Home Blog Page 35

Sell e-cigarettes in hospitals, says PHE report

By
DDN
-

Vaping poses ‘only a small fraction’ of the risks of smoking, and NHS trusts should ensure that e-cigarettes and nicotine replacement therapies are available for sale in hospital shops, says a new PHE report.

Switching completely from cigarettes to e-cigarettes conveys ‘substantial health benefits’, states the agency’s updated evidence review, with the devices potentially contributing to at least 20,000 successful quits per year. However, use of e-cigarettes in the UK has plateaued at just under 3m and there is substantial public misunderstanding on the issue. Less than 10 per cent of adults are aware that most smoking-related health harms are not caused by nicotine, it says, with ‘many thousands’ of smokers incorrectly believing that vaping is as harmful as smoking.

Around 40 per cent of smokers have yet to try an e-cigarette, the report estimates, adding that the evidence ‘does not support’ concerns that the devices are potential routes into smoking for young people. The highest levels of quit success are among smokers who combine e-cigarette use with support from local smoking cessation services, it says. ‘Local authorities should continue to fund and provide stop smoking services in accordance with the evidence base,’ the document states. However a recent report from Cancer Research UK and ASH found that cuts to the public health budget had meant ‘dramatic’ changes service provision, with at least one council now having ‘zero budget’ to address smoking (DDN, February, page 5).

‘Our new review reinforces the finding that vaping is a fraction of the risk of smoking, at least 95 per cent less harmful, and of negligible risk to bystanders,’ said PHE’s director for health improvement Professor John Newton. ‘Yet over half of smokers either falsely believe that vaping is as harmful as smoking or just don’t know. It would be tragic if thousands of smokers who could quit with the help of an e-cigarette are being put off due to false fears about their safety.’

E-cigarettes and heated tobacco products: evidence review at www.gov.uk

* Should e-cigarettes be provided free to smokers who cannot or will not quit? See Neil McKeganey’s article in our latest issue.

Alcohol strategy is ripe for refreshment

By
DDN
-

Time is of the essence in overhauling the alcohol strategy, says the Drugs, Alcohol and Justice APPG. DDN reports.

‘We were asked by government, “what should be in the alcohol strategy?”,’ said Dr Richard Piper, chief executive of Alcohol Research UK – a question he passed on to the Drugs, Alcohol and Justice Cross-Party Parliamentary Group.

Alcohol strategy is ripe for refreshment – and there is plenty of evidence on which to draw, says ARUK chief exec Dr Richard Piper.

The last alcohol strategy was in 2012 and last year’s drug strategy ‘only made passing reference to alcohol’, he pointed out. But Public Health England’s 2016 evidence review had shown that there was a large pool of evidence on which to draw.

‘Any alcohol strategy should be developed with health inequalities in mind,’ he said. It should also be impact based and ‘clear about the difference we are trying to make’.

The strategy had to aim for reduc­tions in alcohol-related attendance at A&E, mortality, and crime, said Piper. Its content should have three key themes – support and interventions; the consum­er side; and ‘other’, which included considerations such as drink driving.

Children and families needed to be central to considering interventions – ‘both as victims and part of the solution’. Mental health was also a critical part. ‘We need to understand more about dual diagnosis,’ he said. ‘When does mental health trigger a problem and vice versa?’ He also reminded the group that the cost of not treating people was much higher than treating it.

Dr Richard Piper of ARUK: Attitude of ‘let’s wait and see if people die’ is indefensible.

On the consumer side, minimum unit pricing (MUP) was evidence based and necessary. ‘Evidence supports it,’ he said. ‘Saying “let’s wait and see if people die” is indefensible.’ Advertising and sponsorship should no longer be targeted at young people; online sales should be addressed (including very easy alcohol sales on eBay); local communities needed to be able to get involved in licencing decisions more easily; and alcohol labelling should be revised to include ingredients, calories and information about health harm.

Alison Douglas, chief executive of Alcohol Focus Scotland, took up the issue of MUP. Scotland intended to implement minimum unit pricing imminently she said, adding ‘it is not a standalone policy, it is part of a package of measures’. Three things stood out – price, availability and marketing – and it was clear that a ‘whole population approach’ was needed.

‘There’s a huge cost in misery and loss of life years and the impact is felt by all of us,’ she said. ‘It’s not just a health problem, it’s fundamentally undermining the fabric of society.’

The logic behind focusing on MUP was that it was an ‘exquisitely simple and targeted measure’. ‘It’s not based on any one product, but applies to all premises that sell alcohol and targets the cheapest high-strength alcohol,’ she said. In answer to the argument that MUP penalises the poor, she said that they were most likely to benefit: ‘Harmful drinkers in the poorest groups are the ones most affected by MUP.

‘We want to see it extended to all of the British Isles because of the benefits to public health and communities,’ she added.

Julie Breslin brought her experience as head of Drink Wise, Age Well, a lottery-funded programme led by Addaction, which helped people over the age of 50 to make healthy choices.

The aging population of the UK consumed more alcohol than other age groups and ‘must be considered in any strategy refresh’, she said. Harmful attitudes relating to alcohol were increased by living alone, chronic illness or disability, while contributory factors could be retirement, bereavement and lack of a sense of purpose as people got older. The long-term health impact of drinking too much was ‘significant’.

The Drink Wise, Age Well programme helps people over 50 to make healthy choices.

The treatment sector was failing to respond to the needs of this age group, Breslin reported. Three-quarters of rehabs had an arbitrary age cut-off and there was ‘a perception that you can’t teach an old dog new tricks’. The new strategy should incorporate age as a cross-cutting theme, with an advisory panel convened to give guidance, she said.

The benefits of the Drink Wise, Age Well programme were illustrated by Vince, who shared his personal story. ‘I’ve always enjoyed a drink with colleagues and friends,’ he said. ‘Then I was signed off work with ill health and this was when drinking became more of a problem. I used it to cope with pain. I saw my GP, and while we discussed the need to cut down my drinking, he didn’t refer me for help.’

Being referred to Drink Wise, Age Well led to being referred to a detox unit, followed by support at home. Peer support meetings became a ‘crucial part’ of his recovery and he became a volunteer helping to facilitate them.

‘If it wasn’t for support, I wouldn’t have had the strength to do it on my own,’ he said.

A moral imperative

By
DDN
-

One year on, an alliance of 13 NHS trusts is gaining momentum in addressing the failings of the sector and developing more effective pathways to care, as Danny Hames explains.

The NHS Substance Misuse Providers Alliance (NHSSMPA) has been in existence for just over a year. NHSSMPA is a collaboration of 13 NHS trusts, all of which provide substance misuse services in the community and prisons. While NHS provision has changed in the last few years and just over a quarter all community substance misuse treatment systems are NHS, we continue to provide inpatient detoxification facilities nationwide and work in numerous prisons. Celebrating 70 years of the NHS, and in this time working with those affected by drugs and alcohol, means it is in our DNA.

Our aims are to work more closely as NHS providers, and with our colleagues in the third sector, to improve outcomes for service users through sharing and de­vel­op­ing practice and to offer policy makers engage­ment with the NHS substance misuse community.

What unites NHSSMPA is a belief that people deserve high quality services which can improve their lives. For us, this means a competent and qualified workforce where volunteers complement but are not relied upon; interventions that are evidence based and individualised; that we are effective partners and contributors to a local health and social care economy; and that we protect the safety of our service users while walking alongside them to provide the best chance of recovery.

Age-specific mortality rates for deaths relating to drug misuse, registered 1993 to 2016, England and Wales

The impact of the abstinence vs harm reduction debates of the last few years, leading directly and indirectly to some some individuals being pushed through treatment systems too quickly, has been over-simplified and dangerous. Thankfully, NHSSMPA believes the new drug strategy and the presentations accompanying this have underlined a change in tone. For us as NHS providers, harm reduction has always and continues to be a priority.

There is (quite rightly) a very prominent debate regarding the reduction in funding for substance misuse services, and of course NHSSMPA strongly believes that services should be adequately funded. However, we should not let this mask the fact that recently doubt has been cast upon the governance and quality of the sector.

The emphasis on ensuring we are competent and thoughtful guardians of funding, and that this properly benefits service users, has never been more important. Local authorities are experiencing significant challenges to their budgets and there are numerous patient groups deserving of funding. So there is a strong moral imperative to use the monies we receive effectively, most importantly because:

1. We are seeing the highest levels of drug-related deaths since records began. In 2016 this numbered 2,593 deaths associated with drug misuse.

2. Recovery rates are dropping for opiate users. In 2011­-12 treatment completion was 8.59 per cent; year to end November 2017 it was 6.7 per cent (NDTMS). This is all despite a narrative underpinning many procurement exercises that service redesign will mean improved performance.

3. The CQC’s recent review of non NHS residential was shocking – 63 per cent of services were assessed as not meeting the regulation on ‘safe care and treatment’ (CQC).

4. The unfortunate demise of Lifeline, a charity with an income of £53m, demonstrated poor organisational governance and left more than 5,300 potential creditors, including other charities.

NHSSMPA is highly committed to advocating for appropriate funding, but we must not ignore that there have been very significant indications that the sector needs to improve its governance and outcomes for patients. NHSSMPA organisations have a public service and moral duty to achieve this. Over the coming years NHS providers will make our contribution and commit our expertise, because justifying the effectiveness and quality of what we offer has never been more necessary.

Danny Hames is chair of the NHS Substance Misuse Providers Alliance

If you are a NHS trust and would like to find out more about NHSSMPA please contact candie.lincoln@sssft.nhs.uk

Facing the inevitable

By
DDN
-

The death of a client can hit you like a ton of bricks – unless you are prepared, says Ishbel Straker.

2017 brought me many surprises; some have been amazing, some a whirlwind of negativity, but all have been an opportunity to reflect and learn. My biggest revelation was death – not the fact that people die, but our differing experiences of it as nurses within the addiction field.

Throughout our nursing training we make the assumption that we will experience death – some being more traumatic than others, some needing hands-on experience and others that we see from a distance. We may then go on to believe that working in the field of addiction – where clients place themselves at risk daily and allow physical deterioration – our mental preparation for the experience of death will improve.

Making these assumptions is dangerous and will leave you unprepared for the reality. Shock and grief are odd things and as nurses we are not immune to them. Our clients are different – yes, they are risky and yes, death at times seems like an inevitability – but our role as nurses is to prevent this, so when it happens there can be a lot of blame attached.

We become close to our clients – boundaried, but emotionally invested in them. We want them to succeed and we believe that they will. If we did not have this belief system we would not be doing the job we do, but it leaves us vulnerable to the emotions that come with their death. All of this is made far more stressful by the inevitable, and of course necessary, root cause analysis (RCA), unearthing fears of possible Nursing and Midwifery Council (NMC) involvement even when there is no cause for concern. We are trained to think, ‘what could I have done differently?’ and these thoughts can be incredibly negative if left to fester.

So how do we safeguard our ability to cope with death? I believe the first step is to have a robust system to manage this after the event – supervision, reflection, and perhaps a group debrief to ensure the focus remains on the client and their family members, to maintain some perspective. It’s also to ensure any RCA systems and investigations do not have a punitive feel but are supportive, and most importantly it is to admit that we are not immune to grief, shock and fear when a client dies and understand that all the preparation in the world will not prevent it hitting you like a ton of bricks.

Our reactions are not just about the death of this client, but about the deaths that have gone before – in both our professional and personal lives. Our reactions can also be about where we are emotionally at that time. Of course, as nurses we are all 100 per cent professional all of the time – but it’s good to remember that we are still only human.

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

Letters to the editor – Feb issue

By
DDN
-

Quadruple bypass

America’s opioid epidemic has been big news for a while now, but amongst all the headlines and documentaries and think pieces one issue seems to be consistently overlooked – and it’s an issue that’s a bit of an inconvenient truth for the ever-more powerful and vocal legalisation lobby.

According to the US Centers for Disease Control, the number of drug overdose deaths rose from just under 17,000 in 1999 to nearly 67,000 in 2016 – i.e. it quadrupled. And according to the presidential commission on the crisis, ‘not coincidentally’ the level of opioid prescribing quadrupled over the same period (DDN, September 2017, page 5).

There were 950,000 Americans reporting heroin use in 2016, but that number is dwarfed by the number misusing prescription opioids, at 11.5m (DDN, November 2017, page 5). What’s more, according to a recent Economist article on a major study of the crisis, a huge number of these deaths are happ­en­ing in relatively affluent communities, rather than the populations usually decimated by drug harms. ‘The epidemic is caused by access to drugs rather than economic conditions,’ it says.

So the only conclusion to draw from all this is that the argument endlessly trotted out by all the usual suspects – that a legal, regulated market would drastic­ally reduce levels of harm – is, as many of us have always said, utter nonsense.

Paul Bennett, by email

 

Pedantic semantics

Despite no longer working in the field, thank God, I like to keep up with the latest pronouncements of the thought police, and so it was with increasing incredulity that I scrolled through the Global Commission on Drug Policy’s new report about language and stigma (see news, page 5).

All very laudable in intention, obviously, but in it we learn that there was a ‘moral panic’ about crack use in the US in the ’80s and ’90s, based on a ‘misconception’ that use was ‘exploding’. That this was a ‘misconception’ may come as surprise to people who lived in deprived American inner city areas during those years, but what do they know, eh? A bunch of rich people in Switzerland are happy to put them right.

My favourite part, however, is the table on page 30 that explains which language is OK and which is no longer acceptable. ‘Drug user’, bad; ‘Person who uses drugs’, good. ‘Drug habit’, bad; ‘Substance use disorder’ or ‘Problematic drug use’, good. Not to be pedantic, but according to the commission’s own criteria aren’t ‘disorder’ and ‘problematic’ more stigmatising than the innocuous-sounding ‘habit’?

‘Recreational, casual or experimental user’ are all bad, we discover, and instead we must use ‘person with non-problematic drug use’ (trips off the tongue). That’s in order to distinguish them from – and therefore stigmatise, I’d venture – someone with ‘problematic’ use. Then it starts to get truly deranged. Despite being used by almost every agency I ever encountered, ‘opioid replacement therapy’ is now unaccept­able, and you would be a fascist to use it, while ‘opioid substitution therapy’ is fine. So that’s that cleared up then.

It’s also good to see commission member Nick Clegg offering his opinions on all this in the pages of the Guardian and the Mirror. One can’t help thinking, however, that if he was so concerned about the welfare of drug users – sorry, persons who use drugs – perhaps he should have thought twice before en­ab­ling a Tory government that went about slashing treatment budgets to the bone.

Molly Cochrane, by email

Free to breathe

By
DDN
-

Should e-cigarettes be provided free to smokers who cannot or will not quit, asks Neil McKeganey.

While smoking rates have steadily declined in recent years, there are still around 9m people smoking in the UK and approximately 120,000 smoking-related deaths per year. Although tobacco control has been one of the highlights of global public health, the challenge of further reducing smoking prevalence becomes harder, not easier, over time.

Those smoking now are doing so in the face of the known harms of smoking, decades of smoking bans, graphic health warnings, tax hikes on tobacco products, age restrictions on the sale of tobacco products, advertising bans and widespread social opprobrium directed towards smokers. If the UK is going to succeed in further reducing smoking prevalence it is going to have to do something radically different to what it has done in the past. One thing the government might now consider is providing smokers with free access to e-cigarettes.

E-cigarettes have been characterised by Public Health England as at least 95 per cent less harmful than conventional cigarettes. We know from research in the US that smokers using e-cigarettes are more likely to have attempted to quit, and that those quit attempts are more likely to have been successful. There is also growing evidence that providing smokers with access to e-cigarettes has a beneficial impact, even if those smokers have not previously committed to quitting. Recent research from the University of South Carolina, for example, found that nearly a third of smokers provided e-cigarettes for free had reduced their smoking by at least 50 per cent over the three-month period the researchers were monitoring them.

Nobody is suggesting that e-cigarettes are harmless, but if they are much less harmful than the alternative and can have a beneficial impact – even for smokers not already determined to quit – why aren’t we doing all we can to reduce the barriers to vaping? Charging smokers a price for using e-cigarettes is one of the barriers that is starting to look decidedly inappropriate.

There is an inverse relationship between smoking and deprivation, with the highest levels of smoking, and the highest levels of smoking-related harm, found in the poorest communities. There is probably nothing that would have a greater impact on reducing health in­equalities than reducing smoking among the poorest sectors of society. On that basis it makes no sense to attach a financial barrier to smokers’ access to e-cigarettes – especially where that barrier is going to be greater in the communities where levels of smoking are at their highest.

Providing free e-cigarettes to smokers who cannot quit, or who will not quit, may be the equivalent of investing millions in flu vaccinations or providing statins to those at risk of future health problems. These are programmes that are funded in the expectation of future savings. There are few savings greater than those that can be achieved by reducing smoker numbers. The cost of providing smokers with free access to e-cigarettes may be a cost that is easily justifiable if it results in a further reduction in smoking prevalence.

Dr Neil McKeganey is director of the Centre for Substance Use Research, Glasgow

Image taken from http://vaping360.com/what-is-vaping/ 

How do we prove our service user involvement?

By
DDN
-

Nicole Ridgwell answers your legal questions

We are disappointed with the results of our recent CQC review – one of the things we were marked down for was not involving our clients in planning their care. We dispute this as patient involvement has always be central to how our service operates. How can we compile evidence to back up our challenge?

To launch an effective challenge, providers must understand the parameters of the process itself. With CQC draft inspection reports, challenges should be made through the factual accuracy process, through which the provider has ten working days to submit a response from the date of receipt.

It is important to note that CQC factual accuracy guidance implies that providers can only challenge facts. That is wrong as a matter of law – CQC must take into account all written representations about the inspection process and the content of the report. It may be, for example, that a provider agrees that specific documentation error occurred but does not agree with the inspectors using that isolated example to conclude that the service has systemic failures in record-keeping.

Factual accuracy representations must be as detailed as possible. When we draft responses, we scrutinise the draft line by line; identifying not just factual inaccuracies but negative or imprecise wording and vague criticisms. This level of detail is necessary to ensure that providers lodge all valid objections. Should matters progress to enforcement action, it is much more difficult to retrospectively challenge something about which providers were initially silent.

For a successful challenge, providers must provide evidence to rebut the criticisms, where possible using CQC’s own language. It is much harder for CQC to ignore a challenge where a provider demonstrates compliance with CQC’s own guidance.

In our question, the touchstone would be CQC’s Better care in my hands: a review of how people are involved in their care, which ‘can be used by providers… to understand what CQC expects to see when we regulate how well services involve people…’. Where possible, therefore, the evidence gathered will explicitly align to CQC’s own examples. In this case:

• personalised care plans – written with people, for people, and with their wishes and preferences clearly identified and monitored

• the sustained and supported involvement of families and carers in the care of their loved ones

• the coordination of people’s involvement in their care as they move between services

A strong challenge will cross-reference provider polices and policy implementation. Care plans, patient notes, minutes of family meetings and patient reviews (to name potential sources) will demonstrate how patients are involved at every stage of care planning and show the outcomes of that involvement.

In preparing for any challenge, success is in the detail. Sweeping criticisms are rebutted only by specific, consistent evidence of best practice compliance. Compiling the evidence may therefore be painstaking and protracted in the short term, but a successful challenge which restores your service’s reputation will always be worth it in the long run.

Nicole Ridgwell is solicitor at Ridouts Solicitors

The ‘Cycle of Change’ – A step too far?

By
DDN
-

Have we been right to embrace the ‘cycle of change’,
asks Natalie Davies.

Natalie Davis from Drug and Alcohol FindingsWhen Bill Wilson, who went on to co-found Alcoholics Anonymous, was hospitalised for the fourth time for alcohol detoxification, he cried, ‘If there is a God, let Him show Himself!’. As AA’s story goes, ‘the room became ablaze with light and Wilson was overwhelmed by a Presence and a vision of being at the summit of a mountain where a spirit wind blew through him, leaving the thought, “You are a free man”. Wilson never took another drink.’

Though Wilson’s story is spectacular – so much so that we might be inclined to think it a ‘fable’ rather than a blueprint for what might actually happen – it’s not unusual to hear about ‘revelatory moments’ or moments in which someone suddenly or spontaneously discards a substance that up to that point they had depended on. An example is the smoker who suddenly becomes disgusted with their smoking, spits out the cigarette half way through, dumps the remnants of the packet in a bin, and never turns back, as if something had overtaken them.

But another important narrative, and perhaps one more pertinent to the conversations between practitioner and client, is of the ‘longer road to recovery’ – of a process of change rather than a one-off event; of an experience mixed with conflict, ambivalence, vacillation, regret, and often relapse. And it’s this process that Prochaska and DiClemente’s ubiquitous ‘five stages of change’ model endeavours to describe.

The five stages of change

The ‘five stages’ plot the journey from Point A (‘no acknowledged problem’) to Point B (‘no problem now’) – each marker along the way representing a shift in motivation, intention, and capacity to change. Dealing frankly with the possibility of relapse, the popular depiction of the five stages as a ‘cycle of change’ (see the illustration opposite) shows the continued work that people can do or redo until the day they successfully achieve what is known as a ‘lasting exit’ to recovery.

Graphic depicting the five cycles of changeThe cycle shows the progression or evolution through the stages of pre-contemplation, contemplation, preparation, action, and maintenance, and how this can come full circle due to (re)lapse. It doesn’t exclude anyone from the process – even ‘not thinking about the harmful behaviour’ or ‘not being sufficiently aware of the health implications’ is a stage in itself.

As well as broadly describing change, the five stages provide a means of separating people into groups. From a practical perspective, if, as its originators have suggested, each stage entails ‘specific unique tasks that need to be accomplished in order to move successfully to the next stage’, the model has the potential to explain and even help generate behavioural change. It acts as a guide to what to do (or not do) with clients at different stages of change – for example, avoiding wasteful change attempts with those not yet ready to change, and recognising when someone is ready to commit to treatment; or if not, how to nudge them towards a more receptive stage.

The model was originally based on a comparison of smokers who were considered ‘self-changers’, versus those in professional smoking-cessation treatment. Although later applied to, and tested on, a range of other health-related behaviours including harmful drinking and drug use, smoking still accounts for the bulk of studies.

Whether the model would be deemed a success in the field of substance use (even if for now we are primarily relying on studies of smokers) depends on how we judge ‘success’ – on the model’s ability to help us understand the process of recovery, or its ability to help clients progress along the road to recovery. If the latter, the key test is the performance of so-called ‘stage-matching’ strategies which deliver different interventions suited to the assessed stage of the client.

man in contemplationAn assessment for the UK’s National Health Service concluded that ‘Overall, whilst there is some evidence favouring the use of stage-based interventions for smoking cessation compared to no intervention, there is little evidence that stage-based interventions are more effective than non-stage-based interventions.’

