Reducing crime and preventing harm, shares many recommendations with Hogg’s, such as diverting people from the criminal justice system, but also proposes a move that could help win over those elements of the press not traditionally receptive to drug policy reform – taking money from organised criminals to help fund drug services. ‘Those profiting from the misery of drug addiction should pay for treatment,’ it states.
Jamieson told the meeting that when his team had started to look at the situation in their area some ‘killer facts’ had emerged – not only were there more than 22,000 people using heroin or crack cocaine but ‘children are affected, social services – the costs are enormous. Half of all burglary is to feed a habit, and the cost on all public services five years ago was £1.4bn – just in the West Midlands. All the shootings in my area are drug-related. It’s time to have a grown-up conversation about drugs.’
The first step had been to draw up his report, he said, emphasising the links between criminality and drug harm, and the cost to public finance, and making sure it was a ‘workable and pragmatic’ policy document. ‘We want to put it into action, and we’ve had enormous support – including from the media, as it talks about saving costs to the public purse.’
The main reason that the drugs issue was one that had traditionally not been led on was that it was simply seen as ‘too difficult’, Dhindsa told the group. The fact that the ‘war on drugs’ clearly wasn’t working had had little impact on government policy, he said, ‘but by joining up with different groups, we can make positive steps in the right direction’.
Hardyal Dhindsa: ‘The fact that the “war on drugs” clearly isn’t working has had little impact on government policy.’
The meeting also heard from a mother whose son had been lured into ‘county lines’ activity by a drug gang, a growing trend that has seen a huge increase in the number of modern slavery case referrals for minors (see news, page 4). This was something that needed cross-departmental action, stressed Dhindsa. ‘The issue is vulnerability – it’s easy income that then becomes something much worse.’
Arfon Jones told the meeting that while as a police officer he’d only been able to make ‘a small dent in the criminal business model’, like other PCCs he was now in a position to genuinely influence policy.
‘We need recognition that addiction is a disease and not a crime,’ he said. ‘We need recognition that there’s no difference between addiction to lawful or unlawful substances – what makes a criminal is the law.’
Prohibition did not work, he said, as was evidenced by the fact that towns and cities were ‘swamped’ with new psychoactive substances (NPS) despite them having now been illegal for almost two years (DDN, June 2016, page 4). Regulation could not only help protect children, but help control the high potency levels found in the vast majority of cannabis currently being sold (DDN, March, page 5), he argued.
‘We need to recognise the difference between use and misuse of drugs, and we have a way to go to recognise how important harm reduction is – people will only go into treatment when they’re ready.’ When it came to recreational use, however, money was ‘better spent on those who have a problem’, he stressed. ‘Why do we punish and criminalise people who cause no harm to others? These people need diverting into an educational programme, in the same way as for a speed awareness course.’
‘I’m really passionate about changing this agenda,’ Hogg told the group, and while his calls for a new approach had originally met with little support, that was now changing. ‘It’s incumbent on those who have influence to change policies,’ he said. ‘I can still see their faces – when I go to tell a mother, brother or sister that someone has died. It’s human misery and tragedy, and it’s our duty to do something about it.’
The government is to establish a £3.6m National County Lines Coordination Centre as part of its new Serious Violence Strategy.
The strategy identifies ‘the changing drugs market’ – in particular, around crack cocaine – as ‘a key driver harming our communities’. Last year saw a 23 per cent increase in the number of people seeking treatment for crack (DDN, December/January, page 5) as well as a two-thirds increase in the number of minors reported to the authorities as potential ‘modern slavery’ victims – due in part to rising number of ‘county lines’ gang referrals (DDN, April, page 4).
The strategy ‘stresses the importance of early intervention’ and also includes announcement of a ‘serious violence taskforce’ with representatives of local government, the voluntary sector, the police and others. Around half of the recent rise in robbery, gun and knife crime is the result of improvements in police recording, the document claims, while ‘for the remainder, drug-related cases seem to be an important driver’.
Drug dealing through gangs will be tackled in the new strategy.
The number of murders where either the suspect or victim were known ‘to be involved in using or dealing illicit drugs’ increased from 50 to 57 per cent in the year to 2016-17, with crack cocaine markets having ‘strong links to serious violence’, it states. The document also sets out how ‘a small minority of people [are] using social media to glamorise gang or drug-selling life, taunt rivals and normalise weapons-carrying’.
At the document’s launch home secretary Amber Rudd stated that the view that increases in violent crime rates were partly the result of insufficient police on the streets was ‘not supported’ by evidence, while changes to the provision of youth services as another potential factor was also ‘far too simplistic’.
County lines activity had become ‘an increasingly popular way of dealing drugs around the country’, she said. ‘This involves gangs grooming and using children and vulnerable young people to traffic drugs using dedicated mobile phones or “deal lines” into new locations outside of their home areas. The wider the reach of the gang, the further their violence, drug dealing and exploitation spreads. So this is the situation we are faced with. And what we’re talking about here are murders, torture and other types of extreme violence.’
Amber Rudd: new centre will provide ‘vital intelligence’ about drugs markets
As well as helping police to arrest perpetrators the new coordination centre would increase protection for vulnerable people who had been drawn into county lines networks, provide ‘vital intelligence’ about drugs markets and support the police to shut down mobile phone numbers used for dealing, she stated, adding that she also stood ‘fully behind’ the appropriate use of stop and search.
‘We need to engage with our young people early and to provide the incentives and credible alternatives that will prevent them from being drawn into crime in the first place,’ she said. ‘We will take the comprehensive approach necessary to make sure that our sons and daughters are protected and our streets are safe. As a government we will never stand by while acid is thrown or knives wielded.’
Belfast’s injecting drugs crisis has prompted a call for action – to bring a drug consumption room to the city as quickly as possible. Report from Chris Rintoul.
There has been a marked rise in people who inject drugs in Belfast city centre over the last two years. This is shown by a dramatic increase in discarded injecting equipment – in back streets, car parks, public toilets, toilets provided by shops and public transport stations, as well as a number of disused buildings. Further evidence is an increase in the numbers of people begging, accessing needle and syringe provision, and presenting for treatment for heroin dependence, which has been accompanied by sensationalist media reporting and frustration among members of the business community.
On 20 February a conference was held at Queens University Belfast. Called Responding to injecting drug use: an exploratory conversation, it was delivered by Extern, a social justice organisation providing services throughout Ireland, and co-sponsored by Queens University and the Belfast Drugs and Alcohol Coordination Team. More than 130 people attended, from diverse perspectives and agencies including the media, politicians, city councillors and the health and social care field.
During the last two years Extern have been working with stakeholders across the city to assist in managing what has rapidly become an entrenched issue. A public expectation that Belfast’s developing heroin ‘scene’ should, could and would be eradicated primarily by law enforcement measures is being replaced with a growing pragmatic awareness that we have to manage what is a health and social issue. As a result, attempts are being made to learn from other cities who have experienced these issues for longer periods.
As Extern’s drugs and alcohol consultant, I was able to use my international contacts to attract a world-class group of speakers from the legal, law enforcement, academic and practice fields. Professor Pat O’Hare of Liverpool John Moores University chaired the event, introducing the
keynote speaker, Professor Carl Hart of Columbia University, NYC. Carl’s impassioned presentation outlined the moral case for a baseline harm reduction response for people who inject drugs (PWIDs) in the city centre, with a drug consumption facility (DCR) in an area where drugs are already bought and used.
Next Durham’s chief constable, Mike Barton, outlined his views on how similar problems in Durham could and should be treated, and made particular reference to heroin assisted treatment (HAT) for those who have not benefited from traditional OST medications. His presence attracted a number of high-ranking officers from the Police Service of Northern Ireland and enabled them to consider HAT and the case for a DCR in Belfast.
The next speakers were Niamh Eastwood, barrister and executive director of Release, and Neil Woods, an ex-undercover police officer and now chair of Law Enforcement Against Prohibition (LEAP). Niamh outlined the legal issues associated with a DCR within the UK – both the apparent barriers and potential ways to overcome them. She made clear that there is a legal way forward in the UK to the provision of DCRs, if enough popular support exists and the local police force and politicians agree with the concept.
Neil then spoke of his very personal journey in discovering the wrongs of the ‘war on drugs’, especially the further damage that law enforcement approaches can do to the most vulnerable. His view is that the legal approach rarely ever reduces the supply of drugs for long and drives the market into the hands of the most vicious criminal supply networks.
**********
In the afternoon delegates heard from experts based in Glasgow, London and Dublin on issues these cities have faced in terms of responding to injecting drug use, and the serious problems faced by PWIDs in public spaces.
Kirsten Horsburgh of the Scottish Drugs Forum stepped in at the last minute for Dr Saket Priyadarshi, to inform us of the current situation in Glasgow, in light of recent advice from the Scottish Lord Advocate that any DCR in the city would require a change in the Misuse of Drugs Act (MoDA), effectively delegating responsibility back to Westminster and dashing Scottish hopes.
Dr Magdalena Harris of the London School of Hygiene and Tropical Medicine highlighted issues she encounters in her current research among homeless injectors, particularly the prevalence of skin and soft tissue infections. Then Marcus Keane, head of policy at Ana Liffey in Dublin explained the process he has been involved in to bring a change in Irish legislation, allowing for the first supervised injection facility in Ireland, which will open up later this year in Dublin.
The final session of the day was delivered by Dr Gillian Shorter of the University of Ulster. Detailing the range of DCRs worldwide, she identified different models in operation such as medically supervised or not, injection-only facilities or those which cater for people who smoke or even snort heroin, those that cater for heroin use only and those that permit the use of a wider range of drugs.
The evidence presented left us in no doubt that wherever a local need is identified, there are clear and unambiguous reasons to consider providing a DCR. The lasting impression I have is of a clear win-win-win scenario in providing DCRs – PWUDs can access a humane, health-promoting alternative to street-based injecting; support services gain an opportunity to engage with them by providing what they most need; and the wider public find that the level of discarded injecting equipment reduces and visible heroin use declines.
Charlie Mack, CEO of Extern, closed the conference with an eloquent call to action – to join together armed with the evidence we’d just heard and work to make a DCR happen in Belfast. There was a very strong consensus that we must do this, and quickly, as vulnerable lives depend on us along with our courage and determination.
A number of other cities in the UK are currently exploring the possibility of providing a DCR of some description. I believe that sooner or later one of these cities will find a way by local agreement with stakeholders in their city (rather than awaiting a change to MoDA) to provide one.
**********
My own thinking is that the terminology we use – ‘drug consumption room’ – may be unhelpful, conjuring notions of a libertarian drugs free for all. A more helpful and accurate term is overdose prevention site (OPS), which describes exactly what it is – although it is still limited in that it doesn’t explain that it will allow PWIDs access to wider healthcare and social interventions such as wound care, housing and substitute opioids. Whatever the model, it will undoubtedly prevent fatal overdoses and the spread of BBVs among the people who use it. Terminology is a secondary consideration to the purpose of the service.
Extern want to build on the success of the conference in the coming months. We operate a street injectors support service, an ‘old-school’ harm reduction outreach service, which engages with this very hidden, vulnerable population. Since starting in October 2017, staff have successfully reversed three overdoses with naloxone, provided and removed large quantities of injecting equipment, supplied naloxone and much more. In addition, they have assisted PWIDs to access accommodation and even treatment. What if we were able to offer them an overdose prevention site as well?
We dream big, and will continue to do so until we have exhausted all options available to us to prevent the need for street injecting.
Chris Rintoul is drugs and alcohol consultant at Extern
**********
‘We did it together’
Tony Duffin describes how through local team work, a small charity helped to change the law to allow supervised injecting facilities.
Catherine Byrne TD, minister of state for communities and the national drugs strategy with Tony Duffin
Established in 1982, Ana Liffey Drug Project was Ireland’s first low-threshold harm reduction service. As a small charity working in Dublin and the mid-west Region of Ireland, we provide fixed site and outreach services to over 2,000 people each year and have 35 staff, supported by a similar number of volunteers.
From 20 January 2012, we were a leading advocate for supervised injecting facilities and played a key a role in lobbying for the introduction of the Misuse of Drugs (Supervised Injecting Facilities) Bill 2017 – which was signed into law on 16 May 2017 by President of Ireland Michael D. Higgins.
The following four key strategies helped us to achieve our goal of legislative change:
Know your case
Gather the evidence and know the argument both for and against your proposed change. While there was only a handful of detractors, it was important to able to respond with certainty.
Speak to your stakeholders’ self-interest
Don’t just know who your stakeholders are, but also know what their needs are. When we communicated with different stakeholder groups, we always tried to speak to their self-interest and explain how our proposed change would benefit them.
Engage with the media
Engage widely and frequently with traditional media and social media. Early on we were reminded of the old journalists’ saying – ‘good news is not good news’. However, we had newsworthy stories which people wanted to hear. We made our own news.
Ask for help
You can’t do it all on your own – we were attempting to do something that had not been done before. We asked for help at a number of key stages. At the end of the day, successfully introducing the legislation was achieved by civil society, legal, statutory and political champions all working together.
Commissioners are on a mission to do things better. But how can they take on board the many complex health issues with less money in the pot? DDN reports.
There’s much talk of developing innovative commissioning practice – prompted, in the main, by the need to ‘do more with less’. As part of the refining process, many services are letting go of the specialist posts that would have been central to operations just a few years ago.
In our March issue (page 20) the alliance of NHS providers, NHSSMPA, highlighted the ‘significant decline in registered staff, including nurses, social workers, clinical psychologists and doctors’ and cautioned that some drug and alcohol services had begun relying on limited clinical expertise.
Through a recent suite of documents for commissioners, providers and clinicians, Public Health England (PHE) emphasised the many and varied roles that specialist doctors, nurses and psychiatrists should play in addiction services. These highly trained professionals are, they reminded us, not just there to provide medical treatment in response to highly complex needs – although those are the elements of their roles that cannot be fulfilled effectively by lesser trained and qualified staff.
PHE named many other skills that enhance quality and leadership within teams, as well as integrating many public health activities and interventions. Furthermore, they pointed out, specialists can help to coordinate resources in a way that adds cost efficiency to a system stretched to breaking point.
MULTI-SKILLED VALUE
The fact that nurses are such ‘a multi-skilled breed’ is without doubt why they bring such good value to drug and alcohol services, says Ishbel Straker, a clinical director and board member of the nurses’ association IntANSA. Their expertise in therapeutic engagement, assessment and care planning, health care delivery, disease prevention and prescribing works alongside their commitment to the NMC standards – ‘prioritising people, practising effectively, preserving safety and promoting professionalism and trust’.
‘We are ever evolving to meet our clients’ needs and the needs of our services,’ she says. ‘We work with harm minimisation at the forefront of our minds, while giving advice, assessing and treating through a variety of activities such as vaccinations, lung function tests, wound care, blood sugar monitoring, ECGs and sexual health – all of which are measurable outcomes.’
‘Looking at the client from the centre of their needs’ has become the way of working at Change, Grow, Live, says Dr Arif Rahman, CGL’s consultant addiction psychiatrist. Far from dispensing with the psychiatrist’s role, CGL have put it right at the centre of their services.
‘It’s really good for the client as it gives them a specialist assessment that’s holistic. We’re medically trained, psychiatrically trained and substance misuse trained… The whole ethos is about getting people to the best of their potential,’ he says. ‘We can identify, support and manage, and if necessary liaise with other specialists around the aspects of clients’ needs. For example, I’m in frequent contact with a pain specialist, a liver specialist and secondary mental health services.’
HOLISTIC AGENDA
Many clients find it easier to engage with a substance misuse charity than to access a liver specialist, engage with a mental health team, or ask for testing for blood-borne viruses or screening for respiratory disorders, he explains. So whatever the need, he is in a position to liaise with other specialists to bring care to the client.
He talks about ‘a new way of working’ – not losing skills, but adapting them to take account of updated Models of Care and the client’s journey. He acknowledges that there have been cuts to services and restructuring in a lot of places, but feels positive that a ‘difficult few years’ have given ‘an opportunity for looking at things again’. Psychiatry as a profession is in a good place to contribute to a holistic public health agenda, he states, having several decades ago experienced and adapted to changes that are now happening in health and social services.
Alongside his client assessments, he feels that one of the most important parts of using his expertise is in finding pathways for clients and linking them to colleagues and partner agencies for their health, psychological and social needs.
CREATIVE COMMISSIONING
Chris Lee, a commissioner in Lancashire and a member of the new Faculty of Commissioning, agrees with the need to ‘create robust pathways to make sure the skill set is there across all organisations’ – particularly as the treatment system now has so many diverse stakeholders including CCGs, the NHS (and the prison estate), local authorities, Collective Voice and the NHSSMPA.
While ‘the front door to treatment has changed’ and clients might enter treatment through one of many different routes, the current challenges mean that leading through specialisms is more important than ever, he says. ‘The money’s going out of the system at 100 miles per hour, but the clinical guidelines have been enhanced. So how do you do that with a population that’s got ever-increasing complex needs?’