Similarly, the verdict reached for the Cochrane Collaboration was that ‘Expert systems, tailored self-help materials and individual counselling, appear to be as effective in a stage-based intervention as they are in a non-stage-based form’. In other words, across relevant studies, it could not be shown that matching to stages led to more non-smokers.

The most stringent test of ‘stage-matching’ would be to provide exactly the same interventions, but at random, to either match or not match these to stage of change. Of the studies reviewed for the Cochrane Collaboration, the most promising found that generally smokers whose computer-generated feedback and advice matched their stage were more likely to progress to the next stage, but were not necessarily more likely to successfully stop smoking.

The crunch point

woman holding her head illustration Unfortunately, it seems that at the ‘crunch point’ – when the model actively engages with change through treatment or brief interventions – research support is largely absent. The best the American Psychological Association could say on the matter was that matching interventions to stage of change was ‘probably effective’ – and looking at the relevant review, even ‘probably’ is optimistic. Could this indicate that there is something flawed about the stages themselves? That the way they are characterised lacks validity?

The underlying idea that motivation and intention to change increase over time and with each stage is a valid one – studies have found strong positive associations between both these variables and the five stages of change. So, we’re clearly in the right ballpark. But these strong positive associations could also indicate that we are dealing with a continuum of change, rather than a stepped pattern of change – meaning that the five stages may not be ‘true stages’ at all, but ‘pseudo stages’ picked at arbitrary points along a continuum.

If this were the case, and definitive evidence emerged to debunk the idea of stages, would this be enough to dismiss the whole model? Or as a tool for discussing recovery, is it useful in itself to be able to refer to stages as symbols of progression, whether or not they constitute discrete experiential or emotional states?

The cycle of change itself was only one part of a broader model of behavioural change proposed by its originators. Other ‘relatively neglected’ parts of the model have addressed the mechanisms that explain how people navigate change, including the ten common processes of change (eg consciousness-raising, self-re-evaluation, and helping relationships), weighing up the pros and cons of changing, and confid­ence in one’s ability to change and avoid temptation. But it’s the cycle of change’s ability to translate a complicated, daunting experience into something tangible for people both inside and outside the substance profession, that has arguably made this the most eye-catching aspect of Prochaska and DiClemente’s work.

Until something comes along to displace the cycle of change from our substance use language, perhaps it should continue to be embraced for what it does rather than rejected for what it does not – first and foremost, helping to understand and visualise the process, milestones, and emotional labour involved in recovery.

Jargon is commonplace in the sciences, but relatable language is not. And as a means to starting a conversation, the cycle of change isn’t bad. As a way of keying interventions to the client’s condition, on balance it has yet to be proven beneficial.

Natalie Davies is assistant editor at Drug and Alcohol Findings

Media Savvy

By
DDN
-

The news, and the skews, in the national media

2018 is already a watershed in global drugs policy. Cannabis is partially legal in most US states; Canada will follow soon; Germany, France and Italy are all reviewing policy… When you consider what a green wave could do for Britain – freeing police and court time and saving lives, as well as unleashing innovation, raising revenue – our approach seems absurd. The only people who benefit from the current situation are criminals. Instead of a safe, regulated market we are awash with psychotic skunk controlled by violent gangs. Richard Godwin, London Evening Standard, 3 January

There’s appetite to reform the UK’s drug laws, but it has to be done right. The public are ahead of politicians, with recent polling showing that more people support a legal, regulated cannabis market than oppose it. The government’s silence on this crucial issue is deafening.
Daniel Pryor, Guardian, 18 January

In this climate of punitive neglect, addiction and obesity are dismissed as diseases of choice, which to use that most class-bound of Tory insults, the ‘nanny state’ cannot cure. It’s true that breaking free from heroin, alcohol or sugar requires an effort of individual will. It is equally true that it is easier to summon the strength to quit when others are on hand to help. These truths ought to be self-evident. But they are not evident in Britain.
Nick Cohen, Observer, 7 January

Lazy stereotypes also let us off the hook when we really should be getting to grips with the deeper social issues that are the cause of problematic drug use. One reason people use drugs is to cope with difficult life circumstances. People who have been through trauma or abuse are more likely to find their drug use leads to dependency. These are people who need our support – they don’t need to be labelled, condemned and pushed further away. Nick Clegg, Mirror, 10 January

With many medical schools failing to include addiction in their curriculum this sends a clear message early on in doctors’ medical careers that patients with drug dependence problems don’t matter… The derogatory language we use to describe people who use drugs is merely a symptom of a deeper problem. The danger of adopting a new vocabulary while retaining the same values and attitudes is that we sound more accepting but really nothing has changed from the patient’s point of view. I hope I am wrong.
Ian Hamilton, BMJ, 17 January

 

DDN February 2018

By
DDN
-

 

‘Service users must stay at the
heart of commissioning’

Disinvestment and the fragmentation of services continue to dominate dialogue and debate. Yet according to Collective Voice, (page 7), we have the best opportunity in a decade to address complex problems faced by service users and their communities. The newly formed Faculty of Commissioning is on a similar wavelength (page 10) in identifying the challenges to be tackled, and they reiterate the call for better integration with mental health and housing services.

We are clear that commissioning needs an overhaul, a situation underlined by the ACMD Recovery Committee. On page 14 we look at why service user involvement must stay at the heart of this process. Tim Sampey’s comments are a reminder that there are many vibrant peer-led initiatives around the country that are leant on when needed for ‘service user involvement’ in strategy papers, but which should be written into tender documents as a core part of services. We’re looking forward to seeing many of these groups in action at our DDN Conference on 22 February.

The other important element of the consultations is to not forget the evidence that should inform them – such as when discussing a new alcohol strategy. As Dr Richard Piper reminds us (page 13), there is a large pool of evidence on which to draw in modernising the 2012 strategy. Consultations focus the mind, but we must remember to stay open to innovation. The growth of partnerships such as the alliance of NHS Trusts (page 12) offer new momentum in tackling old problems.

Claire Brown, editor

Click here to view the virtual magazine or the PDF version

NHS England sets out ambitious plans to eradicate hep C

By
DDN
-

England could be the first country to eliminate hepatitis C, according to plans announced by the NHS. The health service has called on the pharmaceutical industry to work with it to provide ‘best value for money for treatments’ to help it eliminate the virus at ‘least five years earlier’ than the World Health Organization’s goal of 2030.

The NHS has already invested significantly in new hep C treatments but it is encouraging pharma companies to work closely together to meet this more ambitious target. February’s medicines procurement round will be the single largest ever carried out by the NHS, and the health service expects to see ‘more new treatments curing even more patients by October’. The number of patients treated is expected to rise to 30,000 this year, prioritising the sickest patients first. Hepatitis C currently affects around 160,000 people in England.

Part of the agreement between NHS England and pharma companies will involve closer collaboration to identify more people living with the virus and needing treatment. This approach, combined with sustained investment levels, could ‘undoubtedly lead to hepatitis C being eradicated as a major public health concern in the very near future’, the NHS states. England is already one of the few countries in Europe where the number of patients receiving new oral treatments is increasing year on year, enabled by deals agreed with industry including ‘pay per cure’ arrangements by which the health service only pays when a patient is cured.

The NHS has also created 22 new ‘operational delivery networks’ to drive improvements and boost treatment in local areas that have had historically low service provision. A national patient registry has also been established to allow treatment uptake, outcomes and diagnosis rates to be monitored in real time.

Peter Huskinson: We need the best deal for patients and taxpayers

‘The NHS has made major headway in the last three years in the treatment of hepatitis C, which has enabled a once in a generation opportunity to eliminate a major disease,’ said NHS England’s commercial director, Peter Huskinson. ‘With the right response from pharma companies in the coming months, we can strike the most competitive deal possible – improving the future for patients with hep C alongside securing the best value for money for taxpayers.’

‘The progress made in the treatment of hepatitis C has transformed the lives of many of my patients and has been made possible by NHS England working closely with industry to bring prices down and expand treatment options,’ added the NHS’s national clinical chair for hepatitis C, Professor Graham Foster. Yet we have the opportunity to do so much more. Over the last seven decades, the NHS has been at the forefront of medical innovation – to be able to commit to a world first in the year of the NHS’s 70th anniversary would be another remarkable and truly historic achievement.’

Charles Gore: ‘wonderful news that will galvanise action’

The proposed deal was ‘wonderful news’ that would ‘galvanise the action we must take to find all those living with hepatitis C who have not yet been diagnosed so that we can cure them’, said Hepatitis C Trust chair Charles Gore. ‘It will prevent the liver cancer that hepatitis C causes. It will save lives. In the current environment we applaud NHS England’s ambition to be a world leader.’

Introduce cigarette-style labelling for alcohol, says public health body

By
DDN
-

It should be ‘mandatory’ to include the government’s low-risk drinking guidelines of 14 units per week on alcohol labels, says the Royal Society for Public Health (RSPH), alongside calorie-content information and warnings about drink driving. Labels could also potentially feature ‘explicit cigarette-style warning of the link with health conditions such as bowel and breast cancer’ as well ‘traffic light’ colour coding, the organisation states.

The recommendations form part of a new report, Labelling the point, published in response to a perceived ‘alcohol health awareness vacuum’. Only ten per cent of people are aware of the links between alcohol and cancer, says RSPH, while just 16 per cent are aware of the government’s unit guidelines and only 20 per cent are able to correctly estimate the number of calories in a glass of wine.

Including information on calorie content per serving could result in a ten per cent swing in ‘consumer purchasing decisions from the highest alcohol drinks to the lowest’, across all main drink categories and socio-economic groups, the document claims.

The report is partly based on a survey of around 1,800 people originally commissioned in partnership with industry body the Portman Group. However, the Portman Group has since ‘moved to make alcohol labels even less informative to the public than they are at present’, says RSPH, by releasing updated guidelines to manufacturers that no longer include the government’s low-risk drinking limits. Unit information alone is ‘largely useless’ to most consumers unless shown in the context of the recommended weekly limits, stresses RSPH. The Portman Group’s updated guidance indicates that the body is ‘no longer serious about setting a challenge for industry to play their part in informing the public and protecting their health’, it adds.

‘Having a drink with friends or family is something many of us enjoy. However, the potential health consequences of alcohol consumption are more serious than many people realise,’ said RSPH chief executive Shirley Cramer.

‘If and when people choose to drink, they have the right to do so with full knowledge of both what their drink contains and the effects it could have. Consumer health information and warnings are now mandatory and readily available on most products from tobacco to food and soft drinks, but alcohol continues to lag behind. If we are to raise awareness and reduce alcohol harm, this must change.’

The Portman Group’s decision to ‘weaken’ their labelling recommendations showed that ‘alcohol producers wish to withhold information on alcohol and health from the public’, added Alcohol Health Alliance chair Professor Sir Ian Gilmore.

However, Portman Group chief executive John Timothy responded by saying that the original research co-funded with RSPH ‘found little public interest in a radical overhaul of drinks labelling, and strong opposition to cramming more information’ onto packaging. It showed that 86 per cent of consumers ‘only look at labels for factual information and branding’ and 80 per cent wanted to see ‘less cluttered’ labels. ‘When asked specifically about health, 70 per cent said the current approach was about right,’ he stated.

‘These findings support the approach taken by the industry in developing updated voluntary guidance which includes a whole section on how producers can display the CMO’s guidelines on labels,’ he continued. ‘To suggest otherwise is misrepresentative. The Portman Group remains committed to providing consumers with accurate and accessible health information.’

Report at www.rsph.org.uk

Government launches prescription drug review

By
DDN
-

Public Health England (PHE) is to launch an independent review into the ‘growing problem’ of prescription drug dependency, the government has announced.

Dependence-forming drugs such as opioids, benzodiazepines, GABAergic medicines and ‘z-drugs’ like zopiclone were being prescribed to 9 per cent of the population by 2015, according to figures from NatCen, up from 6 per cent in 2000. The year-long PHE review will cover sedatives, painkillers, anti-anxiety drugs and antidepressants.

The All-Party Parliamentary Group (APPG) for Prescribed Drug Dependence has been calling for a 24-hour helpline for people experiencing dependence on these substances (DDN, April 2017, page 4). ‘The APPG is pleased that Public Health England now agrees that prescribed drug dependence is a serious public health issue which needs to be addressed,’ it said.

‘Prescribed drug dependence can have devastating consequences for patients, leading to years of unnecessary suffering and disability following withdrawal from medication which has simply been taken as directed by a doctor,’ said APPG chair Paul Flynn MP. ‘The APPG welcomes the proposed evidence review of prescribed drug dependence and withdrawal by Public Health England as a first step towards the commissioning of services, including a national helpline, to support patients affected by this urgent public health issue.’

The Royal College of General Practitioners (RCGP), meanwhile, welcomed the review but warned that it was important not to ‘automatically jump to the conclusion that more drugs being prescribed is always a bad thing’, as advances in research meant a wider choice of medicines for patients.

‘Many addictive medications, when prescribed and monitored correctly and in line with clinical guidelines, can be very effective in treating a wide range of health conditions,’ said RCCGP chair Professor Helen Stokes-Lampard.

‘But all drugs will have risks and potential side effects. GPs will always prescribe in the best interests of the individual patient in front of us, taking into account the physical, psychological and social factors that might be impacting their health. However, we know most patients would rather not be on long-term medication and where appropriate we will explore non-pharmacological treatments, but these – and this is particularly so for psychological therapies – are often scarce at community level.’

Politicians and charities call for ‘immediate’ minimum pricing

By
DDN
-

More than 100 MPs, police commissioners, charities and health organisations have called for minimum pricing to be implemented in England ‘immediately’.

‘Lives will be lost if Westminster delays further on the issue’, says an open letter to the Sunday Times signed by representatives of the royal colleges of physicians, psychiatrists, nursing, GPs and anaesthetists, as well as the BMA, Cancer Research UK, Thames Reach and the Children’s Society. Among the other signatories are police and crime commissioners and cross-party MPs, including Frank Field, Fiona Bruce, Liam Byrne, Caroline Lucas, Caroline Flint and Norman Lamb.

Minimum pricing will be introduced in Scotland in May, following a five-year delay as a result of legal challenges from the drinks industry (DDN, December/January, page 4). A similar delay in England would lead to more than 1,000 deaths and 182,000 alcohol-related crimes, the letter claims, as well as a cost to the NHS of £326m.

‘These numbers will only increase the longer minimum pricing is delayed – and these costs are all entirely avoidable,’ the letter states. ‘The government should act now.’

Three in five drinking ‘to cope’

By
DDN
-

Almost 60 per cent of adults who drink are ‘doing so because it helps them to cope with the pressures of day-to-day life’, according to a YouGov survey commissioned by industry-funded charity Drinkaware. ‘Motivations for drinking are an important aspect of drinking behaviour and over half of all drinkers (58 per cent) report that they drink for at least one coping reason,’ says the report.

Elaine Hindal: ‘People are drinking to cope with pressures of life.’

Almost 40 per cent of the 6,174 18-75 year-olds surveyed said they drank ‘to forget their problems at least some of the time’, while 47 per cent said they had done so to cheer themselves up. Of the 41 per cent who had drunk because they were ‘depressed or nervous’, meanwhile, 54 per cent were doing so ‘at increasing levels of risk’.

While 33 per cent of drinkers in social grades A and B drank to forget about their problems, among drinkers in social grades D and E this rose by 11 percentage points to 44 per cent. There was a similar 9 per cent difference among rates of drinking when feeling depressed or nervous.

‘What this thought-provoking survey shows is that a worrying number of people are drinking alcohol to help them cope with the pressures of day-to-day life,’ said Drinkaware chief executive Elaine Hindal. ‘Whilst people might think having a drink after a hard day can help them relax, in the long run it can contribute to feelings of depression and anxiety and make stress harder to deal with. This is because regular, heavy drinking interferes with the neurotransmitters in our brains that are needed for good mental health. The number of people who are drinking when they are already feeling depressed or nervous, and at levels which are harmful to both their physical and mental health, is also deeply concerning.’

Regular heavy drinking could also lower serotonin levels, she added, which could lead to depressive symptoms. ‘Alcohol and depression can feed off each other to create a vicious cycle,’ she stated.

Adults (18-75) in the UK who drink alcohol for coping reasons at www.drinkaware.co.uk

DDN Conference – Session three

By
DDN
-

The day’s final session, ‘Insights’, heard personal stories about naloxone, the lack of support for problem gambling, and properly engaging with your past to move on in the future .

Read the full report of the first session as a mobile magazine or download the PDF

———–

Watch session highlights! – Filming by Paolo Sedazzari

Session Pictures – By Nigel Brunsdon
[slideshow_deploy id=’24928′]

DDN Conference – Session two

By
DDN
-

The morning’s second session, ‘The Big Conversation’, focused on the shape of service user involvement and how it should look in the future.

Read the full report of the first session as a mobile magazine or download the PDF

 

———–

Watch session highlights!

Session Pictures – By Nigel Brunsdon
[slideshow_deploy id=’24905′]

DDN Conference – Opening Session

By
DDN
-

The day’s first session focused the current state of play in the treatment sector, the vital role of user involvement, and where things needed to go from here.

Read the full report of the first session as a mobile magazine or download the PDF

 

———–

Watch session highlights! – Filming by Paolo Sedazzari

Session Pictures – By Nigel Brunsdon
[slideshow_deploy id=’24879′]

Media language enabling discrimination, says Global Commission

By
DDN
-

Negative portrayals in the media and politics are reinforcing the perception that drug use is ‘immoral’ and people who use drugs are a threat to society, says a new report from the Global Commission on Drug Policy. This in turn increases stigma and discrimination and means that people who use drugs are seen as ‘sub-human, non-citizens, scapegoats for wider societal problems’ and undeserving of the right to health.

Most drug use worldwide is ‘episodic’ rather than problematic, says The world drug perception problem: countering prejudices about people who use drugs, and what should be factual discussions are ‘frequently debated as moral ones’. Policies and responses are often based on ‘perceptions and passionate beliefs’ rather than evidence, it says, with no medical condition ‘more stigmatised’ than addiction.

‘Public opinion and media portrayals reinforce one another, and they contribute to and perpetuate the stigma associated with drugs and drug use,’ says the document. ‘Commonly encountered terms such as “junkie”, “drug abuser” and “crackhead” are alienating, and designate people who use drugs as “others” – morally flawed and inferior individuals.’ When combined with the criminalisation of drug use, stigma and discrimination ‘are directly related to the violation of the human rights of people who use drugs in many countries’, it states.

Policy makers should aim to change perceptions of drugs and people who use them by providing reliable and consistent information, the report urges, while ‘opinion leaders’ in the media should promote the use of non-stigmatising language. Healthcare professionals also need to be vocal in promoting harm reduction and evidence-based interventions, while law enforcement should ‘stop acts of harassment based on negative perceptions of people who use drugs’.

Michel Kazatchkine: ‘langage matters’

‘“Addiction” remains extremely stigmatised in health care settings,’ said former executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Michel Kazatchkine. ‘Language matters. Research has shown that even trained mental health practitioners treat differently cases where patients are referred to as “substance abusers” than those alluded to as “people with a substance use problem’”.

‘In Switzerland’s direct democracy, drug policy reform promoting a health-centered approach focused on harm reduction and treatment has repeatedly triumphed at the ballot box,’ said Global Commission chair and former Swiss president, Ruth Dreifuss. ‘This is in large part because the public was well informed of the facts and positive outcomes.’

Naloxone provision ‘chronically inadequate’, says Release

By
DDN
-

Levels of naloxone provision by local authorities are ‘chronically inadequate’ and ‘certainly not sufficient to prevent opioid deaths to any meaningful extent’, according to research carried out by Release. Although take-home naloxone is now provided by 90 per cent of local authorities (DDN, September, page 4), Freedom of Information requests revealed that just 12 take-home kits were being given out for every 100 people using opiates.

The charity surveyed more than 150 local authorities, of which 117 provided details of the number of kits they’d given out in 2016-17. Naloxone coverage was found to be between 1 and 20 per cent in more than 70 of the areas, while the best-performing local council, Somerset, still achieved less than 50 per cent coverage. Of those authorities providing naloxone, almost a third did not do so through needle and syringe programmes and almost a fourth did not provide take-home kits to people accessing OST or to family, friends and carers of those at risk of overdose.

Nearly one in five also required people to be referred and/or book an appointment in order to receive naloxone, while more than 20 per cent required them to be assessed first. ‘These requirements are a major barrier to naloxone access and are therefore contributing factors to overdose deaths,’ says Release.

‘There were nearly 1,900 opiate-related overdose deaths registered in England in 2016 – the highest number since records began, and over four times higher than the figure in 1993,’ said Release’s Zoe Carre, who conducted the research. ‘Many of these deaths could have been prevented if naloxone, a life-saving antidote to opioid overdose, was provided more widely for people to take home. The scale of the problem is a public health crisis, as such it requires a national and coordinated response, and government must not leave it to local authorities but must take action to prevent more people dying.’

While the government’s latest drug strategy recommends that all local authority areas should have appropriate provision in place, the approach of some is ‘far from adequate and may be contributing to avoidable overdose deaths’, she continued. ‘A national take-home naloxone programme is needed in England as a matter of urgency to coordinate and monitor take-home naloxone provision across local authorities. This has been successfully implemented in Scotland, and England should follow suit. Government must act now to prevent more of its vulnerable and marginalised citizens from dying.’

Full survey results at www.release.org.uk/naloxone

Sustained budget cuts having severe impact on treatment system

By
DDN
-

The treatment sector’s ability to absorb funding cuts through efficiency savings and service redesign has been ‘exhausted’, according to the latest State of the sector report.

There has already been ‘substantial service redesign and some hard decisions made’ and the system is starting to buckle under the pressure, says the document, which is based on stakeholder interviews and published by Adfam on behalf of the Recovery Partnership. While there had so far been no serious compromise in service quality or safety standards, the capacity of the sector to respond to further cuts ‘has been seriously eroded’ on the provider side and increasingly in terms of commissioning capacity as well, it warns.

‘The sector has passed the point at which efficiencies and service remodelling can continually compensate for the loss of funding, and moved into a period where choices about service configuration have become much harder,’ it states.

A high turnover of commissioners is causing concerns about loss of expertise, and there are ongoing worries about rising caseloads and erosion of service capacity, it warns, with some areas ‘losing valuable one-to-one support’ and many services using volunteers out of necessity. The previous State of the sector document – the third – had already found that almost 60 per cent of residential services and 40 per cent of community services were reporting deceases in funding (DDN, April 2016, page 5). Only central government intervention can now protect the sector from further cuts, the latest report states, as there ‘appears to be high variation locally in priorities and ways of working’.

Vivienne Evans: ‘Potentially serious damage is being done to the treatment system.’

The report had uncovered ‘worrying signs that potentially serious damage’ has been done to the treatment system, said Adfam chief executive Vivienne Evans. ‘These findings echo those of the Advisory Council on the Misuse of Drugs in their powerful commissioning report released in the autumn’ (DDN, October, page 4). While there were ‘many wonderfully talented and dedicated people’ working in the sector, funding pressures meant they were ‘unable to deliver to the gold-standard we’d all like to see’, she stated, leaving ‘some vulnerable people with substance misuse problems not able to get the help they need’.

State of the sector 2017 – beyond the tipping point at www.adfam.org.uk

Harm reduction on a knife edge

By
DDN
-

Disinvestment in harm reduction is hurting services and failing clients, say those struggling to maintain life-saving provision. DDN reports.

‘A couple of weeks ago I had a call from the BBC, asking if I could speak on their breakfast show about issues faced by a pharmacist in Staffordshire,’ says Philippe Bonnet, chair of the National Needle Exchange Forum (NNEF). ‘The pharmacist said he was thinking of stopping needle and syringe programmes (NSP) because of safety reasons – his staff were being abused regularly. He mentioned a couple of incidents where a service user threatened a member of staff with a used syringe, demanding they give him needles. On another occasion someone came into the dispensary with a knife, demanding their methadone and threatening to kill.’

Bonnet pleaded with the pharmacist to reconsider, asking him ‘not to punish everyone because of the actions of a couple of individuals’. He mentioned that NSPs were the reason that HIV prevalence was low in the UK, compared to Europe, and that giving out equipment is so much cheaper than the treatment for blood-borne viruses. He did not get an answer from the pharmacist when he asked him if he was going to stop dispensing methadone.

Philippe Bonnet: ‘Needle and syringe programmes are being forgotten about.’

To the casual listener, the conversation on the radio may sound like discussing sensible precautions on staff protection. But for those working in harm reduction it is another red flag in a public health emergency.

The ease with which people who need these services are being dismissed is being compounded by a crisis in funding and staff morale. ‘In some services, NSPs are being forgotten about,’ says Bonnet.

Mark (not his real name) works in the harm reduction team of a large treatment agency, and says there has been ‘a steady erosion of knowledge about harm reduction approaches since 2010’. Large cuts to funding have meant ‘caseloads of increasing complexity’ and evidence-based practice being replaced by ‘a mush of dubious interventions’, including an over-reliance on urine testing.

‘Significant numbers of drug-related deaths this year, including several believed to be linked to fentanyl’ have not prompted a relevant response. ‘The focus appears to be more on data requirements rather than interventions around reducing risk,’ he says. ‘There has been no information about fentanyl circulated by the manager or the organisation, in stark contrast to the constant emails related to data needs.’

Furthermore, he sees a slide towards a deskilled workforce. Within increasingly complex caseloads, ‘much of this work is done by recovery workers who are relatively new to the field but have received little or no training other than shadowing colleagues’.

Amy (who also asked for her name to be changed, because she feels she is in a ‘speak out at your own risk working environment’) manages a needle exchange and has worked in drug treatment services for the last five years. During this time she has seen ‘the steady erosion of vital aspects of harm reduction’.

‘The stuff we know works – assertive outreach, consistent and persistent support for treatment-resistant individuals – has taken a back seat in favour of assessment, TOPS [information that needs to be supplied for the Treatment Outcomes Profile] and group work,’ she says. ‘There is so much pressure on “positive outcomes” that ultimately very little energy is spent nailing the basics. Ultimately the pressure and expectations we have to impose on our clients is mammoth. The system feels designed for the chaotic to fail – and why wouldn’t it be? Fewer chaotic clients in treatment means fewer drop-outs, fewer representations, and all of a sudden your positive outcomes and numbers are on the up.’

While Amy acknowledges some good initiatives – ‘naloxone has been a game-changer, as long as you turn up to a service to pick it up’ – ultimately, she says, ‘we know that there are so many of our most vulnerable – in the car parks, out camping behind Tesco, sleeping in the underpass – that cannot or will not come into treatment to access such potentially life-saving interventions. What about them? We are not going to get to them, that’s for certain. There’s no time, no strategy, and barely enough staff to keep the hubs running. Yet again, these folks fall through the cracks.’

As well as not receiving the immediate help they need, clients are missing out on a much bigger opportunity to engage with healthcare.

‘NSPs for many people represent the first, and possibly only, engagement with a “professional” agency,’ says Kevin Flemen of KFx training. ‘This toe-hold in a service opens up routes to so many other interventions – overdose prevention and naloxone, vaccines and BBV testing, wound care and treatment. It can be the first tentative step on a longer treatment journey.’ For many it will also offer the right environment to discuss OST and life-changing options for stabilisation – steps that not only transform the individual’s prospects, but also reduce the harm to their families and ultimately to society.

Kevin Flemen: ‘Needle exchanges open up routes to so many other interventions.’

As a trainer he has a fair idea of the level of staff knowledge, and also of the level of priority that harm reduction is getting within services. At the moment he sees that we are devaluing it ‘by failing to provide space, time, privacy and resources to make needle exchange excellent. All too often, staff with no training dole out equipment with no discussion or further engagement.’ He sees that ‘some areas have no trained staff or dedicated space for NSP’. As injectors turn to using lower-threshold pharmacy services, this is seen as a further reason to keep downgrading this essential service.

Amy’s colleagues in another service from the same provider have told her about the ‘no bin, no pin’ policy there to encourage returns, getting rid of pre-injection swabs ‘for good old soap and water – great! Unless of course you don’t have access to such facilities!’, and ceasing the distribution of water ampoules because of unfathomable ‘concerns around legalities’.

According to Amy, a little investment in her needle exchange would go a long way. There are the material items that could be bought with more money – the BBV testing kits and homeless packs; and the specific services they could provide, like access to a nutritionist, wound care specialist or dentist. But what the service really craves is ‘to reduce pressure on staff, invest in quality training and nurture specialisms’.

‘One of the heartbreaking things to watch over the last few years is how so many of my colleagues with a love and speciality for harm reduction have moved into other areas of the care sector, or even out of it entirely. Why? Because it’s not worth the heartache,’ she says. ‘You either have to leave because it’s too much, or suck up your pride and principles and get on with the work at hand.’

‘Most importantly,’ she says, ‘we need to really take a step back and reduce the threshold for those accessing support – it can’t be that we turn away the chaotic, dependent injecting drug user because they are ten minutes late for their appointment. We need to be present, consistently – not just from nine to five in an office, but at 6am in the car parks and at 10pm out with the working girls.’

Amy thinks that introducing key performance indicators (KPIs) for harm reduction might be the way to regain energy and focus, and redress the attitude that ‘no one really cares about what we do or don’t do on the front end’. Having ‘60 clients on your caseload and a mountain of admin on your desk’ translates to telling the client ‘take your script and I will see you in two weeks’, instead of giving them the time and energy required for a meaningful working relationship.

Amy: ‘We underestimate the power of a cuppa and a chat.’

‘We underestimate the power that just sitting down and having a cuppa and a chat, with no expectations, can have. We need time and we need patience, and unfortunately there is no pot of funding for that,’ she says, adding: ‘I regularly sit in team meetings in which discharge stats are sniffed out like dogs with a bone. These are people’s lives!’

Mark is also weary of the attitude that ‘NSP cover is something that can be delivered by anyone, often admin staff’. He believes that the initiative must be taken by treatment providers, in the same way that naloxone distribution has (eventually) been embraced. Just three years ago he remembers that a senior man­ager in one of the larger organisations was instructing members of staff that they ‘must not talk about naloxone as we are not a campaigning organisation’.

Many organisations are still silent about issues such as drug consumption rooms (DCRs) and heroin-assisted therapy, perhaps taking their lead from the government’s drug strategy, which (while acknowledging that we should protect society’s most vulnerable) only fleetingly mentions harm reduction and ignores the importance of outreach.

‘The providers of treatment really need to start to use the language of harm reduction and be clear about a commitment to those approaches, rather than continuing with a culture of harm reduction by stealth,’ says Mark. ‘If they don’t believe that they should do everything possible to campaign for initiatives and interventions that can reduce the numbers of deaths among their service users, then we are in an impossible situation.’

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

Investigate Duterte for ‘crimes against humanity’, says Amnesty

By
DDN
-

The International Criminal Court (ICC) must ‘urgently’ open an investigation into crimes against humanity committed during Philippine President Rodrigo Duterte’s ‘war on drugs’, says Amnesty International.

As many as 60 children have been killed in anti-drug operations since Duterte came to power last year and ‘yet not a single police officer has been held to account’, the human rights NGO states. Family members have told Amnesty how they saw police ‘shoot children dead at point-blank range as they were begging for mercy’, it says, while an Amnesty research term has also witnessed ‘large numbers’ of children suspected of drugs offences being held in overcrowded and unsanitary conditions. ‘Some said they had been beaten and tortured by police on their arrest, and claimed police had framed them by forcing them to pose in photographs with drugs that had been planted,’ it adds.

‘It is time for international justice mechanisms to step in and end the carnage on

James Gomez: ‘Time to end the carnage’

Philippine streets by bringing the perpetrators to justice,’ said Amnesty’s regional director for Southeast Asia and the Pacific, James Gomez. ‘The country’s judiciary and police have proven themselves both unwilling and unable to hold the killers in the “war on drugs” to account. It is time for international justice mechanisms to step in and end the carnage.’

The ICC should ‘cast its net widely’, he added, as responsibility was ‘not just limited to those pulling the trigger, but also those who order or encourage murders and other crimes against humanity’. Duterte and other high-level officials had ‘openly advocated’ for the killings, he said, which ‘could amount to criminal responsibility under international law’.

Duterte recently removed his police force from the violent crackdown on drugs following widespread protests after an unarmed 17-year old student was shot dead (DDN, November, page 4). However the Philippine government has now announced that the police will ‘resume providing active support to the Philippine Drug Enforcement Agency (PDEA) in the conduct of anti-illegal drug operations’, claiming that there had been a ‘notable resurgence’ in drug-related activity and crime since the police and other agencies were directed to leave to the PDEA in charge.

This latest decision would consign the poorest and most marginalised people in the country to ‘another catastrophic wave of violence, misery and bloodshed,’ said Gomez. ‘Since the police were withdrawn from anti-drug operations in October, there has been a marked decline in the number of deaths resulting from these operations. We can only expect that to reverse, as the police have the opportunity to pick up where they left off and resume their indiscriminate killing with impunity.’

 

Focus on Residential Treatment Centres: Acorn Recovery Projects

By
-

Acorn Recovery offers innovative recovery services that enable individuals and their families to break free from drug, alcohol and other addictions. They’ll help service users find not only substance recovery, but emotional, social, lifelong recovery.

Acorn offer a range of innovative drug and alcohol rehabilitation services across the North West, including treatment, reduction and motivation programmes, support accommodation, and social enterprise.

Their primary goal is not only abstinence for clients, but a lifelong recovery with meaning and purpose.

They provide a supportive community not just at the point of recovery, but over, above and beyond, including sustainable job opportunities. Their passion comes through informed knowledge and shared experiences.

Their expert counsellors, professional advisors, and committed volunteer staff have already found recovery, and you or your clients can as well with their help and a tailored recovery programme.

Find out more at Acorn Recovery Projects

For more residential treatment centres see the DDN Directory

 https://calico.org.uk/app/uploads/2015/10/acorn-300x137.jpg

Commissioning is risking lives, say GPs

By
DDN
-

Poor commissioning practice is putting patients’ lives at stake,
declared the GPs’ conference.

‘Only recommission services if they are ineffective, dangerous or wasteful – not on a whim,’ said Dr Gordon Morse, speaking at the 22nd RCGP/SMMGP conference, ‘Managing drug and alcohol problems in primary care’. ‘Don’t recommission services that are absolutely fine.’

Throughout the day, GPs from the platform and the floor expanded on this theme with passion and anger. The existing three-year cycle of commissioning was destructive, it was agreed, and was damaging continuity of care. Delegates shared their stories of how well-functioning services had been retendered and lost to a cheaper bidder, with quality of care sacrificed in the race to slash budgets.

Dr Stephen Willott: ‘The government’s drug strategy has long moved away from harm reduction, OST and choices.’

‘There were over 3,700 drug-related deaths registered in 2016 in England and Wales – a 44 per cent increase on 2012 figures,’ said conference chair Dr Stephen Willott. ‘That’s more than ten deaths a day and each one is a tragedy.’

The government’s drug strategy has long moved away from harm reduction, OST and choices, and the ‘destruction of drug services’ through dramatically reduced funding and constant retendering has increased the risk level for those on the bottom rung of this ‘unequal society’, he said.

More than half of those who died from drug-related causes were known not to have been in contact with treatment for at least five years, so ‘engaging in drug treatment clearly has a protective effect,’ he said. But why were so many people not in treatment, he asked. ‘Is it because of cutbacks, or are our services not accessible enough?’

The ACMD had recommended that access to allied healthcare and other services was important in promoting recovery from problematic drug use and reducing premature deaths. But local authorities often dealt with cuts by recommissioning in three-year cycles, which was ‘bad for all, with dips in services and quality, damage to continuity for individuals and arbitrary changes in prescribing,’ said Willott.

Throughout the day delegates were invited to share their experiences, and a picture soon emerged of (as one GP commented) ‘primary care being hammered so badly that there will be no capacity to re-engage’.

Agreeing that commissioning cycles should be at least five years, the conference called for a change in practice – to ‘recommission services only if the service is failing, after support to change the service has been tried’.

‘I’m left trying to plug the gaps’

A local GP is stretched to breaking point

As a GP, I ran a local enhanced service for patients with a drug problem in my practice for about 14 years. Now LESs have gone, a new agency is commissioned by the council to provide treatment to my patients, and they use my service to deliver the treatment.

Continuity is key in providing an effective service, particularly to this group of patients, but the contract has been transferred every three years – so we’re now on our third agency in four years. Each time the contract is put out to tender the budget is slashed.

Each agency has completely different ways of working, staff, protocols, markers of success, referral and assessment forms, and ways of communicating. We had a reliable, stable support worker with the previous agency and had just managed to set up a support group at the local youth centre. All this was lost in January of this year when the new service took over. We’ve had three different workers and more than six months with no worker at all, when I was left trying to plug the gap myself. My patients are thoroughly fed up with the changes and the poor reliability and continuity of the service.

The budget means staff are spread thinly, there is poor morale, retainment is low, and sickness among workers is high. Patients have come for appointments and not been told the worker is not coming. They have told their stories of past trauma and then not seen workers again – so why should they bother coming to appointments?

I can provide continuity but I don’t have the time to provide all the support that is needed. It should be so much more than a script. I’m relieved to say we haven’t had any drug-related deaths among our patients since our service started 14 years ago – but it is requiring so much more time and effort from me to fill in the gaps and keep the service safe.

I could not sell this type of work to other GPs with things as they are. Previously I would say how rewarding it was, and how good it was to work as part of a team. It’s now stressful for all the wrong reasons, that have nothing to do with the patients.

‘Our patients are casualties of the climate’

Dr Simon Tickle has lost trust in the system

We’ve run a GP practice with additional PMS [personal medical services] funding for socially excluded patients since 2001, but without any increase since about 2005. Some of our patients have lives that might make an ‘accidental overdose’ welcome, but a treatment environment has developed which I feel has made that option more attractive.

Frankly, without increased funding, we did need the help of the new drug treatment contractors with our 150 shared-care patients, but after two years and eight changes in workers they decided they needed to crack the whip. Wit

hin three months of starting a programme to take the least stable and more complex of our patients out of shared care because they were unsuitable for it, we had two heroin overdose deaths – and we’d previously had none for years.

One was a woman with whom we had had a warm and close relationship and had supported through many ups and downs. She had learning difficulties and was on a high dose of oral methadone and ‘injecting on top’. The other was a man whom we had managed to support successfully, but on transfer he disengaged from treatment as he did not want to lose his relationship with us or be managed under their policies, and he too was soon dead.

A supportive relationship with a known care worker is a lifeline for such patients and they

need to be able to opt to stay with the person or agency they trust, or at least have any transition dealt with very sensitively. I’m not attributing blame, but I would like to see more compassion and contrition. My concerned email to the local service was copied to the commissioner, but so far it has gone no further and I feel that the episode has been quietly kicked into the long grass.

These patients are casualties of a climate which puts a positive spin on what has happened in substance misuse management in recent years, but which is in fact deeply sad and bad for many. I have lost trust in the system – the same as many of my patients did very early in their lives.

‘Patients have stopped attending’

Dr Peter Exley witnessed the dismantling of responsive healthcare

I was a GP with a special interest (GPwSI) in substance misuse for around ten years, providing a clinic from my surgery to local and neighbouring practices. When substance misuse services were transferred from the NHS to local authority control in 2013, the service was put out to tender.

The existing service was based on GP patient lists, but the new service was based on local authority bound­ar­ies. As we were a mile from the county border, quite a few of our patients could no longer be treated.

We used to carry out services in a well-equipped, centrally located, modern medical centre. We provided nine hours a week of doctor time spread over two days, with flexibility to see patients outside the scheduled clinic times every day of the week. Patients could collect scripts and provide urine specimens from 8am to 6.30pm, Monday to Friday, and access urgent medical advice or discuss issues with pharmacists. Medical reviews were set as needed, from weekly to every six weeks.

The new service was set up in a church hall with no medical facilities, on the far edge of the geographical patch, and many drug users did not attend as they couldn’t afford the bus fare. Three hours of doctor time were provided one after­noon a week, and there was no easy access to medical support outside this time. Staff had their own problems to worry about – the TUPE’d drug workers were very demoralised as some had needed to reapply for their jobs three times in two years.

I have spoken to patients who have not received a medical review or given a urine screen for more than a year, and have been unable to obtain a change to their OST for over two months. I would frequently treat people’s medical problems when they attended the substance misuse clinic – mainly mental health issues, infections (especially chest), groin abscesses, DVT etc. After the change in service, patients stopped attending for medical problems and turned up in A&E.

In the ten years that we ran the service, one patient died. In the 18 months after the service ended, before I retired, three patients died – although one of these was probably not drug related. GPs preferred the old system, patients preferred the old system, drug workers preferred the old system – but the new system is cheaper.

 

 

 

Review of the year

By
DDN
-

Hanging on in there

Another year of tightened purse strings and record drug deaths for a weary and beleaguered sector, compounded by the shock closure of one of its biggest names

JANUARY The year starts on a comparatively upbeat note, with an evidence review from PHE finding that 60 per cent of England’s opioid users are now in treatment – a high rate internationally – with rates of HIV infection among injecting drug users remaining at just 1 per cent. High drug-related death figures and low rates of abstinence from opiates after three and six months of treatment, however, are cause for concern, it warns. Barack Obama, meanwhile, marks the end of his presidency by commuting hundreds of ‘unduly long sentences for drug crimes’, in sharp contrast to the ‘just say no’ rhetoric soon to be espoused by his successor.

FEBRUARY DDN’s annual service user conference hits double figures with One Life, another vibrant day of debate and networking that sees delegates from across the country gather to make this tenth event the best yet. ‘You have voices, you’re at risk, your friends and family have died,’ Collective Voice head Paul Hayes tells the conference. ‘These stories need to be heard.’

MARCH Durham Constabulary takes a bold step by announcing its intention to offer heroin-assisted treatment to problem drug users, while the Liberal Democrats call for possession of drugs for personal use to be decriminalised as a way of easing the overcrowding problem in Britain’s increasingly volatile jails.

APRIL President Trump dismays activists and harm reductionists as he signals a return to 1980s-style prevention campaigns, while closer to home the National Crime Agency issues a warning about the powerful synthetic opioid fentanyl and its analogues, which worryingly appear to be making inroads into the UK drug market.

MAY The closure of Lifeline after almost 50 years sends shockwaves through the sector, with CGL stepping in to take over many of the contracts for its 80,000 service users. ‘It’s easy for the field to think that this is all the result of big bad commissioners and funding constraints,’ former board member and ex-UKDPC chief Roger Howard tells DDN. ‘But in this circumstance I think that narrative probably needs to be challenged.’

JUNE An optimistic month for the harm reduction community as a new report moves Glasgow’s proposed consumption room a step closer and one of the country’s leading public health bodies calls for music festivals to provide drug testing facilities ‘as standard’. Activists worldwide also take to the streets for the fifth annual Support. Don’t Punish day of action.

JULY The much delayed Drug strategy 2017 finally sees the light of day, and gets a mixed reception from the field. While the government had driven a tough law enforcement approach it had to ‘go hand in hand with prevention and recovery,’ said home secretary Amber Rudd. The sheer scale of the challenge is aptly illustrated by analysis from the King’s Fund revealing that local authorities have been forced to reduce planned public health spending on services like drug and alcohol treatment by £85m as a result of government cuts.

AUGUST Scotland yet again records its highest ever number of drug-related deaths, at close to 900. The figure is 23 per cent higher than the previous year and more than double that of a decade ago, making the country’s fatality rate the highest in the EU, while deaths in England and Wales are also at their highest ever. Meanwhile, Trump instructs his administration to use ‘all appropriate emergency and other authorities’ to respond to opioid crisis in the country, which has seen overdoses quadruple since the turn of the century. ‘Not coincidentally’ the level of opioid prescribing has quadrupled over the same period, points out the interim report from his own Commission on Combating Drug Addiction and the Opioid Crisis.

SEPTEMBER Hot on the heels of last month’s bleak drug death figures and the King’s Fund’s worrying study from July, a report from the government’s own advisers, the ACMD, warns that funding cuts are now the single biggest threat to drug treatment recovery outcomes. A lack of spending on drug treatment is ‘short sighted and a catalyst for disaster,’ states its recovery committee chair, Annette Dale-Perera, while new figures from PHE map out the disproportionate impact problem drinking has on deprived communities.

OCTOBER The Welsh Government introduces a bill to create a minimum unit price for alcohol, despite the Scots’ attempts to do the same still languishing in legal purgatory. Release marks its 50th anniversary with a powerful pop-up exhibition, ‘The Museum of Drug Policy’, while Russell Brand’s interview with DDN proves divisive.