This, he believes, makes the case for a different and more creative brand of commissioning. ‘If I sit down and write a specification for a tender this afternoon that mentions an addiction psychiatrist, your bid will come back with an addiction psychiatrist in there,’ he says. ‘But you can commission differently. You can say, “you’ll be working with people with complex needs, people with co-existing mental health and substance misuse concerns. You’ll be dealing with people with long-term homelessness issues, people who are long-term unemployed – and you need to be able to deliver both the clinical and psychosocial model.”
‘You’re not saying that you must have a psychiatrist or a psychologist or whatever – you’re saying, “this is the level of complexity you’ll be working with; what team would you put out?” It’s up to the provider to come back and say what they will give you.’
Lee sees opportunity in the need to mix cost-effectiveness with addressing complex needs, and says ‘that’s where it gets really exciting, because you can start playing around with different delivery options’.
Traditional ways of working are not ‘the given’ anymore, right down to the buildings that can constitute one of a service’s biggest overheads. The new way of working can be ‘light and agile’, he suggests – meeting in a coffee shop or a library, using community assets, and freeing up money to spend on staff instead of buildings.
LET’S GET DIGITAL
Service delivery might be able to incorporate digital support – a Skype call, email contact, text support, people filling in their own assessments online, or contact with a keyworker that can be anywhere.
‘Even people with highly complex needs could get some of their support through digital means – you could do doctors’ appointments by Skype for example to save travelling,’ says Lee, adding that there will always need to be a balance between this and traditional face-to-face meetings.
His point is that ‘years ago everyone got the same broad-brush approach, but these days you don’t do it that way. And if the money’s draining out of the system, we can’t afford to be working in old-fashioned ways.’
Furthermore, he believes that commissioners have a responsibility to lead on this open-minded approach: ‘If the commissioner pretends they know everything, you’re robbing yourself of some good ideas,’ he says. ‘The good providers out there have some really innovative ideas.’
This article has been produced with support from Camurus, which has not influenced the content in any way.
If treatment is to survive it needs to make a more convincing case and reach out to new groups, argues Paul North.
Seven years ago I, along with several hundred drug treatment workers, sat at CRI’s (now CGL) annual conference and listened to the opening speech by CEO David Royce. The mood was positive. Money was coming into the sector, CRI was growing month by month and treatment centres were, on the whole, robustly staffed.
David stood centre stage and whilst enthusiastically praising staff for their continued hard work and commitment, he delivered a stark warning to the room. The future might not be so bright for drug treatment – we must be careful, prepared and fluid. The money that the sector relied upon might not be ring-fenced in the years to come, and we must be ready to change. It might be that treatment needed to branch out and look for money elsewhere. It was likely there would be fewer jobs, and higher caseloads.
Six years later when I was sat in a council meeting listening to the proposed cuts to the treatment budget in York, the reality of the situation finally hit me. Of the four councillors in front of me, one was unashamedly falling asleep. Another, who despite having taken the time to research the subject, asked questions with next to no passion or concern for the excessive reductions in funding. The whole process was a formality, with no press coverage and no real challenge from treatment, all overseen by a powerless commissioner watching the precious budget slip through their hands like sand.
Having left treatment and now working in policy, I have spent a lot of time considering how this situation can be reversed. How can services reach previous levels of funding? What needs to be done to stop the budget cuts?
In order to answer these questions the first step is to accept a cold hard truth. The public are not concerned by a reduction in drug treatment budgets. The heroin cohort single-handedly created, funded and sustained treatment for years. From concerns around the spread of blood-borne viruses to drug-related offending, providing treatment with money was not a political hot potato – it simply made sense.
Years later, heroin deaths are at an all-time high, treatment services have seen record budget cuts and there has been no significant public fallout. While it is easy to blame austerity and government, the truth is that the majority of the PHE budget is happily spent elsewhere – a decision ignored by local communities and the media. As the heroin cohort dies and leaves treatment, so does the money to support them.
The challenge that treatment must confront, and a surefire way of creating funding, is to connect public need with public concern – raising awareness of an issue to attract new referrals, whilst at the same time educating society on the benefits of doing so. This is no small task for treatment and requires innovative outreach. The truth though is that if treatment does not find treatment-naive groups and make a convincing case for supporting them, the government is unlikely to give out funding on the off-chance of success. There needs to be a clear justification for funding, and concern to match it.
Creating public concern often requires a good narrative, and these narratives must also be backed up by data and evidence. The first step then is to prove the need, by evidencing that there are hundreds of thousands of people who require support. All these people who would benefit so much from treatment need to walk in through the front door – these stats then need to find themselves on the desks of commissioners as well as the local press. At a local level, let people know the great work the treatment service is doing and encourage others to get support. Identify a group and prepare them for treatment, get them on NDTMS and prove treatment still has a use outside of the heroin cohort.
The first group that treatment could target is an easy win. Last year, 23.8m opiate prescriptions were dispensed in the UK. Use of painkillers has risen by 80 per cent in ten years and is costing the NHS billions of pounds – there are no doubt hundreds of thousands of people using opiates problematically on prescription. They are easily accessible, in every community across the UK, and reducing their use would save the NHS millions of pounds. Furthermore such an approach would bring significant health benefits, as it is estimated that up to 90 per cent of prescribed opiates are ineffective at addressing chronic pain. Treatment services are essential if such a reliance is to be reduced – without a planned therapeutic intervention a situation similar to that in the US could emerge where those taken off ineffective prescriptions simply seek out illicit opiates.
It is clear that a very strong economic and health argument could be made for engaging this group. Save money, put some of it into treatment and reduce the vast numbers of people on poorly managed opiate prescriptions.
The next key group is the hundreds of thousands of cannabis users that do not enter treatment. Last year we showed in Liz McCulloch’s report Black sheep that cannabis presentations have risen by 55 per cent in ten years. My report Street lottery estimated that this equates to 200,000 cannabis users in the UK. Cannabis represents both the fastest growing cohort of drug users, and the most commonly used drug among young people and adults. As outlined in Black sheep treatment has not yet made a convincing case for engaging this group as we are ignorant of the health and economic benefits of doing so. This group require bespoke outreach interventions and campaigns to engage. Without any effort at all the group has doubled in size in ten years. Imagine what it would look like if treatment made a more concerted effort.
If services around the country looked up from managing the heroin cohort and engaged treatment-naive groups then the money would emerge – the national press would have a story, further educating the public on the changing face of treatment and encouraging others to seek support. The issue of funding services would then likely receive far more public support. Such a strategy would unite public concern with public support, thereby validating funding.
This is not about ditching the important service that treatment provides for the heroin cohort. It is about ensuring in years to come it can continue to do so effectively. Treatment needs to stay well funded and healthy to support heroin users at a time when overdoses are at an all- time high. Those on the frontline of drug treatment know full well the importance of continued support for this group.
This is an exciting proposition for those working in treatment. The chance to explore a new frontier and engage groups who have historically avoided support. A chance to show government the innovation that the sector is capable of and share the life-changing work that has been going on in key-work rooms up and down the UK for years.
To those who are sat with overwhelming caseloads, complex clients and demanding targets, the only way out of that picture is to adapt. The heroin cohort created treatment but if services don’t act they might also spell the end of it. They are no doubt a vulnerable and difficult cohort to work with who need bespoke support, but they are not the key to future funding. If treatment does not grasp this opportunity quickly and make a convincing case for more money then it will disappear into irrelevance, and only have itself to blame.
Time spent on your own development is necessary investment, says Ishbel Straker.
It’s that time of year again, when we are appraised and more importantly have the opportunity to appraise ourselves. This is a rare moment in our nursing life, but one which is incredibly valuable. We are given the space to consider how the previous 12 months have gone and how you would like things to pan out over the following 12 months for the benefit of your learning capacity and for client care.
This is a time when we can look at how best we, as individuals can empower ourselves to be the best we can be for those in our clinical spheres. I spend a lot of time thinking about this for the nurses under my care, planning out training and CPD sessions over the 12-month trajectory, considering trends within the addiction field and how we can equip the nurses to best manage them.
It is easy to look at this for others, but if you asked me the last time I considered my learning needs I would be searching for the answer. Why is that? Well, I would suggest it is because we as nurses are a selfless race of professionals. Now don’t get me wrong when I say this, we absolutely have our faults and I could spend days listing them for you but I’m sure you have your own list to look at! I mean selfless because that is what we are conditioned to be throughout our training – to think of our patients before ourselves, to feed our patients before ourselves, to hydrate our patients before ourselves, to toilet our patients before ourselves.
Now this is all well and good. However, there are negative implications to this in the form of our own self-worth and development. We need to reflect on our abilities, the changing demographics and our competency levels within this. We cannot continue to ride on the wave of ‘how we have always done things’, but instead become focused on innovation – which means, as difficult as it may feel, looking inwardly at our own learning potential.
I appreciate that there are financial and time constraints within services, but this year, at appraisal, be prepared with your own ideas and personal development plan. Be what you may feel is a little selfish, because I promise, in the bigger picture, the client is still at the centre.
Ishbel Straker is a clinical director, registered mental health nurse, independent nurse prescriber and board member of IntANSA
President Trump has declared that his administration is getting serious about the opioid epidemic several times since taking office. But he has repeatedly failed to offer a substantive plan – and he has floated at least a few truly absurd ideas. He did it again this week. The president went on at length about his preposterous proposal to fight the scourge of drugs by executing drug dealers – an idea that many experts say would not stand up in court and would do little to end this epidemic… It was Mr Trump playing his greatest ‘law and order’ hits – as usual, full of sound and fury but signifying nothing. New York Times editorial, 20 March
It would be wrong to legalise recreational cannabis use, particularly given the evidence that excessive use can cause mental health problems. But that should not prevent scientists and doctors from developing useful medicines to help people who are suffering. Scotsman editorial, 17 March
So long as we leave decisions on drugs that are both medicines and recreational substances to the Home Office we won’t progress, as they seem unable or unwilling to see beyond their failed ‘ban everything’ strategy. David Nutt, Spectator, 19 March
Hepatitis C could be the UK’s next big public health success story. But if we want to eliminate it by 2025 we need a concerted and coordinated effort to find undiagnosed patients and treat them. This is the biggest obstacle we face so it requires everyone to join forces, from homelessness and drug and alcohol charities to GPs and public health directors, and from sexual health clinicians to prison staff. I welcome the approach that NHS England is taking to identify those living with the virus and our work must be carefully coordinated to ensure no areas lose out. Vulnerable patients should be automatically tested at their GP, while testing should also be readily available at sexual health clinics and pharmacies – and amongst the prison population. Steve Ryder, Telegraph, 20 March
Some users might be more susceptible than others to the trap of addiction, but Ant [McPartlin] and others like him are not in the grip of an uncontrollable disease that is to blame for all their woes. They are not victims, and it doesn’t help them to be treated as helpless amoeba at the mercy of their own desire. This whole concept of addiction as a disease originated in the US not very long ago, where it was classified as such so that people could get it covered by their medical insurance policies. If it was a disease, went the reasoning, then you could get treatment for it, and then you could get that treatment paid for. However, it is your choice as an adult whether or not you swallow the drink and ingest the drugs that exacerbate your condition. Jan Moir, Mail, 23 March
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.
Unwanted interventions
I very much enjoyed Mike Ashton’s look at the chequered history of alcohol brief interventions (DDN, March, page 22). My gut feeling has always been that they’re at best useless, and at worst potentially counter-productive and – while I realise the jury is still out – it’s nice to get even a tiny bit of academic back-up for that. And surely, they’re also at odds with much of the current direction of thought around drug use, as espoused by more and more police and crime commissioners – that it’s best to turn a blind eye to the ‘recreational’ and focus instead on the genuinely problematic. James Burton, by email
Hobson’s choice
‘Find out who your local commissioner is, and let’s bring some new thinking in,’ advises Paul Musgrave in your conference reports (DDN, March, page 12). Well I’ve known who my commissioner is for quite a while. The problem is he doesn’t know who I am, nor does he seem to have the slightest interest in finding out, let alone listening to anything I might have to say. I realise my experience may not be all that representative, but somehow I doubt it. ‘It’s all about choice,’ he says earlier in the article. Fine, but whose choice exactly? Name and address supplied
More comment can be seen under the relevant feature articles on this website. You can leave your own feedback and opinions at the foot of each article.
‘With yet more evidence, can we justify standing still?’
How far do you have to go to show that something’s a good idea, it’s cost effective, and that it works? We know that safe spaces, such as DCRs, save lives and that supporting instead of punishing is the only humane approach to drug policy.
When leaders on the frontline of law enforcement raise their voices to tell us our current approach to drug policy is not only failing, but a ‘crazy waste of money’, surely politicians must listen (page 6). These are not isolated voices: the Royal Society for Public Health is among many organisations to back harm reduction initiatives such as consumption rooms and heroin-assisted treatment as a move towards evidence-based policy.
Police officers were among the stakeholders to come together at a recent conference In Belfast on injecting drug use (page 8), and talked about the damage that law enforcement approaches can do to vulnerable people. If the support of the local police force is a critical factor in being able to establish DCRs in the UK, then surely we can’t be far off making them a reality in local areas.
We’re all too familiar with the upward trends in drug-related deaths, so when we’re presented with yet more evidence that a policy change would be cost-effective as well as health-effective, how can we justify standing still? And with police, local government and the health and social care fields calling for a move from evidence to action, surely it’s time for every region to be clear and purposeful in getting on with it.
Aileen Campbell: Discussed policy shift for those most at risk
Leading members of the Scottish Government have discussed a potential shift in policy ahead of the country’s new drug strategy, which is due to be published in the summer. The government aimed to ‘change the provision of treatment and support for those who are most at risk’, said public health minister Aileen Campbell, which meant ‘taking forward evidence-led measures even if they prove controversial’.
Nicola Sturgeon: ‘We should be prepared to do things that may be unpopular.’
Earlier this month Scotland’s first minister, Nicola Sturgeon, also called for cross-party collaboration to implement ‘bold and new’ initiatives to tackle drug-related deaths. ‘We should try and come together and be prepared to sometimes do things that may be controversial and may, in some areas, be unpopular,’ she stated. ‘But where there is an evidence base for them we should have the courage to do them.’ Scotland’s drug-related death rate is now double that of a decade ago and the highest in the EU (DDN, September 2017, page 4).
Aileen Campbell’s comments were part of a presentation to the Dundee Partnership Forum, which has launched a commission to address the rising number of drug-related deaths in the city. ‘The Scottish Government is reviewing our current drugs strategy, recognising that patterns of drug taking and their challenges have changed since we published it in 2008,’ she said. According to the Times, Campbell stated that a ‘public health response’ to problem drug use would require ‘safer injection rooms or heroin-assisted treatment’.
While plans to launch the UK’s first consumption room in Glasgow were approved by city officials almost 18 months ago (DDN, November 2016, page 4) the facility has yet to open, and fears remain that users or staff could be vulnerable to prosecution.
The exploitation of young people by drug dealers is contributing to a significant increase in the number of ‘modern slavery’ cases, according to a report from the National Crime Agency (NCA).
The number of potential victims of human trafficking and modern slavery reported to the authorities rose by a third between 2016 and 2017, says the agency, from 3,804 to 5,145. A two-thirds increase in the number of minors referred also means that British citizens for the first time make up the largest nationality recorded, due in part to a rise in ‘county lines’ gang exploitation referrals where minors had been ‘exploited by criminals involved in drug supply’.
‘County lines’ activity sees drug gangs from urban centres expand their distribution chain to regional and coastal areas using young people to transport and sell the product – a trend that by late last year had been reported by nearly 90 per cent of police forces in England and Wales (DDN, December/January, page 5).
The new figures are taken from the National Referral Mechanism framework, which sees potential victims referred by ‘first responders’ such as the police, and ‘almost certainly represent an underestimate of the true scale of slavery and trafficking in the UK’, according to the NCA.
‘What this report reinforces is that we are now dealing with an evolving threat,’ said NCA director Will Kerr. ‘Particularly concerning to us is the rise in young people being exploited for sexual purposes or drug trafficking.’
‘Modern slavery and trafficking are despicable crimes which see some of the most vulnerable people in society targeted by ruthless predators,’ said crime and safeguarding minister Victoria Atkins. ‘These figures show that more potential victims are being identified and protected thanks to a greater awareness and improved understanding of modern slavery.
‘We are also beginning to see the operational results of the renewed focus on modern slavery, with over 600 live police operations underway, and the first conviction of county lines gang members under the Modern Slavery Act. But we know there is more to do, and we are working to improve the system for identifying victims and supporting them to leave situations of exploitation and begin to recover and rebuild their lives.’
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.
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The power of e-cigs
I am writing in support of Dr Neil McKeganey and his view on the prescribing of e-cigarettes (DDN, February, page 18). As a proponent of harm minimisation in all its forms and bearing in mind the alarming percentage of service users in their forties and fifties with a diagnosis of COPD, anything that can reduce the numbers smoking tobacco is to be welcomed.
In 2008 at Build on Belief we did an impact evaluation and asked our service users how many of them smoked tobacco. The answer was 73 per cent – more than three times the national average. In 2014 we repeated the evaluation and asked the same question. The answer didn’t change by a single percentage point and remained at 73 per cent. Then, in 2016 we did another, smaller survey in one borough and were astonished to discover the percentage of tobacco smokers had dropped to 50 per cent.
The following year, we thought to ask how many of them used e-cigarettes. The answer was 23 per cent, the exact percentage of the recorded drop in tobacco smokers. Interestingly, the great majority of those who had switched to vaping were in treatment and identified as being in recovery.
It seems self-evident that there is a useful piece of work to be done with those service users who smoke, while they are in treatment, to encourage them to make the switch to vaping as a part of moving toward a healthier lifestyle if they are unwilling or unable to give up tobacco. The health benefits would be enormous, and our research suggests that a significant number would, with a little support, do so.
Tim Sampey, chief executive, Build on Belief
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Road to recovery
I sincerely found the experience of the DDN conference really amazing as a new peer mentor for Turning Point Leicester. I had no help from the armed forces and left after 30 years both as an engineering apprentice and soldier, followed by becoming an officer with the rank of captain.
I was simply told ‘as an officer, sort yourself out!’ I had a well-won nervous breakdown and PTSD that will be with me for life. I take professional counselling once a month and have been abstinent from alcohol for nearly four years now. I left the armed forces 20 years ago and never once as a family man thought a road to hell was ahead. I now enjoy life with my lovely wife of some 47 years – without her support I know I would not be here.
Trevor Mills, by email
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Get the picture
Natalie Davies’ outstanding analysis of the Cycle of Change (DDN, February, page 20) was let down by your illustration. Natalie’s discussion demonstrates that the stages of change model is a really good description of what happens when people make a significant shift in habits and behaviour.
When it was first introduced in the early 1980s some in the UK fell on it a little too enthusiastically. Whole services were reconfigured to reflect the stages as though they were discreet, evidence-based stepping stones in a process. In truth, there was probably little harm done. A good description is better than what we had before. It certainly chimed with the emergence of broader, more nuanced understandings of alcohol and other drug use that were overtaking simplistic, diseased models.
The stages of change model has become a staple of addictions training presentations ever since. It is accessible. Many of us will have lost of count of the number of times we’ve been presented with it, often by people who apparently haven’t read any of the articles and books the originators produced.
How many of these trainers and presenters have noted that since 1992 the term ‘relapse’ no longer featured. The diagram describing the model changed from a circle to a spiral. In 1994 the new diagram featured in a book (for the benefit of those of us who don’t have easy access to academic journals).
Your illustration includes the ‘r’ word. Most addictions trainers continue to use the older diagrams and spout on unthinkingly about Relapse (sic) despite the fact that it is over 25 years since the original authors eschewed the ‘r’ word in their model. Obviously there are reasons for this. These probably include:
• It’s a challenge to keep up to date
• People don’t read journals, or books
• It is hard to draw a spiral
• We don’t like change apparently (especially to our favourite model of change)
• The diseased models are alive and sick and worryingly continue to infect the field and the language we use to train new entrants and the wider community.
New ideas take time to catch on. Prochaska & DiClemente’s model was an exception. Their Cycle of Change is here to stay. It has been more than a quarter of a century since they (with Norcross) stopped talking about relapse. Anyone claiming to cite them to add legitimacy to their views on alcohol and other drugs should stop using the ‘r’ word right now.
As a field, we have a duty to advocate for the people who need our services. We do them no favours by education and communications that wilfully misrepresents the work of key academics. We can’t really expect journalists and politicians to get reporting and policy right if we’re 25 years out of date (and counting) ourselves.
References: Prochaska, J,O., DiClemente C.C., Norcross J.C. (1992) In search of how people change. Applications to addictive behaviors. Am Psychol 47(9):1102-14 Prochaska, J.O., Norcross, J.C. & DiClemente, C.C. (1994). Changing for Good. New York: Morrow.
Trevor McCarthy, independent consultant
Natalie Davies, assistant editor, Drug & Alcohol Findings responds: We would like to thank Trevor McCarthy for his comments on our article about Prochaska and DiClemente’s ‘stages of change’ model – especially for clarifying that the diagram featured is no longer an accurate depiction. There are many diagrams of the stages of change in circulation, but just looking at a sample of publications from the originators, it is apparent that they went on to embrace a way of describing the stages where a lapse or relapse did not necessarily mean that people regressed all the way back to where they started.
They recognised that people can learn from their mistakes or what didn’t work, and try something different the next time. For example, this was illustrated in 1992 with a ‘spiral’ diagram (each loop in the spiral taking people closer to lasting recovery), and in 2003 with an adapted ‘cycle’ diagram placing the first stage (pre-contemplation) outside the circle to illustrate that people re-‘cycling’ through the stages would likely not return to where they started. We have made changes to the hot topic on the Effectiveness Bank website to reflect this, and would encourage readers to visit: http://findings.org.uk/PHP/dl.php?file=cycle_change.hot
‘Significantly greater’ numbers of people need to be tested, diagnosed and treated in order to eliminate hepatitis C, according to a report from the All Party Parliamentary Group (APPG) on Liver Health. England needs to agree on a national elimination strategy if it is to make the most of a ‘once in a generation’ opportunity to eradicate the virus, the group stresses.
The report is the result of an inquiry by cross-party MPs and peers, in which expert contributors ‘overwhelmingly agreed’ that England is currently not on track to achieve either the NHS target of eliminating the virus by 2025 or the World Health Organization target of elimination by 2030. ‘The upcoming deal between NHS England and the pharmaceutical industry must include innovative new measures to find those still living with hepatitis C and engage them into treatment,’ says the APPG.
The report urges the government to ‘express its explicit support’ for the elimination agenda, and make sure that the agreement between the NHS and industry includes ambitious national and regional targets, as well as mechanisms to make sure funds are distributed ‘equitably’.
Funding pressures on local authorities are having a negative impact on testing and prevention initiatives, says the report, while levels of awareness among the public and even primary care professionals remain low. Many of the 40-50 per cent of the estimated 160,000 people living with the virus who are still undiagnosed are ‘part of vulnerable populations with chaotic lives’, it adds, while ‘overly complex’ care pathways are still creating barriers to accessing treatment.
The report calls for treatment to be ‘universally accessible’ and available in community settings, as well as the introduction of ‘opt-out’ testing in drug treatment services, with ‘commissioning contracts stipulating clear mechanisms to hold services to account’ for failing to meet targets.
Last month’s Get Connected conference heard how CGL’s hep C strategy was focusing on ‘the huge cohort of people who could benefit from testing and treatment’ in drug treatment services to make the maximum impact (DDN, March, page 6).
Charles Gore: We all need to up our game
‘Much as there has been great progress, as this report makes clear, we all need to up our game,’ said Hepatitis C Trust chief executive Charles Gore. ‘No one should be walking round with a virus that could give them liver cancer. No one should have to wait for treatment. No one should die from this disease when we have these miraculous drugs. We can eliminate this virus so let’s get on with it.’
‘With the exceptional context of a deadly virus now being fully curable with easily deliverable, highly cost-effective medicines, finding those still undiagnosed and living with hepatitis C should be a national ambition,’ added APPG co-chair Sir David Amess. ‘Eliminating a public health issue that disproportionately affects some of the poorest and most marginalised groups in our society is an extraordinary and eminently achievable opportunity which should be seized with both hands.’
US president Donald Trump has said that his Department of Justice intends to seek the death penalty against drug traffickers ‘where appropriate under current law’. The announcement was one of a range of measures set out as part of his latest initiative to attempt to tackle the country’s ever-worsening opioid crisis.
The initiative would address the factors fuelling the crisis, he said, including ‘insufficient access to evidence-based treatment’ as well as both the supply of illicit drugs and over-prescription by medical professionals. The number of opioid overdoses in the US has quadrupled since 1999, as has the level of opioid prescribing (DDN, September 2017, page 5). Trump pledged to launch a ‘nationwide evidence-based campaign’ to raise public awareness of the dangers of prescription and illicit opioid use, and to implement a ‘safer prescribing plan’ to cut opioid prescriptions by a third within three years.
He would also ‘crack down on international and domestic drug supply chains devastating American communities’, he said. Alongside the possible death penalty for drug dealers this would include further securing ports and land borders, shutting down illicit online opioid sales and strengthening penalties for selling fentanyl and other substances that are ‘lethal in trace amounts’. The initiative would also work to ensure that ‘first responders are supplied with naloxone’, however, and increase access to evidence-based treatment ‘as an alternative to, or in conjunction with, incarceration’ for people in the criminal justice system.
‘We will work to strengthen vulnerable families and communities, and we will help to build and grow a stronger, healthier, and drug-free society,’ he said.
Maria McFarland Sánchez-Moreno: Trump’s administration should stop its obsession with killing
The US-based Drug Policy Alliance said that while measures such as improving treatment provision and rolling out naloxone would be helpful if there was a focus on putting the latter ‘in the hands of individuals and community groups’, the president had ‘done little to offer a public health response’ to the situation. ‘Rather than helping people at risk of overdose and their families, Trump is cynically using the overdose crisis to appeal to the worst instincts of his base, and pushing for measures that will only make the crisis worse,’ said executive director Maria McFarland Sánchez-Moreno. ‘If this administration wants to save lives, it needs to drop its obsession with killing and locking people up, and instead focus resources on what works: harm reduction strategies and access to evidence-based treatment and prevention.’
Meanwhile, visits to US emergency departments for suspected opioid overdoses increased by 30 per cent in the year to September 2017, according to the Centers for Disease Control and Prevention (CDC). The Midwest saw the largest increases, with Wisconsin recording a 109 per cent rise. ‘Long before we receive data from death certificates, emergency department data can point to alarming increases in opioid overdoses,’ said CDC acting director Anne Schuchat. ‘This fast-moving epidemic affects both men and women, and people of every age. It does not respect state or county lines and is still increasing in every region in the United States.’
Since mid-2017 the UK has experienced a shortage of hepatitis B vaccine due to global manufacturing issues. In response to the shortage, Public Health England (PHE) developed temporary recommendations on use of hepatitis B vaccine.
Vaccine supplies are now improving and more vaccine is becoming available during 2018. Supplies will remain constrained, however, due to backlog demand from 2017 and low UK allocations from some manufacturers. Supply management and some monthly ordering restrictions will therefore need to continue to prevent stockpiling.
Hepatitis B vaccine remains available for those at highest immediate risk of exposure, ie PHE priority groups 1-3 (see PHE temporary recommendations, August 2017). These include people who inject drugs.
PHE has recently published a recovery plan to support re-introduction of vaccine for lower priority group 4 in 2018 in a phased approach to maintain continuity of supply.
Commissioners and providers of drug services are advised to read the plan, share with relevant staff in their organisation – especially those who purchase and offer vaccine – noting that they can now order larger volumes of vaccine from manufacturers, and increasingly without the need for an override request.
How do we get connected? With healthcare, with peers, colleagues, commissioners, policymakers, politicians? It’s a question that goes far beyond the DDN conference – but the spirit of this event confirmed that where there’s a will, things can happen.
On the following pages you will find not just the record of the day’s events, but a host of possibilities, questions and ideas. How can we make sure the relationship between those providing and seeking healthcare is as good as it can be? How do we ensure these all-important interactions are not one dimensional, but create pathways to other vital support services and branches of healthcare? What do we do if we’re not getting the treatment we need?
The crucial component in a day like this is those who come along to say ‘I did it like this and it worked for me’ – call it expertise by experience, service user involvement, or whatever you will. But whether it’s hepatitis C treatment, supported housing, education and training, or taking part in local decision-making, the people who look back after they have tried the route are the ones who leave doors open for the rest of us.
Equally important was the emphasis on ‘having your say’ – PHE, commissioners and researchers all wanted service user involvement in feedback, planning and ‘lived experience’. This surely must give impetus to including peer-led groups and enterprises as a standard component in every local tender.
Alcohol brief interventions promised a way of improving the nation’s public health – so what happened to this ambitious initiative? Mike Ashton looks back at a 27-year journey.
The advent of brief interventions represented a radical realignment away from aiming for abstinence among relatively few ‘alcoholics’ to reducing risk among risky drinkers of all levels. Instead of narrow and intensive, the strategy was to spread thin and wide, deploying easily learnt interventions that could be delivered in a few minutes by non-specialist staff.
Drinkers whose consumption generated no impetus to seek advice were nevertheless to be offered it, after being identified by screening questions or clinical signs while coming into contact with services for other reasons. Some might not benefit and others only modestly, but – unlike treatment – the population was the target.
Screening and brief intervention was primarily a public health strategy to reduce alcohol-related harm at the level of a whole population, to a degree otherwise unattainable without imposing politically unpalatable restrictions on the availability of alcohol.
This is the story of the partial retreat from those ambitions, traced through three British studies in which the same researcher was involved – Professor Nick Heather, the first to evaluate an alcohol brief intervention in primary care, a venue chosen for its near-universal reach. The most influential thinker and researcher on brief interventions in Britain, his work forms the spine of the research-driven realisation that hopes and potential were one thing, realising them another.
Conducted in Dundee in 1985, the results of his first trial can in retrospect be seen as a harbinger of what was to come. Whether screening had been followed by no advice on drinking at all, a very brief warning from the doctor, or the more elaborate ‘DRAMS’ brief intervention, drinking reductions did not significantly differ. The researchers commented: ‘The results… provide little support for the hypothesis that the DRAMS scheme is superior to simple advice and to no intervention.’
Fifteen years later recruitment started for another study co-authored by Professor Heather, seen as the UK trial closest to routine practice, an essential step in showing ‘potential’ could be turned into public health gains. After suffering from low recruitment to the trial and low rates of screening and intervention, it found no statistically significant evidence that a five- to ten-minute brief intervention by primary care nurses in England was more effective than usual unstructured advice, despite costing nearly £29 more per patient.
Though appreciating the difficulties, in 2006, the year these results were published, Professor Heather still optimistically identified the ‘steadily gathering momentum’ of an ‘international movement dedicated to reducing alcohol-related harm by achieving the widespread, routine and enduring implementation of screening and brief intervention’.
That same year, the UK Department of Health had funded a more definitive study, a real-world test with a sample large enough to detect small effects, overcoming a limitation of the previous two trials. Professor Heather was one of the investigators. For alcohol screening and brief intervention in Britain, the ‘SIPS’ study was critical, intended to help government decide whether to invest in incentivising these activities in GPs’ surgeries – there were also parallel studies in probation and emergency departments.
In March 2012, a conference and factsheets revealed the unexpected results, later confirmed in formal publications: brief interventions as normally understood were generally not found to be any more effective than an unsophisticated 30-second warning to patients about their drinking plus an alcohol advice leaflet:
Thank you for taking part in this project. Your screening
test result shows that you’re drinking alcohol above safe
levels, which may be harmful to you. This leaflet
describes the recommended levels for sensible drinking
and the consequences for excessive drinking. Take
time to read the leaflet. There are contact details
on the back should you need further help or advice.
This terse warning was to be a relatively inactive ‘control’ condition against which the brief interventions could shine. Instead, it captured the limelight. ‘Do just the minimum,’ is the message austerity-hit commissioners might have received, encouraged by the ‘less is more’ take on the findings from the Department of Health’s director of health and wellbeing. In fact, whether any of the advice options were better than doing nothing could not be determined by the trial.
Another important finding was that implementation often required specialist support and patient throughput was low. Though incentivised with per-patient payments, the average primary care practice identified just two risky drinkers a month.
The year these results were revealed, 27 years after embarking on the first trial in Dundee, Professor Heather addressed the key question posed by the title of his article: ‘Can screening and brief intervention lead to population-level reductions in alcohol-related harm?’ The optimism expressed just six years before had evaporated, though not entirely dried up: ‘Widespread dissemination of [screening and brief intervention] without the implementation of alcohol control measures… would be unlikely on its own to result in public health benefits.’
Screening and brief intervention might persuade individuals to cut their drinking, but as a public health tool, it had become relegated to a (still potentially important) adjunct to the primary elements – the availability restrictions to which brief interventions had been seen as a more acceptable alternative.
Of the four requirements for public health benefits, Professor Heather judged only one had been satisfied – evidence that brief intervention ‘reduces consumption to low-risk levels in some of those who receive it’ – and depending on how many the ‘some’ are, even that has arguably not been demonstrated in real-world circumstances. Meeting the remaining three requirements was, he wrote, ‘currently unlikely, either because they are difficult to achieve or because there is no evidence to support them’.