NOVEMBER ‘We constantly need to be saying, “Is our service right? Is it fit for purpose?’” Haringey’s Sarah Hart says in our comprehensive look at the commissioning landscape. ‘And I’m not sure that without a tender process people would do that.’ To illustrate the ever-changing nature of the challenges she describes, the latest NDTMS figures show a 23 per cent increase in the number of people seeking treatment for crack, along with a 12 per cent increase in those presenting with combined crack and opiate problems. And Scotland’s minimum pricing plans finally get the go-ahead after five years of legal wrangles, as the UK Supreme Court’s ‘landmark’ ruling rejects the Scotch Whisky Association’s final appeal.

DECEMBER As another year comes to an end, plans are well underway for the 11th annual DDN service user involvement conference, your chance to have your say on the future of the sector. See you on 22 February in Birmingham!

Hit Hot Topics: The word on the streets

By
DDN
-

The Word on the Streets

This year’s Hit Hot Topics asked, how can we give harm reduction most impact on the frontline? DDN reports, pics by Nigel Brunsdon.

‘What the heck are we doing, criminalising people for what they do to themselves?’ Nanna Gotfredson is the founder of Gadejuristen, the ‘Street Lawyers’ of Denmark. She brings legal outreach to homeless people and witnesses the ‘constant war on drug users – the constant fight between doves and hawks’.

Nanna Gotfredson: ‘harm reduction, outreach, legal aid – and hugs, because we also need love.’

‘Denmark is a welfare country – but the welfare system is designed for middle class people,’ she told the HIT Hot Topics Conference. With her team, she brought harm reduction, outreach and legal aid services – ‘and hugs, because we also need love’ – to people on the streets. It brought her into confrontation, and then ‘a critical dialogue’, with the police – but it also brought progress. Denmark now has five heroin clinics and has had drug consumption rooms since 2012, all with vein scanners.

‘You can get so well within a month,’ she said, adding, ‘We can’t have a situation where people choose between HIV and a penalty.’

Sue McCutcheon is all too familiar with these issues – and the gap between poor engagement with services and the potential for radically improved health. Working as a nurse with the Homeless Primary Care Team in Birmingham, she looks for the substance users who need help but are not coming forward. Her job is about ‘taking the service out to them, so they have healthcare’, working for four hours a day on the street.

Sue McCutcheon: ‘Imagine managing illness when you are homeless on the street.’

‘Rough sleepers generally have multiple healthcare concerns,’ she said, ‘and many present late in the pattern of illness. Health concerns will have gone on for weeks and months, until it becomes a health emergency.’ Many will have had a history of very poor engagement with services and poor care or treatment, which often colour the way they use services.

Homeless people suffered the same illnesses and challenging conditions as the rest of us, she pointed out. ‘But imagine managing diabetes when you are homeless on the street, dependent on soup kitchens and without benefits.’

Within the last 18 months she had noticed skin lesions that looked like impetigo. When swabbed they turned out to be group A strep, potentially serious for those whose immune systems are poor, and PHE Birmingham confirmed there had been outbreaks. Sharing spliffs and bottles and sleeping next to someone infected made such conditions easy to spread and hard to contain, but information in drop-in centres and ‘simple things like hand washing and hand gels in hostels’ were effective in stopping the spread of disease.

Another simple and effective measure had been the widespread introduction of take-home naloxone, equipping people with the skills to manage resuscitation from overdose and minimise harm.

‘I can’t talk about homelessness without talking about NPS,’ she added. ‘In Birmingham, it’s “mamba” – what we’ve seen in the last six to 12 months is shocking. One day last week we dealt with four people who were unconscious, vomit in their mouth.’ Others suffered cardiac arrest in the street. ‘And people say, “it’s just mamba”.’

Most people that McCutcheon saw and supported were groin or neck injectors – people who tended to say ‘I’m alright’ when they weren’t. ‘It’s your role to make sure they’re alright,’ she said. ‘It’s about being vigilant around healthcare issues.’

The reality for many was grim, living and using out in the cold, surrounded by faeces and vomit. ‘We have to look at all possible options to make a difference, including consumption rooms,’ she said. ‘I have a duty as a nurse to minimise harm. We need to look at every option that might produce a better outcome for people. It’s about building relationships… finding ways to deliver healthcare.’

 

 

 

 

 

 

 

Does language matter?

Different perspectives drew a very visible line between language and stigma.

Speakers at Hit Hot Topics covered many areas of harm reduction, drug use and outreach, and their experience came from different countries and contexts. But there was a common theme that ran through each of their talks – the ‘dehumanising language’ that perpetuated stigma.

Professor Susanne MacGregor of the London School of Hygiene and Tropical Medicine charted 30 years of drug interventions. Throughout ‘many contextual changes, during which harm reduction has had to struggle’, language had been adapted and new terms introduced. The New Labour era, ‘tough on crime and the causes of crime’, gave way to ‘the language of recovery’. Gaps grew between those who provided services and the people that used them.

‘Let’s stop using derogatory descriptions of people and move to a society where rights and evidence prevail,’ said Naomi Burke-Shyne, Harm Reduction International’s deputy director, in her talk about the oppressive impact of drug policy on science. ‘We can’t afford to abandon evidence, and language is a big part of that,’ she said. ‘We can’t use stigmatising language. Let’s stop talking about abuse – it implies all use is abuse.’ There were words that were formerly used about the LGBT community that were ‘unspeakable today’, she pointed out, adding ‘we need to move the same way’.

Prof Craig Reinarman of the University of California talked about drug policy reform and the ‘slow motion shift’ in the way we think about people who use drugs. Back in the 1980s, as initiatives spread from Liverpool like a ‘crack in the stone wall of punitive prohibition’, the very words harm reduction were ‘blasphemy, giving the stamp of control to addiction’. Similarly, in the US, scientists ‘couldn’t even use harm reduction in the title of a paper’ for it to be accepted.

Drug terminology became the language of fear: ‘Crack cocaine is the principle cause of urban ghettos’, President Reagan’s drug czar William Bennett had said in the 1980s. Even now, 40 years later, discussions take place ‘in a different register’ for different parts of the population. White people find treatment beds waiting, not prison cells, said Reinarman.

Delon Human of Health Diplomats, Switzerland, found dialogue missing where tobacco harm reduction was concerned. Of the earth’s 7bn population, 1.4bn were smokers and one out of two smokers would have a condition that would limit their life. In the UK e-cigs were resulting in the number of smokers being ‘the lowest it’s ever been’, with the ‘biggest gains in the shortest time’, yet public health seemed unwilling to talk frankly about the benefits.

‘We can all accept seatbelts, but for some reason they’re not accepted in drugs and alcohol,’ he said. ‘We need to find new language to frame the debate’.

Stephen Malloy of the European Network of People Who Use Drugs (EuroNPUD) called for plain language to galvanise the pace of a harm reduction response to drugs such as fentanyl, whose dangers were well known and documented. This was an example of direct action needing to be accompanied by straight talking, he said, quoting the Canadian activists’ slogan ‘they talk, we die’.

For Patriic Gayle of the Gay Men’s Health Collective, harm reduction was being compromised because the conversation between gay men and drug workers was ‘conspicuous by its absence’. Back in the ’80s, the LGBT community and substance misuse field came together to make sure Aids campaigning was as hard-hitting as it could be, but the dialogue had disappeared. Gay men ‘need to be engaged and wooed a bit to trust services,’ he said, and his organisation had had to resort to distributing resources and information that spoke honestly and openly to peers.

In a similar context, Joseph Kean, visiting research fellow at LJMU, looked at the language and culture of image and performance enhancing drugs (IPEDs) and asked, do we have relatable ways of reaching the ‘massively underestimated’ 70,000 people using these drugs?

DrugWise’s director Harry Shapiro felt that disconnection was abetted by the terminology we chose, and that drug workers must take a share of responsibility for perpetuating stigma through using ‘a language of hate’, which made people who use drugs feel ‘expendable’.

‘It resides within the community and the drug sector to challenge it,’ he said. ‘I don’t use addict, clean, drug abuse or misuse.’

Teaching a university course on personal and professional development, Dr Jennifer Randall had had the opportunity of exploring the triggers to attitude change. Introducing students to the Support, Don’t Punish campaign, she witnessed how they embraced a Gabor Maté approach – ‘think of people with love’ and had insight into creating the right language to change culture. Using Dr Carl Hart’s book, High Price, she encouraged ‘slow critical conversations’ that were effective in changing students’ attitudes and preconceptions.

The final speaker, Emma Roberts, demonstrated the value of making grassroots user-led initiatives the mouthpiece, putting them at the forefront of commissioning and capacity building. Through describing her work with the Harm Reduction Coalition in the US, she explained that the voice of people who used drugs was vital, not just in leading advocacy, but in choosing the right language and setting the tone. Working with different drug user alliances she was able to challenge stigma and redefine recovery, demonstrating that ‘it is not the opposite of harm reduction’, but all part of the same necessary conversation.

There’s something in the heroin

By
DDN
-

Claire Gilbert, Tony Margetts, Gilda Nunez, Bryony Sedgwick and Tim Allison describe their response to the emergence of fentanyl and carfentanil in their local area.

Hull and the East Riding have been at the centre of a cluster of drug-related deaths from the end of 2016 to the end of May 2017 that appear to be due to fentanyl and particularly carfentanil, one of the 40-plus analogues of fentanyl in illicit heroin.

Carfentanil is so powerful it is only licensed for use in animals (eg to tranquilise elephants); an amount less than 1/2000th of a grain of salt (1 microgram) is biologically active in humans and approximately 1/1000th of a grain of salt (2 micrograms) can be lethal. This is a brief account of that event, how we responded at East Riding Public Health, and key learning points.

The first death potentially related to fentanyl/carfentanil was in September 2016 – we cannot be sure as it is not part of the standard toxicology screen routinely tested for in the UK and was not tested at the time. Numbers of deaths started to rise and remained well above typical rates until the end of May.

We sent out a request for information and a drugs worker in the local prison, HMP Hull, reported that clients believed the heroin was being cut with fentanyl or Xanax (a benzodiazepine) and witnessed people ‘going over’ (overdosing) as a result. In addition, pharmacists undertaking harm reduction training in East Riding reported users describing a change in how the heroin felt – that they were getting a quick strong hit. Benzodiazepines would be a concern, but were unlikely to be killing people so quickly.

Evidence from North America raised concerns over possible fentanyl/carfentanil as a cause of drug-related deaths. The first case of carfentanil was found in April, and the test was used retrospectively where possible for previous post-mortems. One pharmacist said ‘they are all saying “there is something in the heroin”’, and this became the title of our harm reduction leaflet which was distributed widely (see left). We issued a warning to local treatment services, needle exchanges and prisons, and raised awareness through the local media. Humberside Police issued a separate additional warning.

A meeting was held between the coroner, Hull and East Riding Public Health, the police, and the toxicologist, and toxicology reports were released to East Riding Public Health. Our investigations are ongoing and inquests are yet to be held on the most recent deaths.

There were 31 deaths attributed to accidental opiate overdoses between September 2016 and May 2017 in East Riding and Hull; 35 per cent had evidence of standard fentanyl and 45 per cent had carfentanil. Two cases (6 per cent) alarmingly had evidence of carfentanil but no heroin. The people most at risk were men, average age 39, long-term users, using alone.  There were a disproportionate number who were homeless, living in shelters or recently discharged from policy custody. This raises the possibility that those using a new or different dealer may be most at risk.

Death appeared to happen very quickly, shown by how the deceased were found (eg still holding the needle) and biological measures (relatively low free total morphine/free morphine suggesting a rapid death). Of the 31, only four people (13 per cent) survived long enough to make it to hospital, none of whom survived due to severe brain injury, and naloxone appeared to be ineffective. It is unclear whether, if given very quickly, very high doses of naloxone may work. In one case, a user was admitted to hospital following using heroin, had taken the entirety of one kit of naloxone in the community and started a second and recovered. He died a few days later following a further hit.

Our work would suggest there are indicators that should alert an area to the possibility of fentanyl or carfentanil overdoses and lessons from our recent experience. These are:

• Listen to current drug users from prisons, needle exchanges and elsewhere – they might spot the change in the drug supply early.
• Be alert to changes in the drugs market – police intelligence and treatment services reported a greater availability of heroin, at a lower price and higher strength during this cluster.
• Work with your partners, in our case the coroner’s court, Humberside Police, treatment services, prisons, pharmacists and public health.
• The very high potency of carfentanil has implications for emergency services, who may need to take extra precautions to avoid contact with the substance.
• Watch out for features that suggest fentanyl and carfentanil and consider testing for it at post-mortem – sudden death, unusual spike in deaths, high total/free morphine ratios, lower morphine toxic levels than you might expect.
• Raise awareness of risks to users, eg through a leaflet (above).
• Consider availability of naloxone and need for higher doses.

Dr Claire Gilbert, public health registrar

Tony Margetts, substance misuse manager

Gilda Nunez, public health officer

Dr Bryony Sedgwick, foundation doctor

Dr Tim Allison, director of public health

 

 

CQC: Forewarned is forearmed!

By
DDN
-

The CQC’s new briefing
is essential reading
for the sector, says
Nicole Ridgwell

On 29 November 2017, CQC published ‘Substance misuse services: The quality and safety of residential detoxification’, a briefing of the 2016/ 2017 inspection cycle. The document, which is necessary reading for all within the sector, is significant for its almost exclusively negative tone.

The nine-page document contains no reference to the hard work of frontline staff; no recognition of providers choosing to work with some of the most vulnerable in society; and no thanks for the benefits to individuals and society.

From the 68 services analysed, CQC identified a number of general concerns, including:

• providers that did not assess risk to individual clients adequately
• services that did not follow best practice guidance
• poor management of medicines, including controlled drugs
• providers that did not provide staff with relevant training
• failure to safeguard clients by carrying out employment checks on staff

Certain concerns raised within the document are those that you would likely find in an overview of any segment of the healthcare sector, such as record keeping errors. Other concerns are far more likely to be found in substance misuse services, for example, the reference to failing to provide treatment in line with the NICE guidelines.

NICE guidelines are guidelines not tramlines, and there are valid reasons why a service may choose to depart from them. We have been successful in challenging CQC by demonstrating why the service chose their particular course of treatment or medication.

Inspectors often make judgements about substance misuse services based upon a misunderstanding of the client base. Likewise, the issue of ‘complex and varied healthcare needs’ is referenced.

As providers will be acutely aware, those experiencing long-term drug or alcohol dependence often suffer from a range of health issues, mental and physical – many of which reduce or disappear during detoxification. Providers know this and risk-assess the suitability of admission accordingly. Were one to believe this briefing, it would seem that providers regularly admit clients with health needs they cannot meet, indifferent to potential dangers to the individuals.

Despite reading this in draft inspection reports, I have yet to find this to be true once the circumstances of the examples are explored. Indeed, this briefing could be said to be reflective of a regulator which has entered a new sector and was not prepared for the practices they found.

This is reflected in the statistics, which make for stark reading: Of the 68 providers, 49 (72 per cent) were required to make improvements after findings that they had breached regulations of the Health and Social Care Act and failed to meet fundamental standards of care. Forty-three providers (63 per cent) were found to have breached Regulation 12 (Safe Care and Treatment) and eight providers (12 per cent) were served with enforcement action.

In summary, this is stark but necessary reading. It provides an insight into CQC’s concerns, allowing providers and staff to reflect on their own practices, address any they find wanting, and ensure that they have the evidence to justify why they have chosen a particular course of treatment or medication.

It is not pleasant or encouraging reading, but it pro­vides the sector with an insight into its regulator’s view of it. Whether you agree or disagree with its find­ings, it is always better to know; forewarned is forearmed.

Nicole Ridgwell is solicitor at Ridouts Solicitors

Survey demonstrates need for improvement of hepatitis C services

By
DDN
-

An estimated 160,000 people are living with hepatitis C in England. Yet, in 2015, fewer than 12,000 people were diagnosed and fewer than 10,000 people were treated (1). Infected individuals can unknowingly transmit the infection, which makes preventing new infections – and eliminating the virus as a public health threat – a significant challenge.

People who inject drugs are believed to represent around ninety per cent of total hepatitis C cases (2). Over the last three months the I’m Worth… campaign, in collaboration with DDN has been surveying professionals working in substance misuse services in the UK.* The aim was to help identify and address the barriers and educa­tional gaps around hepatitis C to ensure those working in substance misuse services and campaigns such as I’m Worth…, can provide meaningful support to those most at risk.

Throughout the responses, three major challenges were identified.

1. There is a lack of understanding about hepatitis C care amongst service users  

‘I regularly see service users who are partially or substantially ignorant of issues around hepatitis C.’
Drug and alcohol support worker

Sixty-six per cent of addiction support workers state there is not enough information about hepatitis C diagnosis, care and services available for people with substance misuse problems. There is a lack of understanding of hepatitis C among service users and not enough opportunities to educate them about the disease. This demonstrates the need for additional education and resources to be made readily available for people accessing addiction support.

‘We need loud voices explaining that safe treatment is now available and they [hepatitis C sufferers] are entitled to it. Clear, simple messages of getting everybody treated, and the possibility that hepatitis C could disappear from communities if everyone accessed treatment.’ 
General practitioner

2. Service users often have a poor relationship with health services

‘Most of our clients don’t have a good relationship with the NHS and hospital care through bad experiences.’
Nurse practitioner

Almost two thirds of respondents felt that the number of hepatitis C sufferers linked to care was poor. Stigma associated with both addiction and hepatitis C means that many of these individuals are often reluctant to engage with care.  It is therefore important to tackle the stigma around the disease and develop a more systematic approach to actively seek hepatitis C sufferers and provide them with convenient ways to access treatment.

‘Many clients feel that there is not enough help, support, compassion and facilities available. They suffer judgement every single day.’
Counsellor

3. Chaotic lifestyles are a barrier to care

‘The biggest challenge is their general lack of self-care. Often people will be aware that they have hep C or that they are very likely to have it, but won’t seek testing or treatment for years.’  
Drug and alcohol support worker

Given the challenges people dealing with addiction face, managing their health is often unlikely to be a priority. Many users do not take care of themselves and are therefore unlikely to have the motivation or resources to seek diagnosis, or if they are positively diagnosed, they may be reluctant to undergo treatment. Support is needed to improve the number of people linked to care and opportunities for sufferers to share their personal experiences via peer-to-peer meetings.

‘[Once diagnosed] It can feel like just one more thing they have to deal with and it’s not always clear to them how this may improve the quality of their lives when they are so unstable.’  
Drug and alcohol support worker

The survey results show that more needs to be done to support hepatitis C patients. Despite the WHO worldwide ambition to eliminate hepatitis C by 2030, the UK is without a written disease strategy and has no complete framework in place to trace, track and treat people with hepatitis C. In the absence of a complete care framework for hepatitis C, community-based services become a key component for HCV treatment and drug treatment centres become a gateway for people at risk to access care. It is therefore important that service workers feel confident in encouraging testing and providing service users with advice on next steps and available treatments.

The I’m Worth… campaign aims to help spread awareness and understanding of hepatitis C. It is designed to empower people living with the virus to get tested, access care and services, highlighting that all people living with hepatitis C deserve the chance to be treated and provided with the best care available, no matter how they were infected.

*    48 respondents which included peer support workers, GPs, social workers and nurse practitioners.

References:
1 Public Health England. Hepatitis C in England: 2017 report. (2017).
Available here
2 Hudson, B., Walker, A. & Irving, W: Comorbidities and medications of patients with chronic hepatitis C under specialist care in the UK. Journal of Medical Virology. (2016). Available here

November 2017, HCV/UK/17-04/NM/1634g

New drugs minister pledges support

By
DDN
-

Addaction redoubles commitment to tackling stigma

We are determined to deal with the scourge that is stigma,’ said Lord Carlile at Addaction’s 50th birthday event at the House of Lords. New drugs minister Victoria Atkins (left), under secretary of state for crime, safeguarding and vulnerability, said that stigma was an obstacle to recovery and gave her commitment to exploring options for protecting public health funding for drug and alcohol treatment.

‘I got to the point where I accepted stigma – I was a drain on society,’ said Les, an Addaction volunteer from Weston-super-Mare. ‘I started to believe I was a thief and a junkie – I started to accept it in the end. People focus on failures – they don’t focus on people who actually make it. Addaction has given me a purpose in life. We judge people for their behaviour and we don’t look underneath. To judge them compounds the shame.’

‘Going into the service building was when my stigma started,’ said Hayley from Wigan, who had to let her ex-partner take custody of their young daughter because of her problem drinking. ‘I felt judged going in, and this made me eventually drop out of the service. But then Addaction adapted to me and I had home visits. I’ve been stigmatised at my daughter’s school by staff and other parents, but Addaction made me a recovery champion and really helped me.’

‘We want to confront stigma head-on and this means educating the public to increase empathy and understanding for those tackling drugs, alcohol and mental health issues,’ said Addaction CEO Mike Dixon. ‘By challenging stigma, we believe more people will come forward for support and more people will recover and reach their potential.’

Kate Slater of Addaction North East with Mary Glindon MP
Minister Sajid Javid with Addaction CEO Mike Dixon, Chair of trustees Lord Carlile, Karen Tyrell and Alice Dyke

 

 

 

Winners help transform lives in recovery

Harry Shapiro, DrugWise director (right), was among prize-winners of the Marsh Volunteer Awards, presented by Addaction and the Marsh Christian Trust. The awards recognise those who have helped transform the lives of people in recovery, and his prize for media recognised his articles, lectures and national media interviews representing the views of alcohol and drug users and challenging stigma.

‘Harry is hugely knowledgeable and presents his information and evidence in a skilled non-judgemental way, acting as an advocate for service users and their family and friends,’ said Jon Murray, Addaction’s community engagement and implementations lead, who handed out the prizes to winners.

The regional award winners are Tommy Allan, Joanne Taylor, Sue Peoples, Bryony Homewood and Carole Cliffe, and recovery award winners are Lynsey McKenzie, Leanne Gillon and Harry Shapiro.

More questions than answers

By
DDN
-

As he prepares to leave the substance problems field, George Allan poses a few questions and fires some parting shots.

Has the recovery movement been beneficial?
Recovery as the model for service delivery has dominated the discourse for the last decade – but has this been a good thing? There is much on the positive side: it has challenged the negative mantra that substance problems are ‘a chronic relapsing condition’, it has encouraged the emergence of support networks and attendant activities and it has been a driver for incorporating reintegration into mainstream services.