A major gap was that ‘public health potential… is unlikely to be realised without the widespread deployment of universal screening’, something no national health care system had been able to achieve. The ideal scenario of drinking being asked about at every contact with a health professional, followed if indicated by help or advice, ‘might not be tolerated by the general public, not to mention the health professionals asked to deliver it, and might therefore be an electoral liability to any political party supporting it’.
By 2017 his caution was being cited and reinforced by UK and US brief intervention researchers. Their downbeat verdict was that ‘After more than three decades of study in primary care, it now seems unlikely that brief interventions alone confer any population level benefit, and their ultimate public health impact will derive from working in concert with other effective alcohol policy measures.’
What prompted this conclusion was lack of evidence that in real-world circumstances, brief interventions reduce alcohol-related ill-health, coupled with the difficulty of persuading GPs to focus on not-very-heavy drinking when patients often have multiple lifestyle risk factors – and when they and their doctors may be more concerned with here-and-now problems rather than the risk drinking will cause future harm.
It is in the nature of the methodologies used to evaluate screening and brief intervention programmes that the door cannot be closed on the possibility that they can appreciably improve public health – if, for example, interventions are refined and incentives to implement them and checks on quality strengthened. And although wider public health benefits are doubtful, these procedures can benefit individual heavy drinkers.
Nevertheless, the rather intractable worlds of doctors and patients trying to cram their priorities into a ten-minute consultation in which alcohol has no natural place has helped drain the optimism of past decades. Even in relatively ideal circumstances, screening and brief interventions are not likely to affect the numbers needed to substantially relieve the UK of its burden of alcohol-related harm.
Sunny Dhadley – SUITJames Graham – Phoenix Futures
Dot Turton – Recovery ConectionsStacey Smith – CGL
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A huge THANK YOU to all of you who came to the DDN conference and made it a special day. Our speakers were amazing, our exhibitors were out of this world, and it goes without saying that our delegates were the best! We are indebted to our sponsors who made it possible and to every organisation, large and small, who sent representatives and took part in the exhibition.
With much anecdotal evidence that people are losing their OST of choice, a meeting was held at the DDN conference to ask, ‘are you getting what you want?’ The comments suggest new action points for services.
Drug-related death statistics are well documented and at their highest level since records began. Evidence also tells us that opioid substitution treatment (OST) is protective against opioid deaths, when given at the right dose and for the right duration.
At the DDN conference we took the opportunity to run an interactive session with people in treatment, those who were thinking about it, and others who had experienced it for better or worse. In an informal group, Dr Chris Ford and Stuart Haste invited people to comment on their situation. Could this help to shed light on a lost connection between services and those whose lives – and quality of life – depended on them?
It was clear from the outset that the dwindling state of funding was affecting each group of participants, with many people being told that choice of OST was no longer an option because of cuts: ‘I really wanted to try buprenorphine, as I’d tried methadone twice before. But the worker said I couldn’t have it because it wasn’t right for me and too expensive,’ said one member of the group.
Others were having their dose of OST reduced without their consent, leading to them becoming unstable. In John’s case an abstinence agenda was being used as ‘law’ to reduce his medication: ‘My prescription keeps me alive, and I’ve been on it for a good 12 years,’ he said. ‘But they keep saying I need to reduce – that it’s the law. I know it isn’t, but I have to fight at each appointment. The new staff don’t understand, or believe in, harm reduction – but I’ve seen too many friends die when they stop treatment and I’ve got to live to bring up my kid.’
For those trying to access OST, either for the first time or after a break in treatment, new barriers had appeared.
‘I had to jump through so many hoops to get into treatment,’ said one participant, while another commented: ‘I wanted to try being drug free, but felt very odd and soon relapsed. I asked to come back into treatment quickly so I wouldn’t lose everything but they said it’s not possible to do that because there are rules. I would have been dead when I overdosed if my friend hadn’t been there.’
Climate of Mistrust
This lack of flexibility was cultivating a climate of mistrust. ‘They asked me about my motivation and didn’t like it when I said, “I’m here, isn’t that enough”,’ said one person, while others had become used to feeling that services were not listening to them. ‘If you have your own answers, don’t ask me for mine,’ was Linda’s response to this; while Deb commented that her reaction had been, ‘If you don’t want to listen, tell me what you want to hear.’
In practical terms, services’ unwillingness to be flexible could put an insurmountable hurdle in front of treatment: ‘I missed the first day of my three-day pick-up because my child was ill and I had to go back for re-titration,’ said one mother.
Some felt that they could not risk being honest about their needs or challenge treatment provision for fear of the consequences: ‘I feel that I can never say what’s going on with me or ask for something like an increased dose, because it means they will probably reduce me or put me back on daily dispensing, which is impossible as I need to live,’ said Angela.
Alisha was confronted with stipulations when trying to access hepatitis C treatment: ‘They told me I needed to reduce my dose before I could start hepatitis C treatment, but I knew they were wrong from going to a HCV support group,’ she said. ‘So I agreed to the reduction but bought some methadone to keep my dose the same. It’s madness that I can’t be honest.’
For many, the stigma of being identified as a ‘drug user’ permeated services and blocked the chances of a trusting and beneficial relationship with staff. Linda had frequently experienced the attitude of ‘there’s a queue over there for people like you’, while Billy’s experience was that ‘one worker said to me on first presentation – we know you people lie, so I will decide what you get’.
‘Top-down’ culture
They also speculated that the ‘top down’ culture of many organisations was affecting staff’s capacity to connect, particularly if they were not allowed to disclose to clients that they had themselves been in treatment.
‘My friend disclosed about her history of treatment and was quickly shown the door,’ said one participant. ‘The service manager’s reason for dismissal was that it was colluding with clients, which must not happen.’
Karl backed up this scenario from personal experience: ‘I was doing really well as a drugs worker and was offered promotion to team leader by my manager. I explained that I needed to share something to show I was honest and committed, so disclosed that I was on methadone. Suddenly I went from star worker to being before a disciplinary for using drugs.’
A trusting relationship with a drugs worker was seen as paramount to success in treatment, right from the entry stage. ‘I really need help but I’m scared of what they might ask me to do before I get a script,’ said Jake, while another participant demonstrated the importance of continuity: ‘I have had six key workers in the last six months – how can that be effective care? It’s a shame as well, because number three really listened, and it was then difficult to go back to the usual situation of not [being listened to].’
‘I never feel heard,’ said Dan, a theme echoed by many participants, including Linda, who described the all-too familiar experience of completing an assessment to enter a service: ‘They ask you how much drugs you are using and when you give your answer you risk being told that you can absolutely not be using that amount of drugs… Whenever I came across a person like that, I just used to say that they should fill out the form for me and I will sign it as they obviously seem to think that they know better than me,’ she said. ‘I feel like walking out as I am being called a liar.’
If she gets through this process, there can be a further wait before being scripted, she explained, and then a ‘carrot and stick’ approach to treatment – ‘but without the carrot on the end of the stick. For example, if you are late for your appointment you may not even be given your script and could be asked to come back another time. But if your worker is making you wait for ages, that’s just tough.
‘Sometimes you come to pick up your script and they’ve changed the amount that you will be taking,’ she added. ‘They have not discussed this with you first, but instead inform you when you come to pick up your script and by then it’s too late to do anything about it. Your script has been written up and it becomes a “take it or leave it” scenario.’
Understanding
For some who could benefit greatly from treatment and advice, the opportunity is negated by the fear that they would be misunderstood and coerced into treatment they did not want or were not ready for.
Tom had considered going into treatment to tackle his long-standing use of pharmaceutical opioids – primarily oral morphine capsules, supplemented with a mixture of codeine linctus and promethazine (known as a ‘dirty sprite’).
‘I have described my use patterns to drug services and asked if I would qualify for substitute prescribing,’ he said. ‘The service workers have said yes in principle, but what put me off going through the process was that I would be unlikely to be prescribed what I’m getting hold of now.
‘The other primary issue for me is supervision… I’d have to use something every day [breaking his usual pattern of spending ‘three days per week fairly euphoric and the other days clear headed’] and how long would I be subject to supervision for? I am hearing of people in different local authorities being stuck on daily supervised pick-up for years with no apparent end point… and that would be a problem – a deal-breaking one – for me.’
Clearly these are important issues that need talking about at the start of a trust-based relationship with a drug worker. The question that seemed to come from the session at conference was: how can we make sure that treatment moves beyond ‘take it or leave it’, to be tailored to the individual?
This article has been produced with support from Martindale Pharma, which has not influenced the content in any way.
The group of NHS providers, NHSSMPA, is looking at new ways to make sure service users stay connected with essential skilled healthcare.
‘Nostalgia isn’t what it is used to be’ goes the quote, but are drug and alcohol services what they used to be? Well no. Historically, before the formation of the National Treatment Agency (NTA), some areas saw two year plus waiting lists for opiate substitution therapy (OST), and investment in alcohol services was severely lacking.
While there had since been improvements in these areas, the combination of commissioning by local authorities, the global financial crash and ongoing austerity has conspired to result in devastating disinvestment in our services.
Disinvestment and retendering cycles have resulted in changes in the skill mix of services, with fewer nurses, doctors and psychologists (those registered with professional bodies) in teams, and an over-reliance on staff without professional registration or specialist training, and volunteers. There has been a significant loss of knowledge, practice and skills along the way, as provider organisations design services that try to manage the reduction in budgets while still meeting need.
The need for high calibre clinical skills and expertise were recently highlighted by two eminent leaders in the field – professors Colin Drummond and Sir John Strang in the Mental Health Times and BMJ respectively. Professor Drummond stated:
‘Without proper care there are serious risks including epileptic fits and hallucinations, brain damage, suicide and risk of overdose. Yet many services do not have doctors or nurses with sufficient specialist training and competence to provide safe care.’
This highlights that registered staff and doctors have been in steady decline, but also that many of those recruited lack the relevant training, supervision and support to ensure high quality provision for complex service users. These experts do exist, but more and more they are in a lead role rather than ‘on the ground’, which can affect their contribution locally. There are only so many hours in a week.
A reduction in budgets means cash-strapped services are able only to work the purest interpretation of the service specification, compounding the effect of smaller budgets with a loss of social capital from providers.
As a sector we have been eager to seek solutions, usually through collaborative partnerships across health and social care. The significant decline in registered staff, including nurses, social workers, clinical psychologists and doctors means it is harder to achieve improvements even when the willingness has been there.
Being able to speak the language of those that you wish to collaborate with has its advantages and enables effective partnership to prosper far more easily. The loss of these posts (and the assurance of the NHS badge) has negatively affected partnerships, most notably with health colleagues.
The continued reduction in professionally registered staff in treatment services is diluting the skills and professionalism required to address the needs of our service users. A recent CQC publication reports on serious concerns uncovered in many of the independent detoxification clinics across the country.
Furthermore, the reduction in registered staff and the number of NHS providers jeopardises the overall standard of care and the ability to forge meaningful ventures to enhance care pathways. In short, the loss of these providers, practice and skills means some drug and alcohol services are relying on limited clinical expertise, to the detriment of care.
Public Health England (PHE) recently commissioned three publications highlighting the importance of the roles of nurses, addiction specialist doctors and psychologists within the drug and alcohol sector (available at www.gov.uk). They are a call to commissioners and providers that these skills and professional contributions are core and essential, and that their loss is having an impact on the overall provision of care as well as putting service users at risk.
As a group of NHS providers, NHSSMPA hopes to contribute to changing this. The following examples show innovations by NHS services where good practice has been implemented to improve the wellbeing of our service users. They also illustrate why retaining an appropriately balanced and skilled workforce is essential.
STREET SEX WORKER INITIATIVE
A low threshold initiative was developed for street sex workers who elected to engage with it, and who were provided with 30mg oral methadone. They could pick up on any or all days, seven days a week, giving them the option of working and a safety net. Two pharmacies were part of the team and would work in partnership, closely monitoring risk. The expectation of the sex worker was that they would attend a three-monthly clinic. Its format was devised by service users and access was available for:
• rape crisis intervention • genito-urinary medicine services for smear tests and sexually shared infections, high vaginal swabs and any necessary treatments • family planning for depot contraception injections • midwives for pregnant service users • needle and syringe exchange • condom provision • vaccination for hepatitis A and B
Direct referral to colposcopy and appointments was provided at the time of attendance, as well as the ability to dress wounds, listen to breathing to identify respiratory disorders, examine injecting sites, monitor drug use and move into mainstream treatment if that was what the person wanted. Apart from the obvious direct benefits for service users it also improved relationships between services and the sex workers’ access to these.
Engaging complex clients
Nursing staff learned compression bandaging to work with some difficult-to-engage service users with venous leg ulcers. We worked with people who were not turning up to the dressings clinic, not having doppler studies, continually having breakdown of their ulcers, and suffering widespread infection, cellulitis and venous eczema.
We engaged with their GP practice and developed a shared care type approach. We increased outreach to service users and managed their dressings as per the care plan. We would make sure they attended doppler appointments where the GP and nursing staff would manage the dressings. This allowed a relationship to develop between the service user and the nursing team and allowed us to pull back when the service user was fully engaged.
Derby’s HIT
Derby Healthcare Foundation NHS Trust looked at their care delivery in an effort to address the effect of diminishing resources. They devised a ‘red flag system’ to identify service users most at risk of accidental overdose, through reviewing six years of local mortality data.
The common themes that correlated this risk of accidental overdose were largely expected – continued intravenous use of illicit drugs, erratic engagement, poor physical and/or mental health. But less considered was hepatitis C status and the link with those living in isolation. Other risk factors were a hospital admission in the last 12 months and having a physical health condition such as chronic obstructive pulmonary disease or a deep vein thrombosis. Being prescribed additional medication with a sedating effect by their GP was also a marker.
Collecting and analysing this data identifying who was at risk led to the creation of a health improvement team (HIT) in Derbyshire. This approach was incorporated into a tender for Derbyshire treatment services at the beginning of 2017, and the new service went live in April 2017. The HIT do not carry a caseload, but instead support key workers with their higher risk service users, and the sole focus is on improving their physical and mental health and preventing drug-related deaths.
Those with chronic and deteriorating physical health will have greater priority placed on managing these conditions integrated with their substance misuse treatment. Physical health assessments and advice will be provided by the HIT nurses, including more routine care such as blood-borne virus testing and vaccinations alongside ECG.
The role of nurses was central to the success of the Derby approach, and is fundamental to the other examples provided. Over the past decade or so, nursing and other clinical expertise has been lost – meaning that within drug and alcohol treatment, as many of our service users age and require broader health and social care, clinical expertise is less accessible. The multi-disciplinary team, which includes those with clinical expertise working with other disciplines and those with lived experience, has never been more important.
NHSSMPA is also part of a national working group led by the Royal College of Psychiatrists and PHE, with third sector colleagues, that is trying to reverse the reduction in addiction psychiatrists – an example of the sector responding to an important workforce issue. It is at our peril that we do not ensure that drug and alcohol services incorporate the correct blend of skills and disciplines, including highly skilled clinicians.
Authors are Jon Shorrock, Avon and Wiltshire Mental Health Partnership NHS Trust; Linda Johnstone, Cheshire and Wirral Partnership NHS Foundation Trust; Martin Smith, Derbyshire Healthcare NHS Foundation Trust; Mike Flanagan, Surrey and Borders Partnership NHS Foundation Trust. All are members of the NHS Substance Misuse Provider Alliance (NHSSMPA).
Don’t miss the chance to change CQC inspections, says David Finney.
The Care Quality Commission (CQC) has recently issued a consultation on changes to the inspection of independent healthcare services, and this includes substance misuse services. The consultation has a deadline of 23 March 2018 for responses and is available here. In my view it is urgent that substance misuse services participate in this consultation, otherwise a key window of opportunity will be lost to influence the practice of the regulator.
The consultation document and previously issued Key lines of enquiry for healthcare services (July 2017) contain very little mention of substance misuse services at all, suggesting that they are being overlooked within regulation.
While CQC still publishes some ‘brief guides’, these mostly relate to detoxification services rather than other residential or community services. In practice there are regional leads for substance misuse services, but below that level the experience of inspectors is variable, so there is a danger of inconsistency in inspections. Specialist professional advisors have been used alongside inspectors, but the overwhelming majority have been nurses or doctors with experience of NHS settings rather than independent residential or community services. Once again, it seems that residential rehabs, in particular, are being marginalised within regulation.
The new approach has positive and negative aspects for the substance misuse sector – however, a key problem at present is lack of engagement with the sector by CQC corporately. A report highlighting the failings of detoxification services has been published (30 November 2017), but no other recognition of the residential rehabilitation services has been forthcoming. When substance misuse services were regulated within the adult social care directorate of CQC, many providers felt that they were not understood by the regulator.
To avoid substance misuse services becoming marginalised within regulation once again, providers need to make an active response to this consultation. The sector should come together and lobby CQC to help it to become the informed and proportionate regulator it aims to be.