Aspects of the recovery agenda have, however, had a detrimental influence. An alliance of treatment ideologues – politicians for whom evidence appears to be irrelevant and celebrities determined to persuade others that what has helped them is right for everyone – has promoted an anti-treatment, abstinence-only narrative. Harm reduction has been side-lined in some areas and this has had consequences.

While it would be simplistic to blame the rise in drug deaths on recovery (the ageing cohort of vulnerable users was always going to be a challenge), the anti-OST agenda hasn’t helped. Far from many being ‘parked on methadone’, there is clear evidence that people are often not staying on OST long enough and dropping out of services too quickly to ensure stabilisation, with the attendant increased risk of overdose.

As this becomes more evident, a rebalancing is in the offing. Scotland is looking to a ‘seek, keep, treat’ model to reduce drug deaths. Can we avoid the mistakes of the past by making the shift to addressing the needs of the most vulnerable without losing the gains which recovery has brought to those who feel able to move on?

Why do we pay so little attention to ‘endings’?
In the light of the need to retain some people in treatment for longer, it is alarming that we give little attention to dropout and the wider processes of ‘endings’, both planned and unplanned. A plea to the research community – let’s look more closely at endings in all their shapes and forms.

Whatever happened to controlled drinking?
Around 1980, as the dust settled on the Mark and Linda Sobell affair and the controversies surrounding research that suggested some people with significant problems with alcohol could achieve harm-free consumption, some services began to provide controlled drinking as an option. The agency I was working for was one of these. It had clear guidelines regarding suitability and a controlled drinking programme aimed to help the person to achieve non-problematic use. Few now talk about controlled drinking. There is plenty of guidance on brief interventions, whose goal is nudging risky drinkers towards moderating their consumption. But what about rigorous, individualised controlled drinking programmes? Are they still going on out there under the radar?

How can we enable people to regain a stake in society?
Reintegration means different things to different people but, for many, obtaining paid employment remains just an aspiration. There are many projects preparing people through volunteering and ‘job ready’ programmes, but few which open the door to actual jobs. There are shining examples, including some social enterprises, but the numbers gaining employment are small. One way to increase volume could be to engage with large scale employers who would provide training and subsequent jobs, with substance problems agencies supplying personal support over an agreed timescale. The employer bears the training costs but, in return, has the reassurance, as does the person themselves, that any difficulties will be addressed: a win for all. Piloting such a model on a significant scale is overdue.

Is stigma ever helpful?
The effects of stigma are well documented: it reinforces a negative self- image, erodes self-confidence and can serve to militate against change. But is it always counterproductive? Neil McKeganey was shouted down in the pages of DDN when he suggested that it wasn’t. Far be it for me to defend him, but the critics missed his point. At a societal level, we define what is acceptable behaviour by stigmatising what is unacceptable. The trick, of course, is to censure certain actions (eg public drunkenness; sharing needles) while trying to avoid defining the individual solely by their behaviour – a subtle distinction nigh on impossible to maintain in the real world. Stigma is also about the use of language, of course, which takes me to my next question.

Can we please get rid of the word ‘alcoholic’?
After nearly 50 years linked to the field, I still don’t know what it means. It seems to suggest that there is a group of people who are somehow different in kind, as opposed to conceptualising problems as being a continuum. Worryingly, it plays into the hands of the drinks industry which has a vested interest in maintaining the fiction that there is a group of irredeemably dependent drinkers who will drink come what may, while the rest of us can imbibe with impunity. Is there a better word? How about the phrase ‘person with an alcohol problem’?

Why are governments so resistant to change?
Is it just fear of tabloid headlines? Certainly some politicians are only prepared to emerge from the trenches once they retire. This resistance is not only to legislative change; there is a reluctance to back service options for which there is supporting evidence, such as heroin assisted treatment (HAT) and drug consumption rooms (DCRs). HAT has a lengthy history in the UK; from the original ‘British System’, through the work of Dr John Marks to the RIOTT trials, the lifesaving and stabilising virtues of HAT for carefully identified individuals is well evidenced. From Switzerland to Canada, examples of well-run DCRs demonstrate that they reduce a range of harms and can draw people into other services. Why, then, are the national and devolved governments so coy?

Should we support changes in the law?
And finally, this takes us neatly to different legislative models of control. In the current political climate, the government is unlikely to revisit the Misuse of Drugs Act anytime soon. This is a pity, as lessons from elsewhere tell us that some models of decriminalisation, linked to a health-based approach, have considerable merit.

Such developments are a long way from the more radical reforms advocated by some. It is ironic that the effective legalisation of cannabis in certain countries and states in the US comes at a time when we are beginning to understand the nature and extent of mental health problems associated with it.

While prohibition remains the cornerstone of drug control, laissez faire continues to characterise the approach taken to alcohol, particularly in England. Is this paradox sustainable?

In the minefield of social control, it is a truism that greater availability leads to more widespread use and a rise in health problems, while proscription leads to less use at a societal level but increased criminality. However, there are lessons to be learned from tobacco control. Consistency of policy across successive governments of differing political hues has led to price increases, restrictions on availability for children, the elimination of advertising and the provision of cessation services, and combined, these have achieved a remarkable public health success story. Smoking remains a drug epidemic but one which is in serious decline: a positive note to end on.

Some of the challenges the field faces are changing, many remain the same; I wish those working in services the best of luck in meeting them. And to readers grappling with their own problems I would like to say: ‘if it works for you, it works for you, and don’t let anyone tell you otherwise!’

George Allan is outgoing chair of the Scottish Drugs Forum. He is the author of Working with Substance Users: A Guide to Effective Interventions (2014; Palgrave)

The iCAAD Knowledge Hub

By
DDN
-

Stay with it

Tenacity is vital when it comes to working with troubled young people, Addaction’s Sam Dixon tells DDN.

When Sam Dixon from Addaction’s YZUP young people’s service received an ‘Exceptional Individual’ award at the organisation’s south west regional conference in September, the case study delegates heard was of a 13-year-old girl she’d begun working with several years ago.

The young person was in ‘self-destruct mode’, with issues around substance misuse – alcohol and MDMA, then prescription medications – risky behaviours and self-harm, and who had been let down by a range of other agencies.

‘She’d had a very late diagnosis of ADHD, which didn’t help by then,’ says Dixon. ‘She was self-harming quite significantly – at one point we were seeing her every day, essentially making sure she was still alive. She was in supported housing for a while, which was quite challenging, and even while I was working with her other agencies would come in, get involved and then pull out.’ There had also been substantial police involve­ment around anti-social behaviour, and ‘an attitude towards her that she was a trouble maker, the leader of the pack – another bit of letting down,’ says Dixon.

‘Working with young people is about hanging on in there, even when you’re told to go away,’ says Sam Dixon, who received recognition for her work from Addaction’s chair Lord Carlile.

As those other agencies began to withdraw, what was it that made her persist? ‘Gut feeling,’ she states. ‘My professional instinct was that there was much more going on than was clear on the outside.’

The key elements to engaging successfully with young people are a sense of humour, patience and tenacity, she stresses. ‘It’s about hanging on in there even when you’re being told to go away, and listening to what’s really happening with that person rather than just making an assumption.’

So how did she finally win her trust? ‘This was a young woman who’d had a lot of professional involvement, with people saying, “She’s too hard work, she keeps pushing me away, I’m going to give up.” What she got from me was that that wasn’t going to happen.’

Were there occasions when she did feel like giving up? ‘No, there were times when it was hard, and times when I felt quite distressed myself, but I had brilliant line management support all the way. I never once thought “I can’t do this anymore”. All I saw in front of me was a young person in distress.’

At one point Dixon was making a weekly 120-mile round trip to see her – there was no point when management said, ‘You need to give up on this and focus elsewhere?’ ‘No. I can’t say it didn’t impact on the rest of my working week, but I was very clear about why I was still involved and the work that needed to be done. I was very lucky that my manager listened to that, and the support wasn’t just there – it went to a very high level at Addaction because the safeguarding concerns were so great at times. The extremity of the situation – and the fact we were seeking funding for tier 4 treatment – meant it had to be reported to our commissioner as well.’

For anyone working with similar clients, what advice would she give? ‘Remember that there’s a young person at the centre of it, and that they are not their behaviour. Also, be really, really clear on your boundaries. That young person always knew that it was a professional relationship, and that’s what held her – she knew how far she could push me, what she could expect of me, and that it would be delivered. The building of trust was about keeping those boundaries strong, because sometimes you do just want to pick them up and take them home. In a case like this there were multiple times when I would have done that, but you don’t. Being clear about her boundaries wasn’t something she’d had from a lot of other professionals, so it had a really positive impact on her. And, obviously, it’s about patience.’

Given how long she worked with her, at what point did she feel ‘I’m starting to make some progress?’ ‘The nature of her mental health meant it was very up and down,’ she says. ‘We got her into college and things were going really well, but then they started to go wrong again. But I think once she went into residential treatment, and that had the impact it did – which was amazing – you very quickly saw definite changes in the way she thought about things, the way she felt about herself, and her developing confidence.’

Not only is this ex-client now an Addaction volunteer – ‘she’s very, very keen to put back into the organisation’ – but she has a full-time job and is also studying for a degree. ‘She blows my mind,’ says Dixon. ‘And it says to me, “You were right.” You have to be able to see the potential in people even when they’re in a place where they can’t see it themselves.’

Are you involved in innovative practice? iCAAD is supporting DDN to run the Knowledge Hub – a space in the magazine to share ideas and effective ways of working. Contact the DDN editor to be featured here.

iCAAD is the International Conferences on Addiction and Associated Disorders

Domestic violence: Stopping the hurt

By
DDN
-

Perpetrators of domestic violence are being helped to challenge and change their behaviour, as Phil Price explains.

For all the evidence linking domestic violence with drug and alcohol misuse, there’s little shared knowledge of how we can best collaborate to promote safe and effective solutions. This is a shame, as our experience of working with perpetrators highlights the very real benefits for everyone involved – when the right approach is used.

The Domestic Violence Intervention Project, which takes referrals from around 30 London boroughs, worked with Cranstoun Drug Services to develop the Men and Masculinities programme to help men in recovery challenge and change the behaviour that has caused distress and damage in their relationships.

Four in every ten men attending treatment for substance use have been physically or sexually violent towards their intimate partner in the previous 12 months. Our programme works with men who use physically and sexually violent behaviours, as well emotional abuse and coercive control (we define coercive control in its broadest sense).

Working with drug and alcohol professionals, we use a special screening tool to identify these perpetrators within their cohorts. The tool is a positive mechanism to help perpetrators start taking responsibility for their actions, make sense of the worst of themselves and their experiences, and understand how they ended up in treatment and how they came to be hurting their families.

Using group discussions, perpetrators share their experiences.

Sessions are specifically designed to address intimate partner violence and draw on a wide range of approaches including cognitive-behavioural, social learning theory, psychodrama, psychotherapeutic and relationship skills teaching. Using group discussions, perpetrators share their own stories and experiences and are then encouraged to apply insights they have gained to their own behaviours and attitudes.

We use exercises to explicitly name the substance use and its effects on the partner and children – the perpetrator’s use, what they gain from this in the short and long term, how a partner may use substances as a coping strategy for the abusive man’s behaviour, and how it may be used instrumentally by the man to control the woman and children further.

By the later sessions we expect perpetrators to have stopped their physical and sexual violence and stopped, or significantly reduced, their use of alcohol and/or drugs in a way that instrumentally harms, scares or controls their partner.

None of this is about anger management or counselling groups. Sessions instead create a challenging environment while offering support for personal change by addressing issues of masculinity, sexual respect, the instrumental and systematic nature of intimate partner violence, and intimacy.

They also include specific modules around the impact of domestic violence and substance use on children, considering post-violence parenting, fear and shame-based parenting, attachment, post-separation abuse, and letting go.

Survivor safety is the programme’s most important priority.

The programme makes survivor safety its single most important priority, as do other Respect-accredited programmes. This stamp of approval from Respect (the accreditation body for domestic violence perpetrator programmes in the UK) is very important to us and provides a mark of good practice for referrers, partner agencies and service users.

As part of this safety commitment, any man accessing treatment for his use of violence and abuse must provide contact details for the people at risk from his violence so we can provide support, safety and confidentiality for the victims of his violence.

The Men and Masculinities programme works from a drug and alcohol perspective because it deals with some of the greatest triggers for relapse by encouraging perpetrators to think through fundamental aspects of their life – relationships, conflict and contact with their children.

Working in Islington, we have now run two full programmes and, so far, worked with 30 men in total. Of the 27 men who started treatment in the Men and Masculinities group programme, 77 per cent completed at least 30 hours of intervention relating to their use of coercive control and violence.

Men on the programme recorded (via TOPS) reducing their drug and alcohol use by 29 per cent and recorded a 40 per cent improvement in their quality of life. Active, supportive contact was established with more than half of the attendees’ partners/ex-partners.

At the Domestic Violence Intervention Project, we’re used to saying that no single agency, sector or service can solve DV simply because it is such a complex problem – but the same is true of drug and alcohol misuse. Implementation of the forthcoming Domestic Violence and Abuse Bill and responses to Ofsted’s recent call for a greater focus on perpetrators and DV prevention strategies put an onus on those working in both fields to recognise their mutual need and benefit.

More of us now need to share what we know and build new understandings to fill the current gap in service provision for integrated DV and substance misuse support, while making sure that the survivor’s safety is always at the centre and is the focus of all our work.

Phil Price is development manager at the Domestic Violence Intervention Project (DVIP)

Take part in the Global Drug Survey

By
DDN
-

Global Drug Survey 2018 – the latest version of the world’s largest drug survey – has just been launched. Prof Adam Winstock asks for your help in assessing the new drugs on the block.

All things novel

Can you help us define and describe the new drugs on the block? Your experiences will help us to share information with others on what drugs are worth a mention, what’s best avoided and how to stay safe.

With over 500 new drugs being identified in the last five years, we’re known for having our ear to the ground and learning, before others, about drugs that come onto the market.

Our global drug survey helps us gain a unique understanding of new drugs:

• form (eg pill, powder, liquid)
• how people take it
• what type of other drug it most resembles (eg cannabis, trips, stimulants, opioid) 
• how long it takes for the effects to come on
• how long a single dose lasts 
• intensity of effect 
• positive and negative effects 

Most research on drugs is based on toxicological analyses, web scrapings of user forums and emergency department presentations, whereas our research comes straight from the horse’s mouth, so to speak. That’s 100,000 horses in fact; all sharing their personal stories with us, in depth and in their own way – something we’re really proud of. And since we started, we’ve produced some of the most highly cited papers on mephedrone, synthetic cannabinoids, DMT, the NBOMe series, methoxetamine and LSD analogues (and we have a new one on ayahausca coming soon).

In previous years, drugs were designed to mimic cannabis (the synthetic cannabinoid receptor agonists or SCRAs) and stimulants (cathinones like mephedrone and methylone), however, last year we found that new drugs were commonly being produced to mimic psychedelics. With the rise of fentanyl analogues and other depressant drugs, GDS aims to get a better insight into how they are being used and who is using them. That way we can share information and help support people to stay safe.

If you’ve tried a new drug in the last year and want to share your experiences and opinions anonymously, please take 15-30 minutes to  contribute to the world’s largest drug survey www.globaldrugsurvey.com/GDS2018

Prof Adam Winstock is founder and CEO of GDS, consultant psychiatrist and addiction medicine specialist, GDS2018 #KnowYourDrugs

Media Savvy

By
DDN
-

The news, and the skews, in the national media

Imposing piffling tariffs only targets the poor and looks like the paternalistic meddling of a bourgeois elite that thinks it is okay to sit at home with a bottle of chablis so long as the plebs can’t get loaded on cheap cider and smash up the town centre. As if the rich can take their drink but the poor cannot.
Giles Coren, Times, 18 November

It is not the price of alcohol that has to change, but social attitudes to drinking. But that would be too difficult – a meaningless gesture like this is far more grandiose.
Jan Moir, Mail, 17 November

Cost of beer, cider and whisky to ROCKET after ruling hikes prices by 25%
Star headline, 15 November

We basically tell people with this chronic illness we might be able to help you initiate your recovery, but then you are on your own. Good luck! The journey to long-term recovery for the leading cause of death for those under 50 in America shouldn’t have to be all luck. It’s up to all of us to get involved.
Greg Williams, Guardian, 4 November

Scots get set for ‘booze cruises’ into England as Supreme Court clears the way for minimum alcohol prices.
Mail headline, 16 November

We believe minimum pricing will help in the fight against the scourge of alcohol abuse. It is not certain. It will be judged by results. But the overwhelming feeling among those taking an interest in the matter is that it must be tried… Wearying statistics tell us Scotland has long led the way on alcohol abuse. It is now, we are happy to say, leading the way on tackling it.
Herald Scotland editorial, 16 November

The Scottish government and the supreme court have now shown that public health considerations do not have to take second place to market, competition or any other factors: they have merit in their own right. Westminster should take note.
Mary Dejevsky, Guardian, 16 November

It’s time to shift away from a drug policy framework that’s dripping with moralism while utterly lacking humanity and effectiveness. The evidence is utterly clear on this: making drug use illegal doesn’t stop people doing it, and doesn’t protect them from harm. Make no mistake, prohibition kills and a refusal to change direction at this juncture is unforgivable. Caroline Lucas MP, Independent, 2 November

Focus on residential treatment: ESH Community Home

By
-

ESH Community Home treatment centre is a fully residential CQC registered peer-led and supported rehab facility for men over the age of 18 whose lives have been adversely affected by their addiction.

The property is a smallholding set in four acres of grounds located in the beautiful Warwickshire countryside in the Heart of England, away from everyday distractions providing a safe and supportive setting. The property was extended and fully refurbished during summer 2017.

Residents eat, sleep and undertake all the core activities of the programme either at the house or within the grounds.

Meals are freshly prepared and cooked on site by dedicated catering staff.

The location is supported onsite 24/7.

The rooms are mainly single; however, there are two twin rooms which allow residents to receive additional support at the beginning of their stay.

The facility was purposely established as a small recovery community with treatment and accommodation in the same location as the central site.

The accommodation is for a maximum of eleven residents are supported to provide the best possible support with the right amount of personal dedicated time from the centre’s experienced staff.

The centre is run and managed by professional staff, volunteers and mentors who have all had their own personal experience of addiction and perhaps more importantly recovery.

ESH recognise that addiction is a result of people’s life experiences and the treatment we offer is personalised to accommodate each individual’s circumstances.

Their program has been specifically designed to support and encourage residents to participate in a range of psychosocial and educational sessions to meet their needs.

“Everyone at ESH Community has found their own peace and contentment as part of their journey of recovery.

We have the experience and knowledge to support and guide you to find freedom and peace in your life.”

Find out more at ESH Community Home

CQC voices ‘serious concerns’ over residential detox

By
DDN
-

Clients undergoing medically supervised withdrawal in residential settings are being ‘put at risk’ by poor quality care, according to a briefing from the Care Quality Commission (CQC).

The document, which is based on inspections of nearly 70 services over a two-year period, says that the regulator uncovered ‘multiple concerns’ and warns that ‘many independent clinics in England are not providing safe or good quality care’.

More than 70 per cent of the facilities inspected were deemed to be failing in at least one of the fundamental standards of care that ‘anyone should have a right to receive’, says the commission, with more than 60 per cent not meeting the basic standard of ‘safe care and treatment’. Many providers were not assessing risks to clients’ safety before admission, adequately training their staff or following recognised clinical guidance, it states, and there were also concerns around the appropriate handling, storing and dispensing of medicines.

Examples included staff who hadn’t received appropriate training in basic life support, safeguarding or consent, or who were administering methadone without having been assessed as competent to do so. Others had failed to plan how they would manage a client’s epileptic fits during withdrawal, despite being aware of their medical history.

More than 2,600 people received medical detoxification from a residential service in England in 2015-16, around 1 per cent of the total number in drug and alcohol treatment. Some of the providers had ‘already improved’, the regulator notes, while others will be subject to re-inspection. Four, however, have ceased operating following the concerns raised by inspectors.

‘We are deeply concerned about how people undergoing residential-based medical detoxification from alcohol or drugs are being cared for in many independent clinics across the country,’ said the CQC’s deputy chief inspector of hospitals, Dr Paul Lelliott. ‘While we have found some services that are providing good care and we are beginning to see improvements, all providers need to review their practice so that we can be assured that they are delivering safe and effective care. Detoxification under clinical supervision is often the first stage of a person’s addiction treatment. It can be a difficult, unpleasant and sometimes risky experience. It is vital that providers get this right to support people’s onward rehabilitation and recovery.’

The Royal College of Psychiatrists called the report ‘sobering reading’, while PHE’s director of drugs, alcohol and tobacco, Rosanna O’Connor, said that while residential detox clinics made up a small part of the overall treatment system their ‘vital’ role meant it was crucial that they were in line with best practice as set out by the clinical guidelines. ‘This helps ensure not only safety but gives some of the most vulnerable and disadvantaged people the best chance of getting their recovery on track. PHE has already been working with these services to help them improve and we will continue to provide this support.’

Substance misuse services: the quality and safety of residential detoxification at www.cqc.org.uk

DDN December 2017

By
DDN
-

‘Disinvestment in harm reduction is
deeply damaging’

As 2017 draws to a close we look back at a year of diminishing budgets and record drug-related deaths. While local authorities get to grips with cutting £85m from public health spending, the ACMD warned that slashing drug treatment budgets is a ‘catalyst for disaster’. Throughout the year we have heard many evidence-based arguments for harm reduction initiatives. The call for supervised injection facilities is gathering momentum again, and there is continued progress on naloxone roll-out. But what about those working in harm reduction who feel they are fighting a losing battle?

Disinvestment in harm reduction in the UK is deeply damaging. Not only are we dismissing the rights of people in desperate need of services – we are driving away those who work with passion in the most difficult environments. The result is a deskilling of this vital workforce, as we patch up services and miss out on a huge (and cost effective) opportunity to help clients engage with healthcare.

We opened a debate about commissioning in our last issue, following the ACMD’s call for longer retendering cycles. This month we look at the effect of this on shared care – a disturbing picture of GPs stretched to breaking point trying to make sure patients don’t drop out of treatment. So it’s not been an easy year, but there are clear goals to fight for. We have an amazing bank of evidence in this field – let’s make sure it reaches those who need to hear it.