Key features of the consultation
CQC say that the aim of their new approach is to be ‘targeted, responsive and collaborative’. They propose that some key developments will be:
a. Unannounced or short-notice inspections:
an initiative to be launched in April 2018. This will be a change from the current practice of giving long notice for announced inspections and mean that providers will not have the opportunity to organise the day so that they can present their service to the inspection team. Neither will they will be able to arrange for service users to be available to speak to the inspector, apart from by taking them out of their existing programme commitments at short notice.
b.A new model for collecting data, called CQC Insight. This seems to match the type of data collection used by the NHS, but may prove difficult for smaller residential services that do not have the data systems available to larger corporate bodies.
c. Rating of services. The characteristics for rating services defined in the assessment framework (KLOE) are very general, and do not reflect what a ‘good’ or ‘outstanding’ substance misuse service looks like. There is the possibility that services may be rated according to the subjective view of the inspector, rather than a recognised benchmark.
d. Changed frequency of inspections: so that outstanding services are inspected every five years, good services every three and a half years, services requiring improvement every two years and inadequate services every year. There is also a provision for ‘special measures’, which will lead to more intensive monitoring. I have two major concerns for services awarded a lower rating: if there is a long time before another inspection, this may adversely affect the availability of the service to local authority funded placements and the business overall; and secondly, it is likely that services will not be able to admit new service users, which will very quickly undermine the business financially and not allow it to recover.
e. Effective use of accreditation schemes. In contrast, this is an opportunity for the sector, because CQC say that these schemes could shorten inspections or even replace them altogether. Although previous accreditation schemes for this sector have fallen by the wayside, this is a new chance to focus on the distinctiveness of substance misuse services.
f. Relationship management. This is about the development of strategic planning and the encouragement of improvement within the sector. Some larger providers already have a relationship manager within CQC, but this function has been inconsistent across the country. So the challenge is to regularise the arrangement so that all providers have the advantage of access to this service.
g. Emphasis on well-led domains. Good leadership and governance is clearly important; however, aspects which tend to feature highly in the consultation are document-based factors such as quality assurance systems and methods for implementing lessons learned. These are relevant, particularly in corporate bodies, but it is equally important to recognise the impact of management, which is in regular informal contact with service users and their progress through recovery.
David Finney is an independent social care consultant who has worked with government inspection bodies
Our inspector had insufficient expertise – can we challenge?
Following a recent inspection we were unhappy with our CQC report. We felt that the person conducting the inspection did not have adequate experience of the substance misuse treatment sector and that the specialised nature of our service was not taken into account. Can we challenge our inspection on these grounds or ask for a second opinion from someone with more understanding of residential drug and alcohol services?
This is a scenario we at Ridouts recognise all too well from our regular interactions with substance misuse providers. It is not unique to the sector but is certainly a greater problem here than in some others.
This is because, due in part to the relative youth of the sector in terms of distinct CQC regulation, inspection teams often include no specialist advisors (SAs) with expertise in the field; instead, teams may include SAs with NHS-only experience, contrary to CQC’s published guidance emphasising the important role of SAs in inspections.
CQC’s SA recruitment advert stated that the ‘job purpose’ of an SA was ‘to provide specialist advice and input into the CQC’s regulatory inspection and investigation activity. This advice ensures that CQC’s judgements are informed by up to date and credible clinical and professional knowledge and experience’.
CQC consistently insists that inspection teams attend inspections equipped with individuals skilled and experienced in that specific environment. In the case of substance misuse sector providers, therefore, the appropriate SAs would without exception have substance misuse expertise relevant to that provider. As readers know, the NHS environment is wholly distinct from the independent sector and should rarely be compared. In the absence of appropriate SAs, inspection teams necessarily lack the judgement required for the job; inevitably, mistakes, misinterpretations and simply factual inaccuracies will occur.
Providers should not be afraid to challenge either the conduct or experience-level of the inspection team where this has clearly had an unfair impact on the draft report or seems otherwise inappropriate. This is best done through the factual accuracy process.
Providers should also consider making a formal complaint on conclusion of the inspection, rather than on receipt of the draft report. This stops CQC from alleging that complaints are only raised when providers are unhappy with inspection results.
As said before in this column, challenging factually inaccurate reports and submitting detailed, evidenced complaints are necessary steps all providers must take to safeguard their reputations. All reports should reflect the reality of the service, rather than the prejudice and/or inexperience of the inspection team. Providers must remember that prospective service users and their families will use the finalised report, as will commissioners, to inform decisions about admission.
I also echo David Finney’s article and encourage all providers to actively engage with the new CQC consultation. Providers can help CQC to appreciate the importance of expertise, and indeed the financial, resource and time costs of the legal appeals required to remedy the absence of such expertise. Providers can be the change they want to see, but if they stay silent they will only perpetuate the status quo.
This is a family story of addiction with all its fragmentations and energy-draining disputes.
O’Neill’s own upbringing is the basis of the play. It was so close to home and raw that he requested it not be performed until 25 years after his death. His widow, Carlotta, chose to honour his brilliance as a dramatist rather than his dying wish. Three years on, in 1956, it was on the stage. It secured his reputation as America’s foremost playwright and earned O’Neill a posthumous, third Pulitzer Prize.
It is around Mary Tyrone’s morphine addiction that the myriad anxieties and tensions swirl. Her husband and two sons all drink way too much whisky. O’Neill’s own mother developed the same dependency from being given morphine to ease the pain of his difficult delivery into the world. As a teenager, he found out about her habit and her neurosis over childbirth. She was ‘cured’ only by menopause which took away childbearing and its fears.
In ways perhaps only a family can be, the protagonists are by turns brutally honest, even plain vicious, and then over-sentimental and imploring each other for understanding and forgiveness. The past and what might have been (if it weren’t for you) are recurring and unresolved themes. Mary had known intense happiness with her husband James and waxes lyrically and endlessly about her perfect wedding dress.
It’s a happiness long gone, after following him everywhere to cheap hotel rooms instead of setting up home. This itinerary echoes O’Neill’s own father’s on-the-road acting career which saw him play the Count of Monte Christo 6,000 times. So in the play, Jeremy Irons plays an actor who could have been a great Shakespearean lead, had he not settled for less.
The men of the family alternate between exchanging strong words in vino veritas and declaring their indelible bonds, according to how much whisky they have had. Yet they seem to think their drinking is just fine; it is Mary’s morphine intake that is the real issue.
Mary is extremely affected by her predicament and especially the suspicions around her. She concludes that ‘the only way (to deal with it all) is to make yourself not care’ and ‘the only past, when you are happy is real’. Mary had originally wanted to be either a nun or a pianist. Her hands are now too arthritic to play, she says, and that’s also why she needs the morphine. She concedes the nun ambition is probably done with.
Review by Mark Reid
The resentments and frustrations constantly exchanged sum up the draining emotions and confusions of active addiction. At times I felt like marching them all off to the nearest Al-Anon meeting.
These are only actors of course – albeit brilliant ones – but if you might feel triggered by watching people drink and dash off upstairs to take drugs, then this might not be for you, although I thought the real cigar and pipe smoke really enhanced the play’s atmosphere.
This is a true tragedy because these are not random characters; people who find each other just because they are drunks and addicts. It is paramount that they are family.
Buffeted by three dysphoric drinkers, Lesley Manville as Mary gives a spot-on portrayal of the capricious addict. You feel for all of them as the natural love which they are too entangled to express is ever more lost to their demons.
Long Day’s Journey Into Night by Eugene O’Neill is at the Wyndham’s Theatre, London until 7 April
Medical students need to learn, in a compassionate way, about the particular challenges of treating patients with drug addiction. And they need to learn from doctors who are tolerant and compassionate towards patients… phrases like ‘person that uses IV drugs’, in theory, should remind us that we are indeed dealing with a person and not a diagnosis – in the same way that my patient is a ‘person with schizophrenia’ or ‘a person with alcohol misuse’, rather than a schizophrenic or an alcoholic, defined by their diagnosis. Elizabeth Romer, BMJ, 12 February
You can tell the state of a society, said Alexis de Tocqueville, by its prisons. Today you tell it by its attitude to drugs. Ten years ago the Labour government recklessly upgraded cannabis from class C to class B, ‘because of concerns of its impact on mental health’. Then they were minimal. After reclassification, police evidence is that 95 per cent of cannabis used is now skunk. Simon Jenkins, Guardian, 1 March
Our prohibition of cannabis jeopardises children’s safety, encourages gang violence and leaves millions in the dark about what they’re taking. This approach has failed and the public know it. More Britons support a legal, regulated cannabis market than oppose it. Daniel Pryor, Times, 1 March
More than a dozen times I have pointed out here that almost all rampage killers, all over the world, have one thing in common – the use of mind-altering drugs. I am not trying to exonerate them. On the contrary. But I am trying to prevent these things happening in future by being much tougher on illegal drugs, and much more cautious with legal prescriptions. Sometimes it is cannabis. Sometimes it is steroids. Sometimes it is prescription ‘antidepressants’ – themselves a scandal waiting to be exposed and understood. But it’s always there… The USA has always had legal guns, but these massacres are new. What else is new? Mass use of mind-altering drugs, legal and illegal, that’s what’s new. Peter Hitchens, Mail on Sunday, 4 February
Cuts by councils to funding alcohol and drug treatment services are deeply concerning. Particularly when they come against a backdrop of increasing referrals in some areas. Given the proven links of addiction to mental health and other problems surely the pressing case for investment is self-evident. Sunday Express editorial, 11 February
Services should increase their focus on older people because of the sheer number of ‘baby boomers’ needing help for substance misuse issues, says a report from the Royal College of Psychiatrists.
Improved training is needed at all levels, including the training of more addictions psychiatrists, says Our invisible addicts, an updated version of a 2011 report from the college. With most substance problems in older people ‘going undetected’ there is an urgent need to improve diagnosis, treatment, education, training, service development and policy, it stresses.
Older people with substance issues face a ‘complex constellation of risks’, the report says, which can result in presentation to a wide range of services including drug and alcohol treatment, primary care, acute hospitals, older people’s mental health, social care, housing, criminal justice and the voluntary sector – in many cases ‘the staff in these settings have little specialist knowledge of how to deal with such complexity’, it adds.
The document calls for a multi-sector approach, improved peer support and development of a clinical workforce with the ‘appropriate knowledge, skills and attitudes’ to provide identification, assessment, referral and treatment – ‘in particular, we see a need to reverse the loss of multi-professional specialist training in addictions that has taken place in recent years’.
While older people respond well to brief advice and motivational therapy – and in some cases can have better outcomes than younger people – there is a ‘paucity of UK-based research and evidence for treatment interventions and services’ around the management of substance use disorders in older people, and the population has also traditionally been under-represented in research studies. It is also vital that people not be excluded from treatment because of their age, stresses the report, which was produced by a working group of professionals across a range of clinical specialities as well as service users.
‘In the 21st century, substance misuse is no longer confined to younger people,’ said working group chairs Professor Ilana Crome and consultant psychiatrist Dr Tony Rao. ‘The public is poorly informed about the relationship between substance misuse and health risks in older people. We need a clear and coordinated approach to address a problem that is likely to increase further over coming decades. By improving our approach to substance misuse in older people from detection to continuity of care, we can also improve both quality of life and reduce mortality in a vulnerable group that deserves better.’
The recovery journey of dependent drinkers can ‘markedly improve’ the lives of their family members – as long as the recovery is sustained, says a report from Sheffield Hallam University and Adfam. The research – the first of its kind on this scale and led by Prof David Best – surveyed more than 1,500 family members, around half of whom were parents and a quarter spouses or ex-spouses. Almost 90 per cent of respondents were women.
There are almost 600,000 dependent drinkers in England, and an estimated 222,000 children living with one, while in 2016-17 just over 108,000 dependent drinkers accessed treatment. For those who do enter treatment outcomes tend to be positive, the report notes, with more than 60 per cent completing successfully.
Recovery journeys can be an emotional challenge, says the report.
‘Family members are both a resource to support recovery, and people whose own lives can be transformed through recovery,’ the report says. Those surveyed reported improvements in a range of areas when a dependent drinker was in recovery, including emotional and mental health, debt, problems at work, involvement in the criminal justice system and violence. Around a third of respondents were victims of family violence during their family member’s active dependency, which fell to 10 per cent during recovery, and while more than 70 per cent reported receiving treatment for mental health issues during the drinker’s dependency, this fell to just over a third.
‘Recovery journeys’ can also be an emotional challenge, however, the report points out, with relapses leading to poorer physical and mental health and quality of life. ‘While families as a whole experience significant benefits through the recovery journey of loved ones, not all of the emotional damage is reversed, and relapse undermines at least some of the positive gains,’ it says. Family members need support in their own right, the document stresses, with many respondents struggling to find appropriate help.
‘This report is an invaluable addition to a growing body of knowledge about the impact of substance misuse on families,’ said Adfam chief executive Vivienne Evans. ‘It supports and adds weight to Adfam’s 30 year mission to provide help and support for these families, who are such a key element of recovery and yet need to have a journey of recovery for themselves.’
‘The pressures of caring for a family member who is dependent on alcohol can be overwhelming,’ said Dr Richard Piper, chief executive of Alcohol Research UK, which funded the study. ‘It’s clear that families are a key resource in supporting recovery, and that they benefit significantly where recovery is successful. This research highlights the need for a better focus on families and their role in the recovery journey. In particular, families need better access to support services.’
Can we meet six basic challenges to repair a fragmented treatment system, asks Paul Hayes.
Brexit continues to dominate mainstream debate. But far more important to most people, particularly the poor, the marginalised, and the ‘left behind’ is the cumulative impact of years of austerity and the continuing failure of the economy to grow.
The prime minister’s promise to overcome the ‘burning injustices’ which blight so many lives, seems distant. The reality of sluggish growth, falling wages, and slow but steady degradation of the services on which the poor and vulnerable rely, provide the context in which drug and alcohol treatment providers work and our service users live.
Below are six of the key challenges facing the drug and alcohol treatment system during 2018. As the government recognised in last year’s drug strategy, truly effective interventions depend on their cumulative impact. People need adequate access to physical and mental health treatment, a realistic prospect of a job, a safe place to live, and enough income for food and clothing.
Since the financial crash of 2008, the cumulative impact of squeezed budgets and changes in policy have placed strains on service users’ capacity to survive and recover, which treatment providers cannot address in isolation – no matter how brilliantly they implement the drug strategy or how assiduously they abide by the clinical guidelines.
******* ALCOHOL *******
Only one person in six who needs alcohol treatment is able to access it. Alcohol harm is concentrated in our poorest communities, with 30 per cent of all alcohol consumed by 4 per cent of the population. The health damage, the societal consequences and the costs to the NHS are well understood. Despite this, the government has thus far resisted publishing an alcohol strategy identifying how it will reduce the overall harm of alcohol use and in particular how it will close the gap between the growing need for treatment and shrinking capacity. There is growing political pressure for the government to be more active in social policy, and an alcohol strategy would be the ideal place to begin.
******* DRUG-RELATED DEATHS *******
The Local Government Association, PHE, and the ACMD have all identified treatment for England’s heroin-using population as the key to reducing drug-related deaths. Being ‘in treatment’ is a protective factor: deaths are significantly lower within the 60 per cent in contact with services than the 40 per cent who are not. Every local authority commissioner and provider should be striving to understand why people do not access services and find the most effective way to reach them. However, with providers extended to the limit to meet the needs of the 60 per cent, resourcing will be fundamental to success.
******* DISINVESTMENT *******
In 2012/13, total spend on drug and alcohol treatment in the community and prison was more than £1bn. It is now around £750m. Local authorities are increasingly focusing their commissioning on ‘must haves’; protecting rapid access to prescribing services by limiting the availability of the wider services that are crucial to success – those relating to homelessness, mental health, employment, offending, and services specific to gender, culture and communities. As services become hollowed out, the spectre looms of a government committed to recovery presiding over a system which is forced by financial constraints to focus almost exclusively on maintenance prescribing.
******* FRAGMENTATION *******
The 2013 reforms brought drug and alcohol treatment together as the responsibility of local authorities – but elsewhere we have seen fragmentation of provision rather than its integration. Most significantly, as the cohort of heroin users from the late 20th century epidemic age, their need for mainstream health services has grown dramatically. Decades of heroin use, accompanied by smoking, poor diet, insecure accommodation, fragile mental health, and alcohol misuse, has created a population with severely compromised heart, lung and liver function, whose health needs are more akin to those of the elderly than the middle aged. A hard-pressed NHS struggles to respond to those it experiences as ‘challenging’, and service users are easily discouraged by the bewildering range of NHS signposts and pathways.
Health and wellbeing boards, created to knit local authority and NHS services together, are preoccupied with the massive challenge of integrating health and social care and pay scant attention to lower priority issues such as alcohol and drug treatment. The impact of this is that a vulnerable population is excluded from healthcare, resulting in unnecessarily early deaths – in far greater numbers than the overdose deaths reported in the drug-related death figures.
A similar chasm has been allowed to develop between prison and community services. Since 2013 prison drug and alcohol treatment has been commissioned by NHS England and usually delivered within large multi-site contracts with generic healthcare providers. Startlingly this means that neither the Ministry of Justice nor NHS England know how much is spent on drug and alcohol treatment in custody – however the MOJ’s best estimate suggests that prison treatment has also experienced a 25 per cent reduction since they assumed responsibility. Before this, prison and community treatment was commissioned as one system to facilitate effective transfer between the two settings. The failure of the current system is illustrated by the fact that only 30 per cent of those assessed as having a continuing need for treatment on release actually establish contact with a community service.
******* COMPLEXITY *******
The narrowing of local authorities’ ambitions for their specialist treatment systems is accompanied by continuing decline in the generic services that are fundamental to recovery. Despite the government’s laudable commitment to parity of esteem for mental health within the NHS, the secretary of state has acknowledged that the need to recruit and train enough doctors and nurses will delay the achievement of this aspiration for many years.
The abject failure of the government’s Transforming Rehabilitation reforms of the probation service dramatically curtailed the support available to offenders serving community sentences, and on licence following imprisonment. In addition, the probation service is now largely absent from local strategic planning processes in which they used to play a prominent role. While these failings are largely hidden, what is visible in cities across the country is the dramatic increase in street homelessness, which has doubled since 2010 and increased 16 per cent over the past year. This is only one facet of unmet housing need for people with drug and alcohol problems, but it is currently the most visible manifestation of the failure of society to meet the needs of its most vulnerable citizens.
******* CRIME *******
The government’s modern crime prevention strategy, launched by then home secretary Theresa May in 2016, identifies drug treatment as one of society’s most effective tools to reduce crime. Home Office analysis attributes half the rise in acquisitive crime at the end of the 20th century to the impact of the heroin epidemic, and a third of the reduction this century to the improving availability of treatment from 2001 onwards.
The clear connection between heroin/crack dependence and crime made the police strong advocates of improved treatment access, and they were extremely influential players in drug treatment policy between 2001 and 2010. Over the past decade police interest in drug-related offending and their advocacy of treatment diminished as acquisitive crime continued to fall and priorities shifted to sexual offences, violence against women and girls, cybercrime, and terrorism.
Very recently there has been some reawakening of police interest in drug treatment. Traditional crime is beginning to increase; burglary is up by 8 per cent; theft from vehicles is up by 15 per cent; drug-related gang activity is becoming more of a concern and appears to be linked to increasing use of firearms. Use of firearms declined significantly alongside other drug-related offences from 2005 onwards but the most recent crime figures show an increase, including a 20 per cent increase in the use of handguns. None of these increases can be exclusively linked to the drug market, but if ready access to a well-funded drug treatment system helped crime fall between 2000 and 2010 we should not be surprised to see a reversal of the trend.
Despite the scale of these overlapping challenges there are reasons to be optimistic that we can find effective ways to respond. The drug strategy is a huge step forward in endorsing evidence-based practice and explicitly recognising the breadth of the responses needed to succeed. The routine denial of issues such as disinvestment and fragmentation that characterised official responses before the publication of the strategy has been replaced with greater willingness to own the scale of the challenge and seek pragmatic solutions. The increase in traditional crime creates a rationale for police to renew their advocacy of treatment, which has significant potential to shape local investment decisions.
Most importantly, the home secretary now chairs a cross-government board to drive this agenda forward. Her leadership, supported by the objective grassroots view of a newly appointed recovery champion, and underpinned by the willingness to hold local authorities to account (via PHE) for their delivery of key metrics, provides the best opportunity in a decade to address the complexity and scope of the problems facing service users and their communities.
An independent expert faculty has been set up to consider a vital new approach to commissioning. Mark Gilman, Paul Musgrave, Niamh Cullen, Terry Pearson and Chris Lee explain the context and the plan of action.
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Important progress in developing services for managing problematic opioid use has transformed the outcomes for people with serious drug problems. This has been achieved through a balance of innovation and careful allocation of resources.
Coming together as a group of commissioners with extensive experience, we needed to look at the pathway leading to these successes, to enable us to review the challenges facing us today. Our aim was to define questions that are central to the ongoing development of care.
This pathway to developing opioid dependence treatment may be divided into a series of stages, with defining characteristics:
Initial problems related to heroin
The 1950s saw increasing non-therapeutic opiate use, a trend which continued to grow throughout the 1960s. Early strategies to address dependence focused on prescribing opioid agonist medicines, with methadone a common and effective choice for many. Residential rehabilitation centres were set up following relatively unsuccessful results with outpatient treatment.
Exponential growth of the problem
Treatment approaches emerged in the 1970s. Prescribed methadone doses were often challenged and inpatient treatment duration limited in response to increased demand and financial pressures. Subsequent explosive growth of problem drug use in the 1980s and 1990s led to a resurgence in ‘maintenance prescribing’ and introduction of on-site dispensing facilities with supervised consumption. Treatment availability and coverage were lower than they are today, locally governed, commonly led by NHS specialists and funded to provide services in a relatively limited capacity.
Expansion in treatment
The National Treatment Agency was established in the 2000s with the aim of addressing the increasing problem of heroin use by improving treatment availability and reducing waiting times. More resources and organisational change gave rise to a competitive provider market, while new models of care were designed with an emphasis on performance management. Innovative thinking led to a step change in successful outcomes for people with problematic opioid use.
Evolution: a shift in focus
Recently the incidence of new heroin use has reduced. The existing cohort of approximately 150,000 people remains engaged with treatment services, with potentially greater needs related to comorbidity. The treatment system and method has evolved: policy has promoted focus on recovery-oriented and abstinence-based approaches, and concurrent mental health disorders have received greater attention. In parallel a step-down in resources has occurred in many locations, placing stronger focus on the need to achieve efficiency and cost-effectiveness in providing services.
Challenges today
While funding for treating opioid-related disorders is decreasing in many areas, there has not been an equivalent change in working practices to compensate. At the same time, drug-related deaths have been increasing in all four nations, linked to the ageing population and also unexplained factors. In many cases, services are essentially delivering less of the same, which is keeping the system ‘ticking over’. Looking to the future, it is relevant to consider if services are achieving the impact the population needs and deserves. And in parallel, how can we focus on innovation to maintain continuing improvement in outcomes?
There are a number of areas of innovation: use of digital technologies to provide psychological interventions, different forms of opioid agonist medications, and options to better address comorbidities such as hepatitis C virus (HCV) infection. It is important for commissioners to consider how innovation can play a role in continuing to improve care, while balancing budgets. There is already evidence of a new group of injectable opioid agonist therapies from various pharmaceutical companies which, if approved for prescription in UK, may allow treatment to be delivered with injections weekly or monthly.
Current spending with community pharmacies on medications, supervised consumption and dispensing is substantial. There may be opportunity to restructure services to allow direct supply of medications or on-site storage at clinics, allowing resources to be redirected. Understanding the balance between innovation and organisational change is key in this instance.
Evolving treatment options pose questions about the different ways in which therapy is tailored to the needs of the individual. In some cases, medications for opioid dependency are used chaotically as part of a wider cocktail of drugs; for others it is part of a long-term fluctuating but largely stable lifestyle, while for some it is a tool to help achieve recovery or abstinence. Do the services we commission build treatment systems with the ability to tailor interventions to the individual?
Questions may focus on whether all parts of treatment are employed to best effect – particularly psycho-social interventions. Do the treatment services we commission make the best use of the right kind of quality psychological and social therapies?
Considering future optimisation, commissioners should consider the readiness of the workforce providing care. Is the workforce appropriately skilled, and could a smaller number of competent staff be more efficient and effective? Is comprehensive training, supervision and support provided?
Collaboration is also key to future success. Do care pathways remain largely isolated from parts of the public sector that serve the same target audiences? Greater integration with mental health and housing services could help to reduce duplication.
Equally important is the approach to measuring performance. Do the outputs we measure as a part of the commissioning process tell us enough to improve health and wellbeing, while reducing offending and safeguarding fears?
Addressing questions such as these is key if continuous improvements in treatment and social outcomes are to be delivered while managing the balance of resources – an essential equation for commissioners in achieving continuing improvements in outcomes for all.
Key questions for commissioning
1. Planning based on individual needs
How can commissioning approaches assist providers in planning high quality support, by skilled staff, for groups with different aims, goals and characteristics? How can we improve outcomes while focusing resources effectively? We need to consider introducing case management functions and systematic commissioning for mutual aid.
2. New thinking and innovation
Consider how commissioning can build in new thinking to services which may reduce the need for resources directed to managing misuse and diversion risk, and ensure efficiency in medicines delivery – for example, by using innovative product formulations of opioid agonist therapy, which may not require resource intensive use of dispensing services or supervised consumption.
3. Integration and collaboration Can commissioning ensure that specialist services better align with partner services (mental health, housing, social services, probation, police, justice, etc), to avoid duplication, create efficiency and improve continuity of care? Can we align competencies systematically so that the right skills are used most efficiently?
4. Using the right measures
How can commissioners ensure a complete holistic assessment of impact, including real world measures of health, wellbeing, crime, safeguarding and resource utilisation? Commissioners need to make decisions based on insights from a broad set of outcome measures.
This article represents the authors’ personal views.
An effective review of commissioning will need input and inspiration from everyone involved – practitioners, commissioners, and especially those using services. DDN reports.
There have been many calls for a review of commissioning practice as budget cuts have sliced through services and severely curtailed treatment capacity. So the newly formed Expert Faculty on Commissioning’s consultation (page 10) is certainly timely. ‘The financial squeeze on drug and alcohol services will seriously undermine the quality and effectiveness of services,’ says Annette Dale-Perera, chair of the ACMD Recovery Committee, which at the end of last year announced that the commissioning structure needed an overhaul (DDN, November, page 7).
Annette Dale-Perera: Financial squeeze is undermining quality
The faculty’s review offers key questions for commissioning, asking how we can ensure skilled staff are providing high quality support, incorporate innovative thinking, make sure that services are well integrated with partner support services, and consider whether we are using the right outcome measures.
The question of staff skills and training is being addressed by the Federation of Drug Alcohol Practitioners (FDAP), which is now administrated by SMMGP. Interim executive director Kate Halliday explains that FDAP has been developing an apprenticeship for the sector to drive up standards. A ‘trailblazer group’, including major employers in the field, is putting forward a proposal to the Institute of Apprenticeships for a Drug and Alcohol Practitioner Apprenticeship level four qualification.
Kate Halliday: FDAP’s apprenticeships will bring exciting prospects for workforce development
The standardisation of training for drug and alcohol practitioners represents an exciting time for workforce development in the sector, says Halliday: ‘We can hope to see an improvement in the provision of services, the retention of staff and the encouragement of new talent to the field.’ FDAP hopes that the first apprenticeship courses will be ready for roll-out in 2019.
The question of adopting more innovative commissioning practice depends on ‘a fluid dialogue between commissioners and those at the front delivering the services,’ believes Yasmin Batliwala, chair of WDP – whose organisation, alongside Blenheim and Addaction, supports the Drugs, Alcohol and Justice Cross-Parliamentary Group. The group’s recent Charter for Change called for the creation of a national commissioning ombudsman to address failures in commissioning practice.
Yasmin Batliwala: More innovative commissioning depends on a fluid dialogue
‘By establishing firmly this culture of transparency, the often-byzantine process of allocating funding is made that little bit simpler,’ she says. On the one hand commissioners are put at ease, safe in the knowledge that the money is going to dedicated experts and professionals, and on the other, it instils confidence in the providers on the front line, ensuring that they remain valued and supported.
Blenheim’s interim chief executive, Deborah Jenkins, acknowledges that innovation is difficult when commissioners are under such huge pressure to do the best they can, with continuing levels of disinvestment against a rising number of service users. She sums up the ‘lose-lose situation for commissioners, providers and most importantly service users’, as ‘tenders are issued where it is just not possible for even the leanest organisation to deliver’.
‘Commissioners are facing extremely difficult choices about where to cut back,’ she points out. ‘Do they cut back on needle exchanges, which are perhaps an easy choice but which would lead to wider public health risk of an increase in blood-borne viruses such as HIV and hepatitis C? Do they try to commission innovative digital services which, while largely unproven, are cheaper than face-to-face services and don’t require the overheads of premises? Do they decommission the wrap-around employment, training and education programmes that are designed to help people integrate back into society, sealing that final step on the recovery journey, and without which relapse is highly likely? Or do they cut back on children and young people’s services, where the interventions have the greatest possible lifelong impact for service users and their families?’
Deborah Jenkins: Commissioners need to think laterally, focusing on the return on investment
There is no easy answer, she acknowledges, as all these services are crucial in providing highly effective drug and alcohol support services. But her suggestion is that commissioners think laterally, focusing on the return on investment to the wider economy. And yes, she believes there is scope for a more innovative approach.
We need to ask ourselves whether there are better ways of commissioning drug and alcohol services, she says, such as ‘commissioning jointly with CCGs who are responsible for mental health, with police for prevention of drug and alcohol-related crime, and with housing departments.
‘The same vulnerable and high-risk cohort of people appear in the pathways across all these organisations, so let’s take a people-centric approach and a joined-up view of how to address the problem and complexity surrounding substance misuse.’
‘Successful peer-led initiatives take time
and commitment to design, implement
and grow, and like roses are difficult to
revive if allowed to wither and die.’
The question of integrating services has to take service user involvement as its starting point, believes Tim Sampey, founder and chief executive of the peer-run service user charity Build on Belief.
A lot has changed in service user involvement in the past decade, with peer-led initiatives springing up all over the country – ‘Build on Belief and the FIRM in London, Red Rose Recovery and the Recovery Republic in the north of England, SUIT in the Midlands, to name but a very few,’ he says.
‘In the past couple of months, the importance of these service user initiatives has been the focus of both the APPG Complex Needs and Dual Diagnosis People powered recovery report and the EMCDDA paper, User-led interventions – an expanding resource? But where do they sit in the commissioning framework?’
Tim Sampey: Service user involvement needs to be built into tenders
In too many instances, peer-led initiatives are not written into the tender specification at all, he says – or if there are, they are levered into service provision as ‘added value’. In such cases, the specification is often ‘so fuzzy it risks becoming meaningless’, with the vast potential to add valuable layers of peer support and aftercare completely missed.
The practice of ‘whole system commissioning’ excludes many peer-led organisations with strong track records, who are formally constituted as CICs or charities, from taking part in the tendering process unless they can subcontract their services to a major provider, he points out. He acknowledges that some of the big treatment providers have been highly supportive of such organisations over the past few years, but adds ‘the buy-in is not universal, and there are those who think it both cheaper and less risky to keep everything in house.’ And while some projects are directly commissioned by local authorities, ensuring their independence, ‘this practice is not as widespread as it should be,’ he says.
Sampey does, however, have news about a different approach that he hopes will become more widespread. ‘In the past year, two small contracts were put out in Southwark and Medway separately from the main service provision tender, with the specific intention of attracting smaller, bespoke organisations,’ he says. ‘It’s too early to say if this is the beginning of a trend, or an exception to the rule, but such initiatives are far-sighted and welcomed.
‘I’ve also heard stories, mostly from the Midlands and the north of England, of commissioners protecting small peer-led initiatives by making it clear that they must be supported by whichever main provider wins the contract,’ he adds.
He sees this as good practice. ‘Successful peer-led initiatives take time and commitment to design, implement and grow, and like roses are difficult to revive if allowed to wither and die. Clearer provision for them in overall tender specifications, smaller bespoke commissioning, and protection for existing services in whole system commissioning would go a long way to ensuring that a lot of the effort, innovation and creativity put into the wider service user involvement agenda over the past decade is not lost.’
As Sampey points out, working with service user networks is invaluable in informing consultation documents and strategy papers around complex needs. An important factor in getting this right is to connect effectively with the many other support services, rather than commissioning for substance misuse as a separate entity.
‘The drug strategy acknowledges that the drug strategy in isolation can’t deliver the changes that most people need in their lives – the need to incorporate changes around employment, accessing mental health and physical health services, offending, domestic violence, and caring for your children,’ says Paul Hayes, head of Collective Voice and former head of the National Treatment Agency (NTA). ‘Drug treatment makes a vital contribution to all of those things, but in isolation won’t address any of them.’
Paul Hayes: Drug treatment cannot be delivered in isolation
Commissioning will need to be informed by broader measures than relying solely on the Treatment Outcomes Profile (TOP), he points out. ‘Just as a whole range of services need to be available to people with drug and alcohol problems, so outcome measures need to reflect what’s happening to people’s lives with broader communities, within all of these domains,’ he says.