Have a peaceful festive season and stay in touch with us as we gear up for a vigorous new year. We’ll be back in print on 5 February.

Claire Brown, editor

Click here to view the virtual magazine or the PDF version

Rehabs ‘failing’ older drinkers

By
DDN
-

Three quarters of residential alcohol treatment facilities are failing older adults because of ‘arbitrary age limits’, according to a report from Alcohol Research UK.

More than half of alcohol rehabs on PHE’s online directory exclude people at the age of 66, while 75 per cent impose arbitrary age limits of between 50 and 90, says Accessibility and suitability of residential alcohol treatment for older adults. Older people who do access rehab may then drop out because they find the environment ‘unwelcoming or intimidating’, the report adds, with reports of ‘bullying, intimidation, and ageist language and attitudes’.

A determination to be ‘age blind’ also means that facilities are failing to meet the needs of older adults, it states. Three quarters of services surveyed said they had limited or no disabled access, while diversionary activities on offer usually included things such as mountain biking, caving, kayaking or football. Being unable to take part could create a sense of isolation, says the report.

The latest figures from ONS show that older drinkers account for the majority of the UK’s 7,000-plus ‘alcohol-specific’ deaths, with the highest death rate in the 55-64 age group and the death rate among males aged 70-74 up by around 50 per cent since the beginning of this century. Denying older people access to residential treatment could result in ‘avoidable’ deaths, says Alcohol Research UK, which wants to see policies to reduce discrimination and make sure services are more age-friendly, particularly towards people with disabilities or limited mobility.

‘By imposing these discriminatory age limits, alcohol rehabilitation centres are unfairly, and perhaps illegally, excluding older people, who would otherwise benefit from residential treatment,’ said CEO Dr Richard Piper. ‘This is frankly unacceptable. We urge UK governments and rehabilitation providers to implement the recommendations in this report without delay. Getting this right will make these essential services more accessible to and suitable for older people, which will save lives and improve lives, for these drinkers and their families. With more older people than ever requiring treatment, this issue is urgent.’

Meanwhile, a separate Drink Wise, Age Well report in association with Addaction found that practitioners are prioritising younger people in referrals to alcohol treatment, with reasons including perceptions that older drinkers are ‘too old to change’, that their care needs are too complex or that their age and life expectancy mean ‘it’s not worth intervening’. Those over the age of 65 are also excluded from almost half of clinical trials for alcohol treatment or interventions, it adds.

Focus on Residential Treatment: Acer Unit

By
-

Acer’s inpatient detoxification and stabilisation service is for people who have a primary problem with:

  • Opiate use, including methadone as well as heroin
  • Stimulants such as crack cocaine
  • Alcohol
  • Polydrug use, relating to a combination of drugs and/or alcohol.

The service admits adults (18-65 years) who have difficulty controlling or eliminating their drug or alcohol use in the community.

Many of Acer’s clients are:

  • Service users who have tried and failed community-based drug or alcohol treatment programmes
  • Service users whose social circumstances make it difficult to complete community-based treatment programmes
  • People who use a variety of different substances at the same time.
  • Homeless people
  • Pregnant women
  • People with physical, mental health, and learning difficulties.

The service offers a therapeutic programme which gives structure to each day of admission. The programme involves group sessions to discuss and develop skills to help cope with dependency and avoid relapses. There are timetabled individual sessions to maintain progress, ensure relapse prevention plans are in place and focus on recovery.

The group and individual sessions draw from a range of psychological techniques based on models of harm reduction and relapse prevention.

The service also ensures a balanced programme with physical and leisure activities, as well as opportunities to attend Alcoholics Anonymous and Narcotics Anonymous groups.

AWP’s Acer unit offers high quality treatment to some of the most complex service users. It has gained an excellent rating from the Care Quality Commission.

Acer Unit is a 10-bed, regional resource and has a number of treatment episodes commissioned by Safer Bristol Partnership and Safer South Gloucestershire. Treatment for people from other areas is available to spot purchase.

The Acer Unit has over 10 years’ experience of delivering high quality drug and alcohol detoxification and stabilisation. It can manage high-complex needs for the full range of drugs and alcohol as well as many physical and non-acute mental health conditions . The unit is led by a highly skilled team of psychiatric consultants, speciality doctors, nurses, HCA’s and peer mentors.

Acer works with commissioners, providers and individuals looking to detox and develop innovative packages of care to suit individual and local treatment system needs.

Find out more at Acer Treatment

Check out our Residential Treatment Directory

Afghan opium production up by almost 90 per cent

By
DDN
-

Afghanistan’s opium production has increased by 87 per cent this year, according to the latest UNODC survey. Production now stands at a record level of 9,000 metric tons, with the area under opium poppy cultivation also increasing by 63 per cent since 2016, to 328,000 hectares.

Opium yield per hectare is also up, says the agency, while in the Helmand province alone the area under cultivation has increased by almost 64,000 hectares, or 79 per cent. Poppy cultivation has also expanded to new regions.

Afghanistan is the world’s largest cultivator of the opium poppy, with the record levels of production and cultivation creating multiple challenges for the country, its neighbours and destination countries for Afghan opiates, says UNODC. ‘More high quality, low cost heroin will reach consumer markets across the world leading to increased consumption and related harmful consequences,’ it states.

The increases were ‘dizzying’ and represented ‘a profoundly alarming trend’, said UNODC executive director Yury Fedotov. ‘For both Afghanistan, and the world, we are heading towards uncharted territory. These frightening figures should give considerable pause for reflection on whether the calculus on the illicit drugs flowing from Afghanistan adds up to a workable and achievable solution.’

‘New actors and markets’ were also likely to emerge, he warned. ‘Some of these new actors may be terrorist groups attempting to use the drug trade to finance their global operations.’

Afghanistan opium survey 2017 at www.unodc.org

Supreme Court finally clears the way for minimum pricing

By
DDN
-

The UK Supreme Court has ‘unanimously’ dismissed the Scotch Whisky Association’s (SWA) appeal against last year’s ruling by Scottish judges in favour of minimum pricing. The decision means the Scottish Government can now finally implement the Alcohol (Minimum Pricing) (Scotland) Act 2012. ‘The 2012 Act does not breach EU law,’ says the Supreme Court’s ruling. ‘Minimum pricing is a proportionate means of achieving a legitimate aim.’

The road to minimum pricing has been a long and complicated one. The Alcohol (Minimum Pricing) Bill was passed 18 months after a previous bill had its provisions for minimum pricing removed (DDN, June 2012, page 4), only to face a legal challenge from the SWA and others on the grounds that the measure breached EU trade law. When this was finally rejected by the Scottish Court of Session (DDN, November 2016, page 4), the SWA lodged its latest appeal (DDN, December 2016, page 4).

The ruling makes it more likely that minimum pricing will also be implemented in Wales, following the recent introduction of the Public Health (Minimum Price for Alcohol) (Wales) Bill (DDN, November, page 4). David Cameron’s coalition government abandoned plans to introduce minimum pricing on the grounds that there was insufficient evidence that it would reduce harm without penalising moderate drinkers (DDN, August 2013, page 4). However, a report earlier this year from the House of Lords Select Committee on the Licensing Act 2003 stated that if minimum pricing is introduced in Scotland and proves ‘effective in cutting down excessive drinking’ then England and Wales should follow suit (DDN, April, page 5).

The Scottish Government called the Supreme Court’s ruling a ‘landmark moment’ and said that it will proceed with plans to introduce the measure ‘as quickly as possible’, with ministers carrying out a consultation on the proposed 50p per unit price.

‘In a ruling of global significance, the UK Supreme Court has unanimously backed our pioneering and life-saving alcohol pricing policy,’ said health secretary Shona Robison. ‘Given the clear and proven link between consumption and harm, minimum pricing is the most effective and efficient way to tackle the cheap, high-strength alcohol that causes so much damage to so many families.’ The SWA said that it accepted the ruling and that it would ‘continue to work in partnership with the government and the voluntary sector to promote responsible drinking and to tackle alcohol-related harm’.

Alcohol Health Alliance chair Professor Sir Ian Gilmore said the decision represented ‘a great victory for the health of the public’, adding that the five years of legal challenges to the original legislation meant that ‘many families have needlessly suffered the pain and heartache of losing a loved one’. The spotlight should now fall on England, where ‘cheap alcohol is also causing considerable damage,’ he added.

‘Now is the time for Westminster to step up and save lives,’ echoed Alcohol Research UK CEO Dr Richard Piper, ‘As alcohol has become more affordable, the rates of alcohol-related ill-health have risen. The fact is, something has to be done. Minimum pricing is a much more targeted measure than tax, because it raises the prices only of the very cheapest and strongest drinks on the market – those that tend to be consumed by the heaviest drinkers.’

Meanwhile, plans for a drug consumption room in Glasgow have suffered a setback following the Scottish Lord Advocate’s failure to back a change of legislation to allow possession of heroin within the facility. ‘This is a hugely depressing decision,’ said Scottish Drugs Forum CEO David Liddell. ‘It means that a drug consumption room cannot be delivered in a timescale that will respond to the pressing needs of a group who are among the most vulnerable in our society.’

Focus on Residential Treatment: Sefton Park

By
-

Sefton Park bases its personalised treatment on the belief that no two clients’ treatment needs are the same.

As an alternative to 12-step, the treatment at Sefton Park takes a self-empowerment approach, helping the client to gain a better understanding of their underlying issues, attitudes and behaviours.

The qualified and experienced team deploy a wide range of cognitive and person-centred interventions within the caring and supportive environment of the therapeutic community. In this way, we help our clients to better understand their underlying feelings and anxieties within a person-centred ethos.

The detox facility is now in its second year and has had an excellent response and very good outcomes. We also partner with other units in the South West to provide full medically assisted detoxes.

WORKING WITH THE FAMILY AND SIGNIFICANT OTHERS

Sefton Park recognises that addiction is something that affects the whole family. If requested by the client they will facilitate family conferences in the interest of establishing dialogue and mutual understanding around the impact that substance misuse has on the family. This can also prove to be a good opportunity for the client and their family to consider the choices open to them for the near and more distant future. Staff encourage family visits at weekends as we understand the importance of the family unit and the support that can be provided through social visits.

HEALTHY LIVING AND MINDFULNESS

Sefton Park supports the client in building confidence by helping them to develop their potential.

They provide a ‘Discovery Day’ in a rural environment that promotes new experiences through risk taking and team building. These are outdoors activities such as falconry, rope climbing, orienteering, bushcraft and woodland cooking – lots of team-based exercises and having fun in the outdoors.

Fortnightly, staff organise a ‘Mindfulness Day’, with the opportunity to experience a whole raft of mindfulness activities – acupuncture, meditation, poetry, music and artwork, depending on what’s available on that particular day. The client selects their own choice from the activities. It’s about relaxing, learning, experiencing new things and self-expression through art and poetry – doing things that allow people to reconnect with themselves. It’s all about re-finding your inner self.

FOOD IS A LARGE PART OF RECOVERY

Sefton Park focuses on a healthy lifestyle and the kitchen team ensure that all dietary requirements and preferences are catered for. They bake their own bread each day and clients enjoy a varied diet and healthy range of meals. They have considerable experience of supporting clients with food issues and a well-developed understanding of the support required.

Exercise is also encouraged – there are opportunities to access a local gym and the two miles of sandy beach on our doorstep create the opportunity for walks, running and bike rides. Bikes are provided!

ACCESS TO STRUCTURED AFTERCARE AND SUPPORTED HOUSING

Having access to aftercare support is a very important element of the treatment journey, so aftercare services are available to all Sefton Park clients. If you’re in recovery and you’ve completed Sefton Park then aftercare support is available for as long as it’s needed.  Aftercare support is also offered via Skype.

Sefton Park offers support with housing via their experienced aftercare and resettlement worker and enjoy strong connections with a range of supported housing providers in the local area and across the country. Each client who completes treatment at Sefton Park will normally have access to supported housing locally.

A WHOLE TEAM APPROACH TO CLIENT CARE

The whole team at Sefton Park take pride in supporting each individual client in achieving a successful treatment outcome, with the client’s needs at the core of what they do. The work is intensive, and it’s very much client-centred which means it’s personalised to the needs of each client.

You can put any four clients in a room together and it will soon be obvious that they are not the same. Each client is different and has different issues to address. Each client is on a different journey.

So, each client needs an individualised approach that recognises their differences.

Find out more at Sefton Park

The Right Choice

By
DDN
-

Going to rehab should be an informed decision, not a blind date. Hannah Shead suggests ways to achieve a good match.

Hannah Shead of Trevi House Rehab
Hannah Shead is Chief Executive of Trevi House.

I can still recall the first time that a client told me he wanted to go to rehab. I was working in a community drug service and my client was using heroin chaotically. He had lost his job and his family and was on the cusp of becoming homeless. Yes, rehab seemed the perfect solution. I told my colleague, who promptly advised me which rehab to send him to.

So, off my client went. He did extremely well and it turns out that the rehab, Sefton Park, was a good match for his needs. However, when I look back I shudder that this successful match of need to placement was more a matter of luck than clinical judgement.

This was 17 years ago, and things have come a long way. Many drug and alcohol teams have ‘approved providers lists’ and have a system for placing clients according to their treatment needs.

It should be remembered however, that going to rehab is quite literally a life-changing decision and the importance of choosing the right provider cannot be overstated. So, what sort of questions might you want to ask your client – or be asking yourself, if you are the potential resident?

Choosing the right rehab can be daunting.
Choosing the right rehab can be daunting.

SINGLE SEX OR MIXED?

Some women I talk to are very vocal about their need to be in an all-female environment, as the issues underlying their addiction are not ones that they would wish to work through in mixed groups. Some people recognise the potential distraction of the opposite sex and identify single sex rehabs as providing the best opportunity to focus on recovery.

Equally, there will be those that want the opportunity to work on their relationships with both men and women, and welcome the diversity that a mixed rehab can offer.

There is no right or wrong – only what is right for the individual.

WHICH TREATMENT PHILOSOPHY? 

This is an important part of the decision- making process. People all too often think that rehab is either 12-step or not, but there is a huge scope of choice within the different 12-step programmes on offer so this is not always a helpful distinction to make.

Treatment centres throughout the UK offer a rich variety of programmes, with a wide range of interventions such as CBT, person-centred counselling, family work, education and training, couples therapy, outdoor pursuits and volunteering, to name but a few.

HOME OR AWAY?

For some people, rehab will offer the opportunity to make a fresh start elsewhere, however, for others it is important to stay close to their home environment and community.

WHAT LENGTH OF PROGRAMME 

There are different lengths of programme on offer, according to need.

MAKING THE CHOICE

I am pleased to know that my service is a member of Choices, a group of independent rehabs that have come together to share best practice and make the options easier to understand. Representatives of our 16 rehabs meet every two months to explore ways that we can work together to improve the resident’s experience.

One of the greatest perks of being a Choices member has been the opportunity to visit the other centres. The experience of walking into a rehab and quite simply getting a ‘feel’ for it is unrivalled and we would encourage anyone considering going into rehab to go and visit at least one possible unit. You can also use resources such as the DDN listing Public Health England’s Rehab Online and the Choices website to compare the different centres.

We invite you to look beyond our leaflets and referral paperwork and visit us. Come and meet our current residents – you can be sure that they will tell it as it is! Stay for lunch; check out our hospitality, our food and drinks.

Come and get to know how we tick. Don’t just let us assess you or your client – come and assess us!

Find out more at www.addictionrehabuk.org

Choices rehab logo

Older drinkers account for majority of 7,000-plus deaths

By
DDN
-

Last year saw 7,327 ‘alcohol-specific’ deaths in the UK, according to the latest ONS figures, with the highest death rate in the 55-64 age group.

Most male deaths were in the 60-64 age range and most female deaths in the 55-59 range, with the death rate among men aged 70-74 increasing by around 50 per cent since 2001. Given that many of the deaths will be the result of chronic conditions like alcoholic liver disease the increases are likely to be ‘a consequence of the misuse of alcohol that began several years, or even decades, previously,’ says the report.

While overall alcohol-related death rates have remained stable for the last three years they are still higher than at the turn of the century, says ONS, although they have generally been declining since their 2008 peak. The death rate remains around 55 per cent higher among men than women, and although Scotland is still the UK country with the highest rate it has also seen the largest fall since the early 2000s.

Since its last statistical release ONS has revised its definition of alcohol-specific deaths to include conditions where death is a ‘direct consequence’ of alcohol use – such as alcoholic liver disease or alcohol-induced pancreatitis – but not those where ‘only a proportion’ of deaths are caused by alcohol, such as cancers of the mouth and liver. The definition of alcohol-specific deaths is therefore ‘a more conservative estimate on the harms related to alcohol misuse’, the ONS states.

‘It is tragic that 7,327 men and women in the UK died because of alcohol last year,’ said chair of the LGA’s community wellbeing board, Izzi Seccombe.

Izzi Seccombe: ‘Behind appalling statistics are real people.’

‘Behind these appalling statistics are real people – fathers, mothers, sons, daughters, husbands and wives. What is particularly concerning about these figures is that the rates of alcohol-related deaths were highest in middle aged and older age groups. These statistics should serve as a warning around the dangers of regular drinking over a long period of time.’

‘Alcohol-related deaths are preventable, and councils would be able to do more if government reverses the cuts to the public health grant in the Autumn Budget,’ she added.

Meanwhile the Children’s Society claims that parental alcohol misuse is ‘damaging the lives’ of around 700,000 UK teenagers. The pressures on teenagers in homes where alcohol or drugs are being misused can lead to them ‘developing mental health problems, running away from home or being excluded from school’, says the charity, which surveyed 3,000 teenagers and their parents. Nearly a quarter of teens in homes suffering alcohol misuse were also taking on caring responsibilities for siblings or parents, it adds.

Matthew Reed: ‘Without support, families quickly reach crisis point.’

‘The hundreds of thousands of children whose parent has a drinking problem are sadly just the tip of the iceberg of children in desperate need of support,’ said chief executive Matthew Reed. ‘Specialist services working with families to combat problem drinking, support for teenagers whose parent has mental ill health, or safe spaces for them to go when pressures at home mount, are becoming ever harder to find. Without support at an early stage as problems emerge, these families can quickly reach crisis point and the risks for the children involved grow.’

Alcohol-specific deaths in the UK: registered in 2016 at www.ons.gov.uk

Keeping older users in treatment

By
DDN
-

Playing for Keeps

With Scotland experiencing ever-higher numbers of drug deaths, its government is developing a strategy to keep vulnerable older users in treatment. DDN reports.

This summer Scotland once again broke its own bleak record by registering its highest ever number of drug-related deaths (DDN, September, page 4). The 867 fatalities were more than double the figure from a decade ago and make Scotland’s drug-related mortality rate the highest in the EU.

With the median age 41, and nearly a third of the deaths in the Greater Glasgow and Clyde NHS board area, the twin problems of deprivation and an aging cohort of entrenched users are looking more acute than ever. The Scottish Government has since announced an extra £20m funding for treatment as well as an ‘overhaul’ of its drugs strategy (DDN, October, page 4). It’s also developing a framework to engage older users and keep them in treatment, called ‘Seek, Keep and Treat’, as part of which NHS Health Scotland has issued a new report, Drugs-related deaths rapid evidence: keeping people safe (see news, page 5).

‘If you look back over the last 20 years, all of the increases in fatal overdoses have been in the over-35s,’ Scottish Drugs Forum CEO David Liddell – whose organisation is helping with the ‘Seek, Keep and Treat’ strategy – tells DDN. ‘The under 35 deaths have remained fairly static.’

David Liddell: ‘Underlying health issues aren’t being addressed.’

More than 120 current injectors or people who had injected in the last six months were interviewed for SDF’s expert working group report, Older people with drug problems in Scotland (DDN, July/August, page 4), with an average age of 41. ‘So a very similar profile to those who are dying,’ says Liddell. ‘What we found was that they weren’t being held in services and, alongside that, 79 per cent were living alone. There were massive issues of anxiety and depression, all these underlying health issues that weren’t being addressed, housing issues, welfare benefits issues. So the “keep” part of the initiative is very much about ORT and recognising the protective factors of keeping people in treatment.’

While some countries have up to 80 per cent of problem drug users in treatment at any time – and with that treatment sustained over the long term – Scotland’s current rate is around half that. ‘I think there’s an increasing recognition of the need to hold more of that older population in treatment and maybe try to integrate those other health issues, like COPD, within addiction services,’ he says.

Another issue can be the power relationship between users and those ORT services, he points out. ‘I think advocacy is very important for this population to help sustain contact, but also to help them navigate their way through and better assert what their needs are. In too many cases the individual has to fit the service on offer, rather than the other way round. So while we obviously need to put back some of the core funding to services, we also need to look at how that money might potentially be used to change practice on the ground.

‘When you’ve got a service for 3,000 people it’s very hard to deliver the person-centred care,’ he continues. ‘A key part would be that someone is seen by the same person every time to build up a therapeutic relationship. I think there’s broadly a consensus that things have to change, but in terms of the very big services it can be difficult to turn things around. So there are questions about how the new investment is used, and how you then deliver change.’

The Keeping people safe report stresses the effectiveness of harm reduction interventions, and plans for a consumption room in Glasgow appear to be nearing fruition (DDN, July/August, page 4). A key part of addressing individual need is looking at prescribing options, Liddell stresses – ‘matching the substance to the individual’ – and the facility aims to offer heroin-assisted treatment. Is he confident it will happen?

‘I think the heroin-assisted treatment part is probably easier to deliver in terms of legality issues and so on – I’d be very optimistic that it will happen,’ he says. ‘There’s a consensus in Glasgow that heroin-assisted treatment should have been introduced already. Policy only seems to radically change at the point of crisis, unfortunately, but the level of fatal overdose deaths means we’re certainly there now.’

On that note, when the 2015 figures were announced he called it a national tragedy and the ultimate indicator of the country’s health inequalities (DDN, September 2016, page 4). With the numbers up still further, does media and public opinion in Scotland accept that it is a tragedy, or is there a view that ‘they’ve brought it on themselves?’

‘There’s always going to be a mixture, but my experience in doing media work around the safer injecting facility, as well as the closure of the needle exchange in Glasgow Central station, is that by and large they were very supportive. Obviously they tried to find people who were against it, but it seems there’s much more consensus that this is something that’s worth trying. I do get the sense that there is a shift, and that’s also in terms of conversations with the wider public. In the face of so many overdose deaths it becomes harder and harder for people to argue for the status quo.’