‘TOP is an excellent way of identifying the progress an individual is making towards addressing a number of those issues, but in isolation can’t tell the whole picture about the impact of drug misuse, or its cumulative impact, along with other services, for whole communities.’
The DDN conference on 22 February will give the opportunity to get involved in the commissioning consultation.
This article has been produced with support from Camurus, which has not influenced the content in any way.
Almost 95 per cent of cannabis seized by police in 2016 was of a high potency variety, according to a report from King’s College, London and GW Pharmaceuticals. Researchers analysed almost a thousand police seizures across the country and found that 94 per cent were of strong ‘skunk’ sinsemilla, compared to 85 per cent in 2008 and just over half in 2005.
Increase in potency is significent risk to mental health, says report’s author Marta Di Forti
The study, published in the Drug Testing and Analysis journal, found that the stronger varieties’ market dominance was the result of lack of availability of weaker cannabis resin, which could account for as little as 1 per cent of the product in the London area. While cannabis resin is usually rich in cannabidiol (CBD) – thought to help moderate some of the effects of the psychoactive component THC – this is often absent from sinsemilla. Stronger cannabis strains are thought to be a contributory factor to increasing first-time admissions for drug treatment, says the study.
‘In previous research we have shown that regular users of high-potency cannabis carry the highest risk for psychotic disorders, compared to those who have never used cannabis,’ said senior author Dr Marta Di Forti. ‘The increase of high-potency cannabis on the streets poses a significant threat to users’ mental health, and reduces their ability to choose more benign types.
‘More attention, effort and funding should be given to public education on the different types of street cannabis and their potential hazards,’ she continued. ‘Public education is the most powerful tool to succeed in primary prevention, as the work done on tobacco has proven.’
The Scottish Government has confirmed that it will recommend the country’s minimum price per unit of alcohol be set at 50p, following the results of a public consultation. Minimum pricing is set to come into force on 1 May, after a five-year legal battle with the drinks industry (DDN, December/January, page 4), and the 50p recommended price will now be laid before parliament.
The consultation received 130 responses, almost equally split between organisations and individuals. Nearly three quarters of those who commented on the 50p price were supportive while 17 per cent felt it should be higher and 5 per cent thought it should be lower.
Shona Robison: This move will save thousands of lives.
‘I am grateful to everyone who took the time to respond to the consultation on our proposed minimum price per unit of alcohol and I am happy to confirm that we will be moving forward with our recommendation of 50 pence,’ said health secretary Shona Robison. ‘With alcohol on sale today in some places at just 16 pence per unit, we have to tackle the scourge of cheap, high-strength drink that causes so much damage to so many families. This move will save thousands of lives.’
Scottish Liberal Democrats leader Willie Rennie, however, has called for the price to be set at 60p to reflect factors such as the impact of inflation.
‘In excess, alcohol wrecks lives, families and communities,’ he said. ‘Low prices for decades have increased that harm caused in Scotland. Inflation has eroded the value of the original minimum price during the years that this policy has been caught up in the courts. That is one of the reasons why Scottish Liberal Democrats pressed the Scottish Government to introduce a higher rate but ministers have bottled it. With hospitalisations on the rise, we need to see the Scottish Government do far more to tackle the scourge of alcohol abuse.’
Meanwhile, a new report from the University of Sheffield’s alcohol research group, commissioned by the Welsh Government, has found that three quarters of all alcohol drunk in Wales is consumed by less than a quarter of the population, with just 3 per cent of harmful drinkers consuming 27 per cent.
Nearly 40 per cent of all alcohol bought in Wales is sold for less than 50p per unit, it adds. Last year’s Public Health (Minimum Price for Alcohol) (Wales) Bill (DDN, November 2017, page 4), is set to introduce minimum pricing if passed by the National Assembly for Wales.
‘People who drink alcohol at hazardous and harmful levels drink 75 per cent of the alcohol consumed in Wales,’ said health secretary Vaughan Gething. ‘The report shows the greatest impact of a minimum unit price would be on the most deprived harmful drinkers, while moderate drinkers would experience only small impacts on their alcohol consumption and spending.’
Effective treatment starts with a meaningful partnership, says Dr Steve Brinksman.
We recently had a new doctor join our practice who had worked elsewhere for a number of years. I was chatting to her about how she was settling in and interested to hear that she felt the biggest difference was that we were a genuine partnership working together, whereas where she worked previously she’d felt that she’d been a partner in name only.
This led me to ponder on the many occasions we are in situations with clients that are essentially unequal in terms of who holds the power, and how this can cause dysfunctional relationships. Sometimes this is due to pushing back against perceived authority, and sometimes from complete passivity – neither of which is likely to produce the best outcomes.
Gary had been in and out of treatment for years; he knew more about substance use and misuse than most doctors and he knew it. However he also frequently used on top, was in and out of prison, and was hep C positive. He had dropped out of treatment with the community treatment agency about six months before registering with us.
The first time we met I let him talk, and the second and probably the third and fourth as well, then gradually we started to explore what had happened in his life and what he really wanted. By now he was on 60mls methadone and still using heroin and crack a couple of times a week. I was keen that he increased his medication dose to see if we could stop the on-top use; he wasn’t.
Despite his bravado and subject knowledge about street drugs it became apparent that he had very low self-esteem and that this was tied in with his poor literacy. We have an excellent adult education college in Birmingham and with a little encouragement he eventually contacted them and started a course to improve this.
The change in Gary was profound. He started to develop real confidence, rather than just a front. He met people who had struggled like him, and who like him were looking to make a positive change. He stopped his own ‘use on top’ without ever agreeing to an increase in medication dose.
I thought I knew what was needed for Gary from a medical perspective, and yet what was really needed was for us both to form a real partnership where he had the confidence to talk openly about what mattered to him and I listened and helped him achieve his goals.
Whatever our professional role may be, the balance of power seems heavily stacked in our favour by those we see. We need to realise this and make an extra effort to develop meaningful partnerships that facilitate change rather than impose it.
Steve Brinksman is a GP in Birmingham, clinical lead of SMMGP, and RCGP regional lead in substance misuse for the West Midlands. He will be speaking at the DDN Conference on 22 February.
A new project is helping steroid users to recalibrate their lives while providing evidence for better treatment, says Jody Leach.
At Open Road we launched a project – Steroids, Weights, Education And Therapy (SWEAT) – in 2017 in direct response to the growing number of steroid users accessing our needle exchange programmes across Essex. SWEAT is funded by The Big Lottery and tackles the increasingly complex needs of those using image and performance enhancing drugs (IPEDs). The service is based in needle exchanges, where steroid users are first identified, and offers support to those who are using, thinking about using, or have previously used IPEDs.
We work alongside local gyms and pharmacies to promote our SWEAT contact points, but the project goes way beyond generic needle exchange provision. We ensure access to specialised psychosocial interventions, harm minimisation programmes and educational resources to dispel myths and promote understanding of the potential side effects and long-term harm of IPED use.
Our project guides clients through post-cycle therapy (PCT), good diet and nutrition, training regimes and sleep, to support them in making informed decisions about steroid use. A combination of one-to-one sessions with specialist workers and formal in-house counselling allows them to explore their motivators for using and the impact this lifestyle could be having on their mental health and relationships.
SWEAT is a three-year project and will be formally evaluated in collaboration with the University of Essex, with the intention of informing IPED-specific service provision at both local and national level. In April we will be running a conference, ‘A Shot in the Dark’, to bring together experts, practitioners and support services to learn, inform and share their expertise in IPEDs and to hear about the impact of our project in its first year of operation. Among the speakers will be Prof Jim McVeigh, director of the Public Health Institute at Liverpool John Moores University.
‘The use of anabolic steroids and other IPEDs amongst the general population is now a recognised public health issue,’ he says. ‘However, there are few services providing and evaluating interventions for this population. While some of those beacons of good practice remain, others have fallen victim to the current funding crisis. The SWEAT Project is an exception and an important development, not just for the population it serves, but in generating evidence of effectiveness.’
There are many health implications associated with IPED use, with physical risks ranging from superficial harms such as acne and balding, through to sexual dysfunction, cardiovascular disease and impaired liver function. Injecting-related harms are a potential feature of steroid use, with site swelling, abscesses and exposure to blood-borne virus infection being possible. Users’ mental health can be impacted in varying degrees, with changes in mood, levels of aggression and an impact on general psychological wellbeing relating to existing body image and/or self esteem conditions.
IPED users rarely view their behaviour as being similar to users of other substances. This mindset results in many users being reluctant to access any formal treatment services outside of generic needle exchange programmes. Consequently, IPED users are less likely to recognise and acknowledge, let alone address, the potential risks and behavioural issues associated with this group of substances. Jody Leach is SWEAT project manager and quality coordinator at Open Road
‘It helped me help myself’
Most other services just give you your needles, but SWEAT actually listened, says Justin
Justin was a long term steroid user. During 20 years of use, he recognised that steroids were having serious negative effects on his life but he was afraid of letting go of the habit and he didn’t know how to stop. In particular he feared damaging his relationship with his wife and young family, if his image changed.
Justin constantly feared losing respect from his children – they were proud of his hulk like figure, often asking him to ‘show off his muscles’ to their friends – and he was afraid of how they would feel about him if he stopped using steroids became just an ‘ordinary dad’.
He also felt that his steroid abuse was affecting his libido but did not know how to tell his wife for fear that she would feel it was her fault. He had been using steroids for so long he feared that, even if he stopped now, it was too late for his testosterone levels to return to normal and he worried about any withdrawal effects on his mental health. Justin knew he got the short term boost from steroids he needed, but he also realised it was time to stop.
Justin discussed his options with the SWEAT worker and we looked into ways to boost testosterone naturally through diet, workout regimes and mind-set. We then looked at how to reduce his dependency and eventually cease his current cycle of behaviour. We discussed what his side effects or ‘come down’ may be, to prepare him.
As Justin’s testosterone levels started re-balancing, he was ready to cope with the low moments and he stuck with the programme. A new healthy diet and workout regime meant, to Justin’s surprise, that his testosterone levels began to return to normal after a few months – he even kept most of his ‘pumped-up’ physique.
He also conquered all the self-doubt and re-built his self confidence. His relationship with his wife is now more honest and fulfilled, his children are even prouder of their father, and he spends more time with them now because he is no longer obsessed with weight training. And he’s no longer feeding dodgy suppliers with cash that should be spent on his family.
‘SWEAT is the first service that actually listened to my needs and understood the difficulties behind my steroid misuse,’ he said. ‘Most other services just give you your needles and don’t ask how you are.
‘The team gave me hope and helped me help myself into a sensible diet and fitness routine, and I would probably still be using now with no way out, if I hadn’t found them.’
Open Road’s conference, ‘A Shot in the Dark: Steroids, IPEDS – the hidden harm’ is on 26 April in Colchester, Essex. Details and booking here
Shocked by cases in his constituency, Bambos Charalambous MP is calling for government action on Xanax.
The powerful sedative Xanax is being used by young people across the country (DDN April, page 6). Some are taking it to self-medicate to cope with anxiety, while younger teenagers are being groomed and exploited by drug dealers taking advantage of the drug’s ‘zombie-like’ effects.
On 15 January, Xanax was mentioned for the first time in the House of Commons chamber. I held the debate to bring to light a disturbing case of a 14-year-old girl in my constituency who had become hooked on the drug. Her mother had contacted me shortly after I was elected to ask for my help and this was the first time I had heard of Xanax. I then became aware of how widespread its use is.
For the next six months, I pretty much asked every young person that I met if they had heard of Xanax. They almost laughed in my face at my ignorance and I’ve since been instructed to use the word ‘Xanny’. I’ve now listened to more rap music than I ever thought I would and was utterly shocked by the selfie Youtube video shot just six hours before the death of Lil Peep from a Xanax overdose.
Some young people in their early twenties told me that they easily buy Xanax online for as little as £1 a pill and use it to self-medicate for their anxiety. This is worrying enough, but the case of my 14-year-old constituent is far more sinister. Zoe (not her real name) was a bright and popular girl with lots of friends, but after she was approached by an older girl at her school and an ex-pupil, she started going to private raves and parties in houses across North London. She was swept up in a whirl of excitement by this new lifestyle and was introduced to Xanax, mixing it with alcohol and becoming sedated.
Zoe would go missing for whole weekends and would come home with marks and bruises on her arms and legs with no recollection of how she got them. The vulnerable state that Xanax puts users in leaves them extremely vulnerable to abuse, and who knows what happened to Zoe – she certainly can’t remember. On some occasions, Zoe became aggressive towards her mother and after a fraught evening she ended up spending the night in a police cell. Again, she had no recollection of any of this.
Despite help from the police and abduction warning notices that were served on six people, Zoe was now being heavily groomed. ‘Baggies’ were hidden in Zoe’s bedroom and things took a turn for the worse when Zoe and her best friend were found in a mess on the school premises after taking Xanax. Zoe wasn’t excluded and was allowed to stay on at school with some extra support services. Zoe’s mother, and the school tried their best but she was still able to get hold of dirt-cheap Xanax, peddled by a dealer from a booth in a McDonalds restaurant right next to a police station. All the information that had been pieced together was passed on to the police who arrested three people on drug-related charges in December. This was not before Zoe and her best friend were found to be drunk on the school premises and then permanently excluded from school.
Whether the glamourisation of Xanax use is a matter of art imitating life or life imitating art, the problem is certainly a real one in the UK. The truth is that there is a cultural and age divide and, for whatever reason, the fact remains that Xanax is the drug of choice for some young people. Maybe it’s because it helps numb the pain, maybe it’s because it is fashionable, maybe it’s because it is cheap and easy to get hold of – I can only speculate. I’ve called on the government to research the prevalence of Xanax use in the UK, to raise public awareness about the effects and potential harms and to provide specialist support for those who have developed a dependency.
A range of proposed harm reduction measures to cut drug-related crime and deaths, and reduce costs to public services, has been set out by West Midlands police and crime commissioner (PCC) David Jamieson. They include prescribing heroin in a medical setting for people who have not responded to other forms of treatment, establishing a formal scheme to divert people away from the courts and into treatment, and ‘considering the benefits’ of consumption rooms.
Other measures in the PCC’s report include joining up funding streams for police, public health and community safety to increase efficiency, introducing on-site drug testing in the night time economy, and equipping and training police in the use of naloxone. More money could also be seized from large-scale drug dealers to invest in treatment, it says.
Half of all burglary, theft, shoplifting and robbery in the region is thought to be committed by people with serious drug issues, at a cost of £1.4bn per year. Jamieson’s announcement follows similar proposals from other PCCs including those for Durham (DDN, March 2017, page 4) and North Wales (DDN, September 2017, page 5).
‘Despite the good work being done by many, collectively our approach to drugs is failing,’ said Jamieson. ‘It means people are forced to live with more crime, public services are put under strain and not enough is done to reduce the suffering of those who are addicted. If we are to cut crime and save lives there’s one thing we can all agree on; we need fresh ideas. These are bold but practical proposals that will reduce crime, the cost to the public purse and the terrible harm caused by drugs.’
Jamieson wanted to see many of the measures ‘in place and having an effect’ by the end of his term of office in 2020, he said. ‘I will be working with partner organisations intensively over the coming period to deliver on these practical and common-sense proposals.’
The announcement has been welcomed by organisations including Release, Transform, the Association of Police and Crime Commissioners and the Royal Society for Public Health (RSPH). The recommendations were an ‘important and welcome contribution to the growing momentum behind common sense drug policy reform in the UK’, said RSPH chief executive Shirley Cramer. ‘Health professionals, police, and the public are all agreed that a public health – rather than criminal justice – approach to drug policy is what is needed to tackle rising rates of drug harm in this country and beyond. It is heartening to hear more influential voices, with on the ground experience of these issues, give these measures their backing.’
The measures ‘would undoubtedly save lives if implemented’, added Release executive director Niamh Eastwood. ‘Yet again, the police are leading the way in the debate for drug policy reform while the government continues to pursue the failed approach of prohibition and criminalisation. The government must consider the insight of police officers, many of whom are on the frontline of the so-called war on drugs, witnessing the horrific impacts that prohibition has on communities every day.’
Thank you to everyone who made the conference a success. Watch this space for photos, video and our special conference issue of DDN!
Here’s what happened on the day…
DDN conference, 22 February 2018
The New Bingley Hall, Birmingham
9.00-10.00am – Registration
10.00-11.15am – Opening session. Chair: Claire Brown, DDN editor Welcome, setting the scene, making the most of your day. Introducing the ‘Get Connected’ theme and the DDN ‘Wider Health’ initiative.
Treating the whole person: Stacey Smith looks at addressing linked conditions and better healthcare through a journey of hepatitis C treatment.
Finding the right match: Sue McCutcheon considers screening, outreach and getting into treatment, whatever the health need.
It takes two – the unwritten contract of mutual respect: Nick Goldstein shares experience of communicating effectively with healthcare professionals to get the best from the therapeutic relationship.