Big rise in numbers seeking treatment for crack

By
DDN
-
Crack paraphernalia

There has been a 23 per cent increase in the number of people seeking treatment for crack cocaine, from 2,980 to 3,657, according to the latest figures from the National Drug Treatment Monitoring System (NDTMS). The number presenting with combined crack and opiate problems was also up by 12 per cent, to 21,854.

People presenting with a dependency on opiates made up the largest proportion of the 279,793 people in contact with drug or alcohol services in 2016-17, at 52 per cent. However this overall total marks a 3 per cent reduction from the previous year’s figure, with the number seeking treatment for opiates down by 2 per cent and the number receiving treatment for alcohol alone down by 5 per cent, to 80,454. The number of alcohol only clients in contact with services is now 12 per cent below its 2013-14 peak.

The median age of people with alcohol-only problems was 46, while opiate clients had a median age of 39. The number of under-25s commencing treatment is now 45 per cent below the level of a decade ago, with just over 11,600 18-24 year olds presenting – mainly for cannabis, alcohol or cocaine.

The number of people presenting with NPS problems was 29 per cent down on the previous year, to 1,450, largely driven by an almost 50 per cent drop in presentations among the under-25s. Individuals who present to treatment using NPS are also ‘more likely to be homeless’, the report states.

Rosanna O'Connor, PHE
‘likely to be driven in part by the affordability and purity of crack and cocaine’

The exact reason for the increased prevalence of crack use was not clear but ‘likely to be driven in part by the affordability and purity of crack and cocaine’, said PHE’s director of alcohol, drugs and tobacco, Rosanna O’Connor. Changes in ‘dealing patterns and drug supply networks, such as the “county lines” phenomenon’, are also likely to be playing a role, she added.

Meanwhile, figures from the Home Office show that drug seizures in England and Wales are down by 6 per cent to their lowest level since 2004. While seizures of class B drugs fell by 9 per cent, there were almost 15,000 seizures of cocaine, amounting to more than 5,500 kilograms – the largest quantity since 2003. However, ‘what are portrayed as massive seizures are a minor cost of business for organised crime,’ said Transform’s head of campaigns Martin Powell, and ‘less significant than the 2 per cent food wastage supermarkets like Morrisons factor into their supply chains’.

Adult substance misuse statistics from the National Drug Treatment Monitoring System (NDTMS) 1 April 2016 to 31 March 2017, and

Seizures of drugs in England and Wales, financial year ending 2017, at www.gov.uk

 

Commissioning: What’s the Name of the Game?

By
DDN
-

Has commissioning lost its way – or are there opportunities to be grasped? DDN reports.

The commissioning structure needs an overhaul, according to the ACMD Recovery Committee, which recently advised government of the drastic effects of funding cuts (DDN, October, page 4). Since commissioning was moved to public health structures in local authorities in 2013, there have been dramatic reductions in local funding that ‘are the single biggest threat to drug misuse treatment recovery outcomes’, says their report, Commissioning impact on drug treatment.

The stark truth for the treatment sector, ACMD Recovery Committee, service user representatives and many commissioners themselves is that the level of disinvestment is causing drug-related deaths. ‘The loss of funding is resulting in drug-related deaths, blood-borne viruses, crime and human misery,’ the committee’s chair, Annette Dale-Perera told the Drugs, Alcohol and Justice Cross-Party Parliamentary Group.

Gathering evidence for the report brought strong evidence of an overall reduction in funding of around 12 per cent, she added. ‘There was a definite decrease when money went over to local authorities. But many commissioners and providers told of cuts that were more severe than shown.’ DDN is hearing of cuts of up to 30 per cent in some areas.

The situation is no surprise. Blenheim chief executive John Jolly said at the latest meeting of the parliamentary group, ‘I take no joy in arriving where I said we’d be five years ago, when everyone said I was shroud waving.’ The difference now is that it’s being felt all over the country and the effects are critical – on service users’ lives and on the skillset of a sector whose workforce are voting with their feet at having their wages cut and their roles merged and changed beyond recognition.

Current commissioning practice is taking much of the blame for the disastrous slide into chaos being felt by the sector. Such is the cut-throat climate of retendering that treatment agencies are paring their tenders to the bone – or walking away from areas where they just can’t make the funding work. Bristol City Council received no bids from service providers when attempting to retender drug and alcohol support services recently, with feedback that the money offered was just too low.

Those that have ‘gone for it’ at any price find themselves tethered to uneconomic contracts with the risk of harsh ‘payment by results’ penalties and financial liabilities that come with TUPE arrangements for transferring staff. The sector is still shuddering from the recent demise of Lifeline and speculating on a toxic mix of contributing factors. Many are angry that their winning bid helped to drive tender prices down to a dangerous new low and blame the commissioning team for exacerbating a ‘race to the bottom’ culture.

John Jolly: ‘Local authorities are between a rock and a hard place.’

Jolly is among the providers who recognise that local authorities are ‘between a rock and a hard place’, with dwindling budgets and some difficult choices to make: ‘do you spend on substance misuse, or do you spend on social care for the elderly? They’re in a difficult space.’ Blenheim is on the commissioning rollercoaster with everyone else, having to remodel services to try and fit new specifications. The experience of working for decades in a neighbourhood suddenly counts for very little against shaving a third off the contract price. There’s no getting away from the fact you have to do much more with fewer resources.

The loss of expertise is one of the many things that bothers him. Gone are the days of specialist services for different substances. Everything – including alcohol, cocaine and stimulants, which would have had specific services a short time ago – is combined into the same service, which ‘can be a problem if people don’t see that it’s for people like them’. Young people’s drug services are no longer standalone, but combined with sexual health services.

‘People are returning to opiate use because
they’ve got absolutely nothing to lose.’

This contraction of services has meant a cut in the skilled workforce, which does not match well with a depressed economic climate and emergence of new drug trends – young people are returning to opiate use after a generation away, and the growing threat of more fentanyl deaths looms. Drug and alcohol use accompanies deprivation all too readily, and street homelessness is commonplace. ‘In every major city now, you’re seeing street homelessness in a way that we’ve not seen for a decade, maybe 20 years,’ says Jolly.

Furthermore, the cuts mean people who use services are often couch surfing, in hostels, or living rough, he explains, and ‘many of them are returning to opiate use because they’ve got absolutely nothing to lose’.

Bill (not his real name) is a drugs worker who is being transferred from one service provider to another, as part of retendering. He blames the last round of tendering for bringing an assortment of providers together to create a system that did not work. ‘By the end of the process, what you’ve got is a complete history of poor key-working, inappropriate allocation, poor assessment and a situation where the top staff, who had come over from the NHS or previous places, had been replaced by kids without any real experience or qualification,’ he says.

He describes how it felt to be caught in the middle of the process. ‘Since the tendering process began, there was an exaggerated bonhomie about the success of partnership working, which was unrealistic,’ he said. ‘There was some fairly desperate grabbing of intellectual property, which was grubby, and there was a real sense of isolation for the individuals involved in the process. And for people in active recovery, people in the community, there was a sudden loss of the security they’d built up in those five years.’

‘We had a 40 per cent relapse rate
among service users and a huge
drop in engagement.’

Most disturbingly, ‘in the six months after we announced the contract was lost, we had about a 40 per cent relapse rate among service users and a huge drop in engagement,’ he says. ‘So it’s been devastating on the community and devastating on individuals.’

He believes that the cost-cutting led to cutting corners with staff training and development and a dismissive attitude towards peer support. Assessments of new clients were conducted through a deficit-based approach – ‘when did you last commit acquisitive crime?’, ‘when were you last a sex worker?’, rather than an asset-based assessment with scope for ‘holistic solutions from the get-go’. His service has lost its way, he believes, and the ability to see that ‘prescribing isn’t anything but a tool. It isn’t a raison d’être’.

Bill is also worried that this blinkered culture is making the workforce slow to react to trends and the ‘constant shift in the way people are doing drugs’. The commissioning process has brought the focus away from specialist services based on the needs of the area; so it doesn’t, for instance, allow for the fact that solvent abuse has soared during the past five years, or that staff have come across ‘strange behaviours and violent reactions’ among cocaine users that has left staff wondering if investigation is needed into what they are actually taking.

Such matters became absorbed in the business of jobs being reassessed, and staff being asked to take on more responsibilities for the same money. Bill thinks staff no longer have the time or the vision to understand that in so many cases, substances are the least of their clients’ problems.

‘It doesn’t matter what commissioning process is happening if somebody has got no house, no benefits, no transport, no food, no friends,’ he says. ‘We’re working in the age of isolation, and every single person I work with now has got multiple complex needs.’ He worries that ‘things have to get really bad before they start to get any better’, adding ‘many of the good workers have already walked away… If we have many more cuts, I don’t know where we’ll go really.’

‘I’ve been a provider myself – I can believe that there are bad things that happen out there,’ says Sarah Hart, senior commissioner at Haringey. But despite the very obvious challenges, she does see many opportunities with the move into public health at the council.

‘It lets me meet more partners around the table,’ she says, describing her work on improving life expectancy, bringing health checks and interventions for long-term conditions to hard-to-reach groups and ‘further integrating substance misuse into broader public health’.

As far as the money is concerned, ‘the important thing is to have commissioners who ensure that substance misuse services don’t get disproportionately affected’ – which she acknowledges is difficult when those who use council services are likely to be economically disadvantaged.

One of her main challenges is to keep community safety colleagues on board, she says, ‘because as we know, it was the crime that got the money’. The 33 per cent cut in MOPAC grants (money provided by the Mayor’s Office for Policing and Crime) has led to some particularly tough decisions, pitting the value of the Drug Intervention Programme (DIP) against services to tackle gang culture, and violence against women and girls.

Another difficulty has been having less time than before to work with providers, ‘particularly if a provider is struggling’. Gone are the days of specialist commissioners holding provider meetings to look at best practice – and gone are the days also when larger commissioning teams could work strategically with partners in probation and housing. There are no longer even the youth leads to work with schools.

It’s become more important for providers to showcase what they’re doing, feeding evidence of their work to commissioners, ‘so they become passionate about substance misuse’, she says. Having come into commissioning via the substance misuse worker route she needs no convincing, but is aware that in many areas providers will need to ‘win hearts and minds’ of their commissioners.

‘Tendering justifies organisations constantly
reviewing what they’re doing… We need
to be saying, is our service right?
Is it fit for purpose?’

The campaign for longer commissioning cycles makes her wary of leaving systems in place that no longer work for clients. ‘Change is difficult in organisations and tendering justifies organisations constantly reviewing what they’re doing and what they’re delivering,’ she says. ‘We get complacent and our clients change. We constantly need to be saying, “is our service right? Is it fit for purpose?” And I’m not sure that without a tender process people would do that.’

The suggestion of a ten-year contract certainly does not appeal. ‘Would a specification that I’d written ten years ago still be relevant? It would say nothing about club drugs, legal highs, over the counter medication. It wouldn’t have anything about recovery in it.’ But she supports the idea of longer tenders with a break clause. ‘I’ve just done a five-year tender – three years plus two. And why it matters is that at the “plus two” stage, the service redesigned itself. If it had been a ten-year contract they might have waited seven years to go “well actually, it’s not quite working”.’

She believes that, as with everything in the sector, it’s about balance – and about recognising that substance misuse services really matter: ‘This isn’t about buying paper, this is about services that people value highly and they get very very frightened when those services are being changed.’ And the welfare of the sector going forward will depend on better partnership working, she says, and a willingness to showcase the work of good providers and organisations – those who add social value.

To fellow commissioners, she suggests: ‘You may well have a provider that’s been in an area a long time and creates jobs and does a lot of extra things in the community – lets people use its buildings, supports homeless charities. It’s about trying to draw that out when you’re tendering, scoring, and evaluating.’

And to providers worried about the ‘race to the bottom’ in stripping a service bare to compete for a tender, she says: ‘I’ve been a provider, and I would say if there’s not enough money in the tender, don’t bid for it. It’s the thing that commissioners most fear, that no one will bid for their tender – but don’t bid against each other.’

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

In a nutshell…
The ACMD Recovery Committee has made the following conclusions and recommendations in its review of commissioning:

Loss of funding is threatening recovery outcomes
Funding should be protected by mandating drug and alcohol services within local authority budgets or including treatment in NHS commissioning structures. Government needs to review key performance indicators to ensure quality of treatment.

Lack of money is compromising treatment quality
National bodies should develop clear standards. The government’s new Drug Strategy Implementation Board should ask PHE and the Care Quality Commission to lead a review of the drug misuse treatment workforce to achieve a balance of qualified staff.

Drug misuse treatment is disconnected from other health structures
Local and national government should strengthen links between local health systems and drug misuse treatment, and include it in clinical commissioning group planning.

Frequent reprocurement is costly and disruptive
Commissioners should ensure recommissioning drug treatment services is normally undertaken in five to ten year cycles. PHE and the Local Government Association need to support local authorities to avoid unnecessary reprocurement.

Current commissioning practice is undermining research
The new Drug Strategy Implementation Board should include government departments, research bodies and other stakeholders in building effective infrastructure for research.

From the ACMD Recovery Committee’s report, Commissioning impact on drug treatment

Drug misuse is a health issue

By
DDN
-

Taking part in a recent political debate, Andrew Horne noticed a keen appetite for policy change.

At a political debate in Inverclyde, led by MP Ronnie Cowan, I shared my professional and personal views on drugs being a health and social care issue rather than a criminal one. It was heartening to hear the other panel members, all from very different backgrounds, share common ground – although for very different reasons.

At Addaction, our 50 years of working with individuals, families and communities, tells us that treatment is the thing that works. Our position is simple: people with drug misuse problems should be diverted out of the criminal justice system and into treatment – a view shared by the Scottish government, who only last week, at the SNP party conference, agreed a motion to decriminalise drugs.

During our debate, several of us discussed this topic with interested members of public. We also heard from Rod Thomson, the Royal College of Nursing’s deputy president. He spoke candidly about how his views of substance misuse changed dramatically as a student nurse, when his community placement showed him the people affected.

On the flipside was panel member Anthony Gielty from The Haven, whose own drug and crime activity saw him spend 15 months of his teenage life in solitary confinement, labelled one of Scotland’s most violent prisoners. After years in prison, he now provides pastoral care to men at The Haven and he’s passionate about recovery and a change in Scotland’s drug policy.

Neil Woods is chair of Law Enforcement Against Prohibition (LEAP) – an organisation made up of people from law enforcement, military and policy backgrounds, who campaign for evidence-based drug policy. As a former police and undercover operative, Neil’s frontline career led to a personal realisation of how punitive measures do not make for cultural change, but can worsen the bigger picture.

Last, but not least, we heard from Mike McCarron, one of the founders of Transform Drug Policy Foundation Scotland, who brings tangible empathy to his diverse work.

Our audience held nothing back in the debate that followed. Their honesty, insights, beliefs and determination reminded us that we are not fighting a losing battle. People from all walks of life share common ground when it comes to issues like this – and seeing this gave us all hope.

Lessons have been learned, culture is changing and there’s no doubt that pressure is rising on decision-makers to change policy. At our own services within Addaction Scotland, we see every day how change is possible in the most testing of times.

Andrew Horne is Addaction’s director for Scotland

We welcome your letters

By
DDN
-

DDN welcomes your letters for publication. Please email the editor, claire@cjwellings.com, or post them to DDN at Romney House, School Road, Ashford, Kent TN27 0LT. Letters may be edited for space or clarity.

 

Self-aggrandising nonsense

Russell Brand: Useful quest or self-aggrandising nonsense?

I am a little shocked and disappointed about Mr Brand’s comments regarding people prescribed methadone/ buprenorphine (DDN, October, page 11). I am ‘on a script’, and certainly do not think I am ‘fucked’ as Mr Brand so eloquently puts it.

My life is going excellently since I have been optimally prescribed methadone. I have a job/family/give back to my community and all in all am bobbing along rather well.

The problem, as I see it, is that there are MANY people doing very well on OST but as they are just busy getting on with the business of living, we are not very visible.

As a result, the only real visible OST patients are the slightly chaotic ones.

Honestly, given what he said, I’m disappointed that DDN gave Mr Brand such a large platform to spew his self-aggrandising, anti OST nonsense.

Sapphire Matthews, via DDN website 
You can add your comments at the bottom of our online article

Scripted sense

So, Russell thinks I’m fucked due to being on a maintenance script. I must admit that in the past I did use on top until I got on an optimal dose of methadone. I’ve been working for over five years and many years ago I got a first-class degree while maintaining myself on OTC meds.

His views are indicative of the 12-step hardliners. Has he not read William White on medically assisted recovery? Or been in NA meetings where someone on anti-depressants has been advised to come off them as they’re psychoactive?

I used to go to NA often while scripted but couldn’t maintain it due to being honest about how methadone had saved my life and my complete refusal to accept the supernatural elements of the programme as I’m a dyed-in-the wool atheist and member of Humanists UK. I’ve heard other 12 steppers state that they wished everyone could have the programme which, to me, sounded like drinking Jim Jones’ Kool Aid.

Meanwhile I’ll happily stay ‘fucked’ according to Brand and get on with my day job helping disadvantaged people in Camden.

Peter Simonson, by email
You can add your comments at the bottom of our online article

Clarification
UKAN are here!
In and article in our last issue, ‘Help at hand’, UKAN introduced their new online community for people working in the field of addiction. We should have included the website address in the article – you can find the UKAN community at www.ukan.network

Alcohol Awareness Week

By
DDN
-

Family focus

Alcohol Awareness Week 2017 shines a spotlight on alcohol and families, sending the message that support is always available. DDN reports.

Alcohol Concern has partnered with Adfam for this year’s Alcohol Awareness Week, ‘Alcohol and Families’, which runs from 13-19 November. The aim is to promote ‘an honest discussion about alcohol’, particularly when it comes to the stigma that still exists around families affected by harmful drinking.

 

The week kicks off with an All-Party Parliamentary Group on Alcohol Harm session on families, and Alcohol Concern has produced a set of free resources including a comprehensive guide to family support services. The pack also includes infographics and factsheets for parents, carers, children and practitioners on subjects like alcohol-related bereavement, setting up a family support group and challenging stigma. People can also order a set of ‘Rethink your drink’ scratch cards, which contain useful information about units and sensible drinking guidelines.

The number of dependent drinkers in England is estimated at around 595,000, and it’s thought that around 220,000 children are living with an alcohol-dependent adult. As well as being twice as likely to experience difficulties at school, children of alcohol-dependent parents are also four times more likely to become dependent drinkers themselves.

‘We know how few people who are alcohol-dependent actually end up engaging with services, and then obviously families are even less likely to seek help,’ says Alcohol Concern’s communications manager, Maddy Lawson. ‘Lots of people we’ve spoken to anecdotally don’t even know that there are services available. This week is about trying to get people talking about it, and to try to signpost them towards help.’

‘What we’re trying to do is raise awareness of the fact that there is family support out there – that organisations like Adfam, DrugFAM and Al-Anon are there to support people who are worried about members of their family who may be drinking too much,’ adds the organisation’s director of research and policy development, Dr James Nicholls. ‘One of the main things we’re trying to draw attention to is that people aren’t alone. One of the most common feelings is that no one else is experiencing the same things, so we want to try to raise awareness that there is support out there.’

That sense of loneliness is even more acutely felt when a loved one dies an alcohol-related death, compounding the grief by adding a profound sense of shame and isolation. In circumstances like this it’s vital for people to reach out, the charity urges.

‘The Bereaved through Alcohol and Drugs (BEAD) partnership between Adfam and Cruse has unfortunately come to the end of its funding, but one of the things that came out of that was that people really felt it was a particularly difficult experience,’ says Nicholls. ‘They felt this enormous stigma, enormous sense of guilt and enormous anxiety about how people may react, while some had experienced really problematic reactions from people around them because they just didn’t know how to respond. What came out of it was that it was incredibly important to seek support.’

The simple realisation that other people are going through the same thing can be hugely beneficial, he stresses. ‘Collectively working with each other can be really powerful in overcoming – not the pain of bereavement, because that is what it is – but certainly some of the issues around isolation and anxiety.’

‘There is support there,’ he says. ‘And the more people talk about these issues, the more people might feel comfortable about seeking that support.’

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

‘I wish we had been able to seek support’

Amy Beth describes losing her sister Carys

My sister was a 21-year-old university graduate when she first became ill. Seven years later, aged 28, Carys passed away as a result of the irreparable damage alcohol had caused to her body.

Shortly after completing her accountancy degree in 2009, Carys’ long-term relationship came to an end and her life began to fall apart. As a family we started notice worrying changes in her behaviour. I returned home from university for the summer holidays and I was shocked to see the change in my sister. Within a few weeks, it was apparent that Carys was drinking daily. I frequently found bottles of vodka stashed our bedroom and in her handbag.

After much persuasion Carys agreed to attend the GP but, once there, she denied that she had a problem with alcohol and just explained that she was upset following the break-up. The GP reassured my mum that it was most likely a ‘phase’ and Carys was simply sent away with leaflets and advice.

For seven years we battled as a family to get Carys the help she needed to beat her addiction. Many people, including medical professionals, found it difficult to accept that Carys was an alcoholic and often assumed that we were exaggerating the extent of her addiction. Carys didn’t ‘look’ like an alcoholic. She was a blonde-haired, blue-eyed woman in her early twenties. She had a degree, a home and a loving and supportive family – she didn’t fit the bill.

The stigma that surrounds alcoholics, or indeed any addict, followed her and my family throughout her illness. While my sister was desperately ill, I didn’t feel that I was able to share her illness with the people around me. I quickly learnt that if I opened up about it, people were eager to judge, which made an already difficult time harder. Even close friends failed to appreciate the severity of the situation, and I felt very alone.

I have come to accept that many people view alcoholism as a ‘self-inflicted’ illness. This is drastically inaccurate – and besides that, the cause of the illness itself is irrelevant when considering the impact it has on family members. We were still the family of a person with a terminal illness. We were still having to witness our daughter, sister, loved one, deteriorating in front of our eyes. The only difference for us was that we were going through that process without sympathy or support. I wish that we had been able to seek support from our friends and colleagues. That would have made a horrible situation a little easier.

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

‘We showed her she could manage without alcohol’

Ellie tells how tailored support transformed a mother and baby’s future.

When Kirsty* first came into the Hackney Orbit project, where we provide support to parents with young children, she was struggling emotionally and experiencing high levels of anxiety. With a baby just a few days old, the 40-year-old mother had been referred by her local hospital, where she had been treated for depression and anxiety.

Kirsty recognised that she needed to find new coping strategies as her drinking was putting her child at risk, but she was scared that she would be unable to manage without alcohol. She had a long history of problematic alcohol use, including a period of dependency, and had suffered with depression for many years.

Initially, I worked with Kirsty in one-to-one sessions while she was on day release from hospital. In these sessions we explored triggers, her habits and beliefs about her drinking and her relationship with substances. After a couple of appointments, she agreed to us introducing her and her baby to the stay and play area where she was welcomed by the crèche team, the specialist substance misuse midwife and other service users. This helped to put her at ease and she soon felt able to engage with some of the group sessions.

Kirsty maintained abstinence from alcohol use for almost nine months and engaged well with all aspects of Orbit. When she first arrived, her baby was subject to a Child Protection Plan. However, following her positive progress, her case was de-escalated from Child Protection to Child in Need.

Having been with us for just over a year, Kirsty decided to visit her family for Christmas. Her outpatient psychotherapy at her local hospital had just come to an end and this, combined with the season and other complicating factors, resulted in a lapse. She became distressed when she left the family to go home, and began drinking.

She was distraught and struggling to forgive herself, but her relationship with Orbit staff meant she was able to disclose this lapse and address it before it could become a full-blown relapse. A plan was agreed with the multi-agency team (MAT) and she was allocated a family support worker and linked into other community groups.

Kirsty has not drunk for almost a year now and is accessing universal childcare and starting college. Her case is now closed to children’s social care, but she continues to attend one-to-one appointments at Orbit. Without our help, Kirsty would not have been able to access support as the main drug and alcohol services are adult-only services which do not cater for families.

I’m delighted to see Kirsty and her baby thrive. They have both come a long way. Kirsty’s primary trigger for drinking was anxiety combined with isolation, so it’s really pleasing to see her grow in confidence and engage so positively while continuing to develop a support network.

*Name changed to protect identity

For more information or to download the resources, visit www.alcoholconcern.org.uk/alcohol-awareness-week

OST: When enough isn’t enough

By
DDN
-

Controlling cravings is an essential part of treatment, says
Dr Steve Brinksman.

 

Sean and I go back a long way. He first started treatment 15 years ago and has had quite a few treatment episodes over the period he has been with us. These tend to follow a pattern; he starts opioid substitution with methadone, titrates up to about 60mls at which point he stops using heroin.

Then after a variable period of time – usually between four to 12 weeks – he starts to use again, occasionally at first and then more regularly, often missing pick-ups and appointments, before dropping out of treatment for a spell. Sometimes he comes back to us after a few months, sometimes more than a year goes by, and there have been interruptions while he has been in prison.

He has often done quite well in prison, away from his usual environment, and has been released on a moderate dose of methadone a number of times – but then the usual pattern kicks in. At the beginning of this year he told me he was fed up with this recurring sequence of events but not sure how we could change this.

On discussing his previous treatment episodes, he told me that when he started methadone he quite quickly stopped having withdrawal symptoms, and this was the point at which his dose titration stopped. However he would still crave heroin and despite his best intentions his resolve would eventually crack and he would use again; sometimes sporadically, but always increasing until the point of falling out of treatment.

On exploring this cycle with him, he felt there was constantly a trigger, like having extra money or bumping into the wrong people. Then it occurred to me that his craving might be the main factor, so we discussed increasing his dose beyond merely stopping withdrawal. I explained this didn’t mean he would never come off treatment and that long-term abstinence could still be a goal; however to get to that point he first needed a sustained spell of not using heroin.

He agreed that we should try this and we titrated him over the next few weeks to 90mls of methadone. Nine months on he remains heroin free and is as well as I have ever seen him. I expect that at some point in the future he will want to try and reduce with a view to becoming abstinent. That will be at a time of his choosing, and meanwhile he is enjoying not constantly fighting against craving.

Sean has made me wonder if we often underdose with OST, in that we treat withdrawal symptoms yet leave our patients to deal with cravings. Is simply controlling withdrawal enough? It is gratifying to see this as an area picked up in the revised Drug Misuse and Dependence: UK Guidelines on Clinical Management (‘the Orange Book’) and I now make a point of asking about craving as well as withdrawal symptoms, when assessing dose titrations.

Steve Brinksman is a GP in Birmingham and clinical lead of SMMGP. He is also the RCGP regional lead in substance misuse for the West Midlands.

Just Be Yourself: support in the LGBT+ community

By
DDN
-

Robert Mee grew up feeling that he didn’t belong and used alcohol and drugs to counter his loneliness. Now, as chief executive of a thriving LGBT+ charity, he shares his story to reach out to others.

I was born in a women’s prison in 1972. I was taken away from my birth mother and fostered, then six months later my mother was released from prison and got me back – but sadly only for a short while. I was taken away by social services and the lovely couple who had fostered me decided to adopt me. Growing up, I knew none of this.

When I was around seven years old my parents told me I was adopted, and they spent hours explaining how I was loved and their real child. But that was not what I heard. All that got through to me was that my mummy didn’t want me and nor did my daddy, and I couldn’t understand why.

Obviously at that time I had no idea about safeguarding children and how it worked. I was in a lovely caring home and loved by my parents, yet inside I felt as if I didn’t belong. It was as if a bomb had gone off in my head: why didn’t my birth parents love me?

As I got to around 11 years old I started to struggle with my sexuality, although at the time I didn’t quite know what I was struggling with. I went to church every Sunday and that’s where I learned to drink with the other altar boys – after the service, any wine left was ours. I also heard in church that ‘man shalt not lie with another man’. When I started to realise that I fancied my best friend more than I fancied my girlfriend, this was quite difficult.

Slowly I found out what and where cruising areas were – and that there were plenty of them about 20 miles away in the nearest town. It was probably not something that a 14-year-old should have known about.

I didn’t really know what being gay was, I just knew I liked men more than women. This made me very frightened. I couldn’t really find out information or even know who to talk to, and I felt alone and quite isolated.

My secret kind of came out at school when I was 16. I stopped doing A levels as I was being bullied daily – how was I supposed to achieve good school results when I was fending off bullies all the time?

When I was 18 I had a job that took me away from the village to a city, and I still had my secrets. On a work night out, my colleagues warned me about a street that I should not go down, as that was where all the gays went. I took note of the street name and knew I would be there the next night. It was a private members’ club and they wouldn’t let me in. I had developed ways of acting straight so I didn’t get my head kicked in, and I couldn’t even convince a gay club to let me in. Eventually I just pressed the buzzer and kissed the bouncer, who let me enter.

In the club it felt like I belonged for the first time in my life and I was at ease with who I was. I met a guy older than me, ex-army, and we got into a relationship quite quickly. It was hard being in a relationship with a guy in public, though. Once we left the safety of the club we had to be very careful – no showing affection towards each other as it was illegal to be gay if you were under 21 and not very widely accepted at any age. You could get beaten up by anyone and the police were not exactly helpful in those days.

Just after my 19th birthday I found out that he had kept a secret from me about himself. We had gone to the hospital for his appointment for cancer and the nurse suggested to me that I needed a test. A little confused I had agreed, and two weeks later I was called back. The hospital told me that I had got HIV from my partner and that I would be lucky to live another six months.

Six months to live – God really did hate me. ‘I’m only 19, what do I do, who do I ask for help?,’ I thought. ‘My family don’t even know I’m gay yet.’

Enter my coping strategy – my old friend alcohol, that had been there for me since I was 11. If I was going to die it was going be on my terms, dancing on tables, off my head on drink.

My partner blackmailed me to stay with him. He said if I left him he would tell everyone what I had got. I was very scared and very lonely. Freddie Mercury had died of Aids, so what hope was there really for the rest of us? I saw so many of my friends die of pneumonia and many just disappeared – so many people just dying in front of me.

For the next few years I watched my partner become very ill and slowly deteriorate in front of me. I was watching him die and in my head I struggled with pain and fear that this was going to happen to me quite soon. I would die a very slow, painful death.

At 25 I suffered liver failure. I woke up all yellow and was told that this was my body’s way of telling me I needed to stop drinking. ‘Don’t be so stupid,’ I replied. ‘I’m dying of Aids and drinking is my way of coping.’

When I was 28, after a number of failed relationships that I realise now were all based around alcohol consumption and not love, I actually met someone who didn’t drink. Maybe I would stop drinking now, I thought.

Sadly I had fallen in love with someone who was on heroin and crack cocaine and I quite quickly became addicted. My life took a whole new downward turn. The weight fell off and I really did look like an Aids victim. I was once again overwhelmed by feeling lost and lonely.

In March 2006 I overdosed on heroin and crack for the fourth time and I was taken to A&E and told I would be lucky to live for four hours. I remember the horror of people trying desperately to save my life, but thought that all the pain would be over soon – no more feeling unwanted, no more feeling that I wasn’t good enough, no more being battered in relationships. Dying seemed the only way for the pain to stop. I had full blown Aids, pneumocystis pneumonia (PCP), and not much chance of living.

My parents had rushed to the hospital and entered my room in masks and gowns. I heard my father say to my mother: ‘No father should ever have to bury his son.’ Obviously I had overlooked the fact that they loved me as their child.

As I left the hospital some six months later, I went to detox for two months at Hafen Wen in Wales. I was allowed home for Christmas and spent time with my family – my mum and dad, my brother, his wife and their two kids, my two nephews. This time was so valuable to me.

Then it was time to go to rehab in January, at Littledale Hall in Lancaster. I spent 12 months there and made a lot of new friends. I kept the fact I was HIV positive quiet, as I wanted to be able to sort my addiction problem out rather than deal with the health condition. I really didn’t think I would live long enough to complete the programme.

But complete it I did, and thought ‘what do I do now?’ I volunteered for a local re-use charity, Furniture Matters, then for Lancaster Advocacy. In July 2008, with the help of a few people, I set up an LGBT+ group called Out in the Bay. I wanted to support other people and let them know they had options, so that maybe they didn’t make the same mistakes that I had made in life.

Today I am the CEO of the charity, we are all volunteers and I am very proud of what we do and stand for. We work with many agencies to try and support the LGBT+ community. It can be very draining at times, as finance is limited. But we offer hope when sometimes there seems to be none, we value every single human being as an equal, and we pride ourselves on who we are, offering a safe space for people to just be themselves.

Robert Mee is chief executive of Out in the Bay

Nursing column: ‘And breathe…’

By
DDN
-

Take time for the all-important moments of therapeutic engagement, says Ishbel Straker.

I was discussing with a close friend the other day her newly acquired qualification in counselling. We talked about the various approaches and which methods we leaned towards – I’ve always been a Berne groupie myself [the Eric Berne method, based on transactional analysis].

My friend asked me how I knew so much about counselling and asked if I had completed a course. I explained that as a psychiatric nurse I was trained in all of the above, with the majority of my course spent learning how to therapeutically engage with patients. I came away considering how far removed we have become as nurses from the intentions of our qualification within the addiction field, and wondered where have the majority of us have landed.

As I’ve mentioned before, I stumbled into the addictions field at the beginning of my nursing career and the aspect that captivated me most was having the freedom to invest my time and training in clients who were responsive. This remains the best part of working in this field for me, and one which I have made a priority for the nurses I supervise. This has been a welcome change for most, and one that has been embraced by all staff and clients. It feels important to enable nurses to use their learned skill in all areas of their working practice for their own motivation and for the quality of care provided to our clients.

Therapeutic engagement within a key work setting is like breathing for a psychiatric nurse and I have come to realise that when it is taken away, it leaves nurses bereft of their ability to have a positive impact through meaningful interactions.

That is not to say that administering medication, vaccinating clients, providing them with health checks and harm minimisation support is not essential. What I am saying is, as nurses, we should give ourselves and our clients time for a significant interaction, one which we are able to reflect upon, digest and follow up. Simply give yourself time to breathe.

Ishbel Straker is clinical director for a substance misuse organisation, a registered mental health nurse, independent nurse prescriber (INP), and a board member of IntANSA.

Strategy for Survival

By
DDN
-

Challenging times mean smaller organisations must embrace new ways of thinking, says Caroline Cole.

We operate in difficult financial times, and for charities delivering addiction services in England the landscape is particularly challenging. As interim CEO of an exemplary residential abstinence-based 12-step treatment centre, and observing similar charities closing while private ventures open up, I have been pondering the feasibility of our charity and designing plans for our survival in this difficult world.

There are two key questions. First, can we free ourselves from the fierce statutory commissioning environment in which we work, and on which we have for a long time been dependent, while remaining true to our altruistic vision and mission? And second, can we use learning from the profit-driven corporate world to inform our strategy?

I am primarily concerned with how rehabs that are charities rather than businesses can position ourselves and borrow from corporate strategy to support sustainability. Things are not getting easier – investment in abstinence-based treatment is not on the political agenda, and the stigma of addiction prevails so public understanding and support for our services is at best limited and at worst dismissive.

Broadway Lodge in Weston-super-Mare is the oldest 12-step addiction rehab in the UK, having been operating for 43 years. Throughout this time we have supported well over 13,000 people to rebuild their lives and we have a huge cohort of alumni, some with decades of recovery. As pioneers in the 1970s and 1980s we functioned as a consultancy for other 12-step treatment centres that followed this highly successful model – people who found recovery asked us how to do it, we told them and they set up more treatment centres.

In these early days there was sufficient statutory support for people to be treated without knowing who was paying, and these people were treated alongside people who were paying privately – duke or dustman, we mucked in together. Treatment then was based on a public service and charitable ethos rather than a profit-grabbing corporate ethos.

Since then, statutory funding for treatment has gone from abundance to austerity and a place of uncertainty and peril. In the 2000s drug money was ring-fenced for many political reasons, not least the emphasis on crime reduction and public health, and although it was sensibly targeted mainly at harm reduction services there remained a small niche that offered abstinence. Clients therefore still had some choice of the treatment modalities they were offered.

The change of government in 2010 brought hope that the new PM, a strong supporter of 12-step recovery, would occasion a revival of treatment centres by insisting on a more evenly balanced provision between harm reduction and abstinence-based recovery. Sadly, this aim never percolated through to commissioners and when ring-fencing was lifted and budgets reduced throughout 2014-15 and 2105-16, 12-step and other abstinence rehabs were the main casualties.

Add to this the focus on fewer but larger contracts to drive down costs and the sector has seen integrity give way to greed and the pursuit of profits, with small/medium charities squeezed twice – at commissioning level with the cuts in overall funding, and as a potential sub-contractor to larger organisations for whom it is easier to provide the service themselves and retain the revenue. In this model, clients lose choice.

Bargaining powers are limited for charities such as ours. Because of our position in the supply chain, our suppliers (of referrals) are also our customers and this creates a dual difficulty. We as providers are both buyers and sellers but we lose any buying advantage in our need to sell. Statutory services have to be delivered in accordance with the expectations of the commissioners and all contracts or spot purchases are a trade-off between what we, as experts, know to be effective, and what the commissioners require or allow us to provide.

So what options remain? Regarding statutory commissioning, I for one am not convinced that our long-term lobbying for change at high levels is effective. So, on the principle that if something is not working, instead of continuing to try harder let’s do something different.

What we have learnt with the response to the horror of Grenfell Tower is that grass roots movements are powerful. Governments cannot control them, and they often arise where governments have failed. If we stop wasting energy doing what doesn’t work, and concentrate on ‘doing it for ourselves’ by garnering support from the public and previous beneficiaries of our treatment, rather than the politicians, we may just be able to raise enough revenue to create a treatment and recovery system; one that actually works and is more attractive than the uninformed, misguided but dominant political narrative and broken, ineffectual system we have at present.

Harnessing alumni and family members as ambassadors and champions draws down potent support. A quick look on Facebook shows the huge cohort of fans of Broadway lodge who are eager to help and promote the rehab that gave them or their loved ones their lives back. By recognising this loyalty capital and monetising it through events and involvement, an authentic exchange of energy takes place that delivers outcomes from Broadway’s commitment to, and investment in, treatment and recovery.

Negotiating collaborations with other, similar, treatment providers in order to widen the referral net and then allotting the clients fairly and accurately according to their needs is a strategy that depends on a trusting relationship that has to be built between all players in the system. This takes time and risk, but the results are profound and provide a win for all participants. Thus we develop a network of collaboration, liaising and negotiating cost savings and identifying nascent markets and those with excess capacity that we can collaboratively penetrate and secure.

Instead of remaining dependent on statutory funding and dancing to someone else’s tune, Broadway Lodge – working in concert with other providers and collaborating on projects that identify synergies, share efficiencies and extend our thinking beyond the statutory realm – can deliver new and exciting strategies that foster success and enable everyone to shine.

When society improves, the people within it improve as well. Linking with like-minded providers who also trust this premise, and extending that trust to each other, provides a powerful, self-supporting system for treatment delivery that is independent of government. It involves sharing and transparency but the benefits are manifold. It is a game changer and one of the ways in which small and medium sized charities can survive and shine in this very challenging environment.

We can maintain presence and power in the treatment system, allowing us to develop a more extrovert personality and a stronger voice predicated on power harnessed through collaboration. This in turn means that clients have a wide choice and people with severe addiction be offered full abstinence-based, in-depth treatment that creates a platform for real recovery and a fulfilling life.

To return to the two questions I asked at the beginning: Can we free ourselves from the fierce statutory commissioning environment in which we presently work while remaining true to our altruistic vision and mission, and can we use learning from the profit-driven corporate world to inform our strategy going forward? The answer is a resounding YES.

Caroline Cole is interim CEO of Broadway Lodge

‘Can we ask CQC for more time?’

By
DDN
-

Nicole Ridgwell of Ridouts answers your legal questions

Our service is undergoing many changes after being recommissioned and we haven’t enough hours in the day. We are very short staffed and a CQC inspection is the last thing we need – we haven’t even time to complete the paperwork. Are we legally obliged to comply with the CQC’s timescale?

Nicole answers:

The short answer is yes! If you are regulated by the Care Quality Commission as a provider of regulated activities, you must comply with the reasonable requests of your regulator. The CQC in return must produce guidance to help providers to comply with the regulations. Regulation 21 of the HSCA 2008 (Regulated Activity) Regulations 2014 (as amended) says that registered persons ‘must have regard’ to this guidance.

There is a level of discretion in the regulations, in that the provider is responsible for meeting the regulations and deciding how to do this. It is not CQC’s role to tell providers what they must do to deliver their services. However, there are certain fundamental aspects of the regulations which are non-negotiable, and compliance with the request for pre-inspection information is one.

A provider which considers itself to have a good relationship with the local CQC inspector might consider asking for a little extra time to produce the requested paperwork, but I would urge caution. Any such request must be phrased very carefully. Inspectors are rating on the five key questions; the fifth of which is ‘well-led’, analysing the leadership and organisational culture of providers. Being able to show how you document your provider activities is key to this. Informing your inspector prior to inspection that you do not have the current capacity to demonstrate compliance is unlikely to be interpreted kindly.

While any provider (let alone the short-staffed and under resourced majority) may be tempted to consider providing pre-inspection paperwork as an unnecessary inconvenience, it may prove motivating to look at it another way. Providing evidence prior to the inspection is a key part of the inspection itself and can help to shape the physical inspection to come. A provider who appears enthusiastic and engaged will be viewed very differently by the attending inspectors than a provider who appeared truculent and unwilling.

My recommendation would be that providers aim to take the pressure off the last-minute scramble to pull information together by preparing for the inspection throughout the year. Consider the type of information CQC has requested in the past and prepare a file with that information. Include your policies and procedures (ensuring, of course, that they are up-to-date and reflective of your current practice), service user feedback, letters from families, and external assessments.

Feeding this file throughout the year will be significantly less time-consuming, less stressful, and (given that you will be including all the positive news from your service) will be an encouraging reminder of the successes over the past year.

Nicole Ridgwell is solicitor at Ridouts Solicitors

Media Savvy

By
DDN
-

The news, and the skews, in the national media

Public health crises come in two forms – those resulting from naturally occurring diseases and those that are the by-product of medical care itself. The opioid crisis is the latest self-inflicted wound in public health. In the US alone, there were 240m opioid prescriptions dispensed in 2015, nearly one for every adult in the general population. In order to tackle the opioid epidemic, we must first tackle a major contributor – physician overprescribing. BMJ editorial, 19 October

I was surprised to read last week that the Czechs are not only the unhealthiest people in the EU but are the unhealthiest people in the world… It turned out that the report’s authors simply assumed that countries with high rates of alcohol consumption, smoking and obesity were sick while those with low rates of alcohol consumption, smoking and obesity were healthy… This is clearly bonkers, but it is what happens when you mistake inputs for outcomes. The ‘public health’ lobby has become obsessed with three modifi­able lifestyle factors – alcohol, obesity and tobacco. Unable to see beyond this trio of risk factors for diseases of affluence and old age, there are some who have convinced themselves that they are all that matters.
Christopher Snowdon, Spectator, 2 October

Health messaging relies on a kind of biblical simplicity. There’s no room for nuance if it’s to hit the solar plexus. And so the call goes out: there’s no such thing as safe drinking. You’re hurting yourself – and, worse, your children! This is treacherous territory.
Anne Perkins, Guardian, 18 October

I wonder about parents who are up in arms at the latest findings that even moderate drinking can leave children feeling anxious, and that a tipsy parent is never a good role model… The reason this news has come as a shock is that parents these days don’t even see their drinking as a problem. It’s their right. They came of age in an era when we are supposed to have it all. No one will countenance hardship of any kind: not a moment of hunger or thirst.
Liz Jones, Mail on Sunday, 22 October

Officialdom is still baffled by the Las Vegas mass murders. That’s because they’re only interested in standard explanations. Almost all such killings are committed by people who have been using legal or illegal mind-altering drugs – eg ‘antidepressants’, steroids or cannabis. And we know that the killer Stephen Paddock had been taking diazepam (whose side effects include rage and violence, especially if the person is an abuser of other drugs). It really is time this connection was examined.
Peter Hitchins, Mail on Sunday, 15 October

DDN Subscriptions

By
DDN
-

Click here to add a new subscription, change your details or make a cancellation.

DDN is a free magazine self-funded through advertising. We offer cost effective promotion and recruitment advertising both in print and online, please contact ian@cjwellings.com for more details.

To suggest articles, or submit letters and comments please contact claire@cjwellings.com 

DDN conference consultation

By
DDN
-

DDN Conference

DDN National Conference 2018

22 February, Birmingham

Help us plan the eleventh DDN Conference, let us know what you want at your event.

Click here to be part of the programme planning

[slideshow_deploy id=’17887′]

 

1...343536...57Page 35 of 57