What a team: Dr Steve Brinksman explores the best kind of patient-doctor alliance.
11.15-11.45am – Refreshments
11.45-1.00pm – Session two
More than bricks and mortar: James Graham shows how supported housing can open so many doors.
Current data on prevalence and harms, and your experience on the ground: Session led by Pete Burkinshaw and a team from PHE. This session will give an overview of some of the key data and engage you in an ongoing conversation about trends and causes, and whether the data reflects your experience.
We’re listening to you: an interactive session with the Faculty of Commissioners on planning addiction care services for the future. With Mark Gilman, Terry Pearson, Paul Musgrave and Kerrie Hudson.
1.00pm- 2.30pm – Lunch and networking. Enjoy the amazing DDN Exhibition, with information, expertise, and peer-led support groups. Special features include dedicated zones for health, training and employment, support and advice, and wellbeing; naloxone training and kits; and taster therapy sessions.
2.30-4.00pm – Session three
Returning to learning:Dot Turton explains the dynamic initiative called collegiate recovery, helping students in higher education to thrive.
Thinking about drinking: Ben Parker and Chris Campbell explain their pathways for reaching clients with harmful alcohol use in their homes, so they can start their wellness journey whatever their health problems.
Get connected!: Sunny Dhadley shares inspiration on how you can make the most of potential to widen your horizons.
Co-production and partnership working can help organisations thrive in troubled times. DDN hears from the MD of Equinox Care and Penrose Criminal Justice Services, Kelly Hallett.
‘As a sector we can still do more to work together to find better or more innovative ways of pooling resources and supporting people,’ says Kelly Hallett. ‘Certainly one of my priorities is to identify more opportunities for us to be building these relationships and combining expertise.’
Joined-up working is a subject she knows quite a bit about – late last year she was appointed MD of Equinox Care and Penrose Criminal Justice Services, both of which are part of the Social Interest Group (SIG), which was established as a charity in 2014. ‘At the time Equinox was looking for a merger partner and Penrose wanted to build a much stronger infrastructure, which it couldn’t afford on its own,’ says Hallett. ‘SIG was the answer.’
The group now includes five charities, and provides the framework to support them and help develop their strategies. This means organisations can remain true to their charitable aims and retain their own boards while benefitting from being part of a ‘much bigger picture’, she explains. ‘It’s about strengthening our charities by opening up opportunities to freely learn from each other and innovate, working closely together and remaining financially robust enough to enjoy the back-office services that they could not have achieved on their own.’
The new MD role offers the opportunity to ‘lead two charities as businesses that truly care about individuals’ recovery and rehabilitation’, she says. ‘I have great ambitions for Equinox, Penrose and our service users.’ She’d worked at Penrose for more than six years, rising to director of operations and director of criminal justice services, before taking on the current role. Before was Turning Point – first as regional manager for Kent and then assistant director for substance misuse – and before that a period in prison drug treatment. ‘I started as a volunteer, progressing to CARAT worker, CARAT manager and then eastern area manager, overseeing 11 drug treatment services in prisons across the East of England,’ she says.
So was the drugs sector something she’d always been interested in? ‘Not specifically. I always knew I’d work with vulnerable people and I always had an interest in prisons. Many years ago I worked with the elderly, then I had a temp job in a prison doing admin which gave me the opportunity to be introduced to the prison substance misuse team. I started volunteering with them in 2003, which led to a job within the team – this field has captivated me from day one, and I’m still very grateful to have been given that volunteer position.’
Drug treatment in prisons is obviously facing hugely challenging times, with the consequences of the dramatic increase in NPS use making regular headlines. What could be done to improve treatment provision in the current climate? ‘I think that whilst there are some excellent examples and outcomes out there, there are still many challenges to providing effective, choice-based treatment,’ she says. ‘The cuts to funding and staffing are well known, and the environment itself is restrictive – prisons are facing their own challenging times. Access to, and movement of, prisoners is not always easy, and prison regimes often mean that it’s hard for meaningful activity to take place – boredom and lack of daily structure can be very demotivating.’
Despite all the evidence showing that ‘safe environments improve outcomes’, access to specific resettlement, wellbeing or drug-free wings isn’t always an option, she points out. ‘And we need to think about where we locate offenders post-treatment within a prison setting.’ Healthcare-led models can also dilute the emphasis on treating substance problems, she adds. ‘The focus on overall wellbeing is welcome – we know that offenders will almost always have many needs – but it does mean that there are fewer opportunities for intensive treatment for offenders. I think every positive outcome achieved in a prison is a testament to the skill and dedication of the support provider.’
In terms of the specific challenge of NPS, their use has changed the prison landscape ‘significantly, if not completely’, she states. ‘There isn’t an easy answer. Availability is high, it’s difficult to detect, and it makes an already difficult environment even harder in terms of treatment and – from a prison perspective – control.’
Education around the risks and effects needs to be dramatically stepped up, she stresses, with the allocation of dedicated resources alongside more action to interrupt supply. ‘It should be a top priority – the introduction of NPS has created the perfect storm, and I don’t think we saw it coming in time to be anything other than reactive.’
A key concern that predates the NPS crisis is the crucial period immediately after release, when the risk of overdose can be high. What kind of support should organisations be putting in place? ‘We know from experience and data that the take up of treatment post-release is lower than anyone would like, and there are many ways it could be improved,’ she says. ‘We’re still in the position where a great many offenders across the country walk out of the gate on release alone, and that can be scary – no matter how many appointments have been made – and transition between support and/or treatment agencies can be particularly hard for some.’
Many prisoners will have multiple needs to address, and little support when it comes to safe and positive influences – just trying to navigate services can feel overwhelming. While peer support and ‘meet at the gate’ services can undoubtedly be effective they remain underfunded, and those that do exist struggle to meet the demand. ‘A true through-the-gate model that holistically supports offenders through that first few weeks would be welcomed by many agencies,’ she says. ‘Then there are the challenges of working effectively with someone who may only be in prison for a few weeks, or remand prisoners who come and go so quickly and yet can have the highest needs.’
Our current sentencing system also means we’re ‘still sending far too many offenders to prison for short periods’, she says, which mainly serves to ‘disrupt already unstable lives further’. Far more people would benefit from intensive drug and alcohol treatment, mental health treatment or both, she states. ‘I am determined for Penrose Criminal Justice Services to successfully develop and promote alternatives to prison for this cohort – and we haven’t even touched on the need for safe and secure accommodation.’
When it comes to populations whose needs have traditionally been under-served by the sector perhaps the most obvious is women, and part of her remit was to set up a residential complex needs service in Brighton, which opened last month. How important are specialised services like this in the sector? ‘There’s such a need for female-specific services,’ she says. ‘Demand for our service is high, and that’s just three weeks in. These services are essential, and there need to be more. We’ve been able to create a safe, female-only environment, and all of the evidence shows us that when women feel safe and are appropriately supported they achieve greater independence and higher self-esteem.’
The women in the service have ‘multiple and very complex needs,’ she continues. ‘Lots of emotion, lots of trauma – domestic violence and exploitation is a prevalent need – and all of our residents have chosen our service because it’s female only. That speaks volumes in itself. Women in our service are able to articulate themselves away from stigma, away from control, and reflect. They’re supported with all individual needs within the service, including those who have children, and what we can’t provide ourselves we bring in. Brighton has some amazing partnership working, some of the best that I’ve seen anywhere – there’s clear progression within the service towards independent living and this gives our women hope. I definitely plan to develop more female-only services in the near future.’
As someone whose experience covers substance use, offender services, mental health and more, how far has genuine joined-up working become a reality? ‘I think things have improved, but there’s still a long way to go,’ she says. ‘Again, there’s a mix of examples in the field, from excellence to non-existence. It’s always troubling when we meet service users who have failed in recovery or resettlement simply because they couldn’t navigate, or find cohesiveness between, community support services. Just a few months ago I was talking to a service user who had had eight assessments from different services in ten days. Is this really where we still are?’
The flipside of that is the excitement that comes with seeing great services or innovation, however. ‘I come away thinking “I want that!”’ she says. ‘It’s not always reflected in data – what I want to see is the tangible impact. I hope that one day health and social care can be used in the same sentence in a much more meaningful way. They’re all too often miles apart.’
The answer ultimately lies in ‘truly joining things up solely to the benefit of service users, co-producing services and improving access using their experience – they really do know best’, she states. ‘To see that across the board would be phenomenal. It’s actually one of the biggest strengths of the Social Interest Group – we have all of that expertise under one umbrella and we can work in a very cohesive way to offer more joined-up services, but it’s more than just us.’
So what sort of strategies should the voluntary sector be adopting generally in these challenging times? ‘Co-production and partnership working – there are so many great organisations out there, and many examples of organisations really strengthening their offerings to service users by joining forces.’ Funding keeps going down while demand keeps going up, and there’s ‘still a lot of duplication in what we do and how we do it’, she says. ‘We could be working together in a much more powerful way to influence and deliver real change in the sector – both locally and politically. We’re so good at what we do – our voices should be heard more.’
Targeted training leads to a ‘significant increase’ in the delivery of alcohol brief interventions in primary care, according to new research. Specifically trained nurse mentors are able to play a key role in leading and delivering interventions and brief advice (IBA), says the study, which was funded by Alcohol Research UK and conducted by SMMGP.
Even provision of a ‘relatively low level of support’ to nurse mentors can lead to a significant increase in the delivery of IBA, it says. Supporting nurse mentors to lead on their implementation can help reduce alcohol-related harm ‘within existing resources’ in primary care settings, while awareness raising and training across the practice also help staff become better at both identifying harm and providing effective advice to those at risk.
NICE guidelines urge the prioritisation of IBA as an ‘invest to save’ measure, as around one in eight ‘higher or increasing risk drinkers’ receiving it go on to lower their consumption levels. However uptake in primary care has been patchy through a combination of issues such as perceived lack of staff support, confidentiality concerns, low levels of monitoring and a feeling among professionals that they lacked the necessary knowledge, skills and ‘role legitimacy’.
‘The primary care team has great strengths in identifying, assessing and preventing health harms,’ said the study’s lead author, Dr Steve Brinksman.
Dr Steve Brinksman: potential for reducing alcohol-related harm within existing resources of the surgery
‘By supporting nurse mentors in leading on the implementation of IBA there is potential for reducing alcohol-related harm within the existing resources of the surgery. This could support primary care in the practical implementation of an evidence based cost effective intervention which has experienced patchy uptake.’
‘Alcohol brief interventions are a key component in helping to identify people at risk of alcohol harm and in giving them the best advice to reduce that risk,’ added Alcohol Research UK’s director of research and policy development, Dr James Nicholls. ‘But, despite the benefits, such interventions are not always implemented effectively. This research shows that with improved leadership, knowledge and training, alcohol brief interventions can bring about important benefits in primary care settings to those drinkers who are experiencing alcohol-related harm.’
There were 82,135 hospital admissions with a primary or secondary diagnosis of drug-related mental and behavioural disorders in 2016-17, according to figures from NHS Digital, up from 81,904 the previous year. The total is nearly double the 38,170 figure from a decade ago, although NHS Digital says this increase will be ‘partly due to improvements in recording of secondary diagnoses’.
The number of admissions with a primary diagnosis of drug-related mental and behavioural disorders, however, was down by 12 per cent in 2016-17, to 7,545, although that figure is still 12 per cent higher than a decade ago.
The figures are from the ‘hospital episode statistics dataset’ section of NHS Digital’s annual Statistics on drugs misuse report, which is a compendium of new and previously published data. Around a third of people admitted for drug-related mental and behavioural disorders were in the 25 to 34 age group, while just over a quarter were aged 35 to 44. Three quarters of those admitted were male, with the highest admission rates in Liverpool and Hull. The highest admission rates for a primary diagnosis of poisoning by illicit drugs were also found in the 25 to 34 age range, the report states.
Karen Tyrell: Harm reduction must be taken seriously
‘People with both mental health and substance misuse issues can find it extremely difficult to access mental health services,’ said Addaction spokesperson Karen Tyrell. ‘All too frequently mental health services refuse treatment because a person is not abstinent, or has not been abstinent for a sufficient length of time. This is despite government guidance and best practice. Getting people connected with community services at an earlier stage could prevent hospital admissions.
‘It’s positive that the numbers have come down over the past year, but we know that there is still a long way to go before they could be said to be acceptable. Harm reduction must be taken seriously and services such as needle exchanges must be adequately provided across the country.’
We could be about to see a big upsurge in crack use – but are we ready for it? How seriously should we treat the reappearance of ‘crack horror’ warnings? In this month’s cover story, Kevin Flemen suggests a pragmatic response.
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Older people with substance issues face a ‘complex constellation of risks’, the report says, which can result in presentation to a wide range of services including drug and alcohol treatment, primary care, acute hospitals, older people’s mental health, social care, housing, criminal justice and the voluntary sector – in many cases ‘the staff in these settings have little specialist knowledge of how to deal with such complexity’, it adds.
Brexit continues to dominate mainstream debate. But far more important to most people, particularly the poor, the marginalised, and the ‘left behind’ is the cumulative impact of years of austerity and the continuing failure of the economy to grow.
Below are six of the key challenges facing the drug and alcohol treatment system during 2018. As the government recognised in last year’s drug strategy, truly effective interventions depend on their cumulative impact. People need adequate access to physical and mental health treatment, a realistic prospect of a job, a safe place to live, and enough income for food and clothing.
The Scottish Government has confirmed that it will recommend the country’s minimum price per unit of alcohol be set at 50p, following the results of a public consultation. Minimum pricing is set to come into force on 1 May, after a five-year legal battle with the drinks industry (DDN, December/January, page 4), and the 50p recommended price will now be laid before parliament.
We recently had a new doctor join our practice who had worked elsewhere for a number of years. I was chatting to her about how she was settling in and interested to hear that she felt the biggest difference was that we were a genuine partnership working together, whereas where she worked previously she’d felt that she’d been a partner in name only.
At Open Road we launched a project – Steroids, Weights, Education And Therapy (SWEAT) – in 2017 in direct response to the growing number of steroid users accessing our needle exchange programmes across Essex. SWEAT is funded by The Big Lottery and tackles the increasingly complex needs of those using image and performance enhancing drugs (IPEDs). The service is based in needle exchanges, where steroid users are first identified, and offers support to those who are using, thinking about using, or have previously used IPEDs.
SWEAT is a three-year project and will be formally evaluated in collaboration with the University of Essex, with the intention of informing IPED-specific service provision at both local and national level. In April we will be running a conference, ‘A Shot in the Dark’, to bring together experts, practitioners and support services to learn, inform and share their expertise in IPEDs and to hear about the impact of our project in its first year of operation. Among the speakers will be Prof Jim McVeigh, director of the Public Health Institute at Liverpool John Moores University.
Justin was a long term steroid user. During 20 years of use, he recognised that steroids were having serious negative effects on his life but he was afraid of letting go of the habit and he didn’t know how to stop. In particular he feared damaging his relationship with his wife and young family, if his image changed.
The powerful sedative Xanax is being used by young people across the country (DDN April, page 6). Some are taking it to self-medicate to cope with anxiety, while younger teenagers are being groomed and exploited by drug dealers taking advantage of the drug’s ‘zombie-like’ effects.
Zoe would go missing for whole weekends and would come home with marks and bruises on her arms and legs with no recollection of how she got them. The vulnerable state that Xanax puts users in leaves them extremely vulnerable to abuse, and who knows what happened to Zoe – she certainly can’t remember. On some occasions, Zoe became aggressive towards her mother and after a fraught evening she ended up spending the night in a police cell. Again, she had no recollection of any of this.
‘Despite the good work being done by many, collectively our approach to drugs is failing,’ said Jamieson. ‘It means people are forced to live with more crime, public services are put under strain and not enough is done to reduce the suffering of those who are addicted. If we are to cut crime and save lives there’s one thing we can all agree on; we need fresh ideas. These are bold but practical proposals that will reduce crime, the cost to the public purse and the terrible harm caused by drugs.’
‘As a sector we can still do more to work together to find better or more innovative ways of pooling resources and supporting people,’ says Kelly Hallett. ‘Certainly one of my priorities is to identify more opportunities for us to be building these relationships and combining expertise.’
Even provision of a ‘relatively low level of support’ to nurse mentors can lead to a significant increase in the delivery of IBA, it says. Supporting nurse mentors to lead on their implementation can help reduce alcohol-related harm ‘within existing resources’ in primary care settings, while awareness raising and training across the practice also help staff become better at both identifying harm and providing effective advice to those at risk.
There were 82,135 hospital admissions with a primary or secondary diagnosis of drug-related mental and behavioural disorders in 2016-17, according to figures from NHS Digital, up from 81,904 the previous year. The total is nearly double the 38,170 figure from a decade ago, although NHS Digital says this increase will be ‘partly due to improvements in recording of secondary diagnoses’.
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