Please find full job descriptions and application forms for BAC O’Connor and O’Connor Gateway vacancies. If you have any queries please contact Louise.Watts@bacandoconnor.co.uk
WORRYING PREDICTIONS Alcohol is expected to cause around 135,000 cancer deaths over the next 20 years, costing the NHS an estimated £2bn, according to a new Sheffield University report. Oesophageal cancer is expected to see the largest increase, followed by bowel cancer, mouth and throat cancer and liver cancer. ‘These new figures reveal the devastating impact alcohol will have over the coming years,’ said Cancer Research UK’s director of prevention, Alison Cox. ‘That’s why it’s hugely important the public are aware of the link between alcohol and cancer.’ Alcohol and cancer trends: intervention scenarios at www.cancerresearchuk.org
RISK MANAGEMENT HIV levels in the UK remain low but there are continuing risks among people who inject drugs and ‘outbreaks still occur’, according to PHE’s updated Shooting up: infections among people who injected drugs in the UK report. Diagnostic testing for HIV should be offered to all those at risk, it says, while ‘new patterns of injecting drug use among some groups of MSM’ is also a concern. Only 1 per cent of people who inject drugs in the UK are infected, although 17 per cent reported sharing injecting equipment and around half have been infected with hepatitis C, often without being aware. Bacterial infections also remain common, it states, some of which can lead to severe illnesses. Report at www.gov.uk
UNAPPEALING DEVELOPMENTS The Scotch Whisky Association (SWA) has said it intends to appeal the Scottish Court of Session’s ruling on minimum unit pricing (MUP) (DDN, November, page 5). The decision to appeal to the UK Supreme Court – and so extend the seemingly endless MUP saga – is not one the organisation has ‘taken lightly’, said its acting chief executive, Julie Hesketh-Laird. ‘It comes after wide consultation with our member companies and other parties to the case to see whether there is an alternative way forward. However, given our strong view that minimum pricing is incompatible with EU law and likely to be ineffective, we now hope that our appeal can be heard quickly in the UK Supreme Court.’ SHAAP director Eric Carlin said the decision ‘beggared belief’, while Alcohol Focus Scotland chief executive Alison Douglas called it ‘truly shocking and saddening news’ and accused SWA members of putting shareholder profits ‘above the public interest’.
HIGH VOTER TURNOUT Last month’s US presidential elections also saw citizens vote on commercial models of recreational cannabis supply in five more states. Maine, Massachusetts, Nevada and, significantly, California – which has a population of nearly 40m – all voted in favour of legalising the sale and consumption of recreational cannabis, while Arizona voted against. Meanwhile, a new report from the Global Commission on Drug Policy calls for UN member states to explore regulatory models for illicit drugs and end all penalties for possession for personal use. ‘It is time to highlight the benefits of well-designed and well-implemented people-centred drug policies,’ said commission chair Ruth Dreifuss. Advancing drug policy reform available at www.globalcommissionondrugs.org
SKEWED SYSTEM Black and Asian men are about 1.4 times more likely to receive a custodial sentence for drugs offences than white men, according to the interim report from David Lammy MP’s review of race and the criminal justice system. For every 100 white women handed custodial sentences at crown courts for drugs offences, meanwhile, 227 black women are sentenced to custody. The review, which was commissioned by David Cameron, is due to publish its full report next year. ‘These emerging findings raise difficult questions about whether ethnic minority communities are getting a fair deal in our justice system,’ said Lammy. Black, Asian and minority ethnic disproportionality in the criminal justice system in England and Wales at www.gov.uk
EASY DECISION France has opened its second consumption room, less than a month after the country piloted its first project in Paris (DDN, November, page 4). Councillors in the city of Strasbourg voted 90 per cent in favour of the facility, which has a capacity for up to 150 visits a day. A third facility, in Bordeaux, is set to open soon.
URGENT UPSCALE There is an urgent need to scale up needle and syringe programmes (NSP) and opioid substitution therapy (OST) to keep pace with growing need, according to HRI’s latest Global state of harm reduction report. Out of more than 150 countries where injecting drug use is reported, nearly 70 still do not provide NSP – with no new countries establishing it since 2014 – while just 80 implement OST. ‘The 2011 UN target to halve HIV among people who inject drugs by 2015 was missed by 80 per cent,’ said report author Katie Stone. ‘Now people who inject drugs are being left ever further behind.’ Report at idpc.net
DESPERATE MEASURES New guidelines for the management of coexisting severe mental illness and substance use – ‘dual diagnosis’ – have been published by NICE. Aimed at commissioners, providers, frontline staff, families, carers and others, they cover issues like referral, care plans and improving service delivery. The guidelines were ‘desperately needed’ said chair of the guideline committee, Professor Alan Maryon Davis. There needs to be ‘much wider recognition that this group of people, despite their complexities, have as much right to dedicated care and support as anyone else,’ he stated. ‘They should not be turned away or left to flounder. Every effort should be made to help them benefit from the services they so badly need. Crucial to this is a non-judgmental, empathetic approach and the building up of mutual respect and trust.’ Available at www.nice.org.uk
As the old Chinese curse has it, ‘may you live in interesting times’…
A truly seismic year for world events saw the triumph of populist policies, and politicians, across the globe – including one head of state elected after a campaign promise to eradicate drug users.
JANUARY
As people are getting over their festive hangovers, the chief medical officer starts 2016 by revising the UK’s alcohol guidelines. The official recommendation is now that men should drink no more than 14 units per week, bringing the level in line with that for women and making the UK’s recommended consumption levels among the lowest in the world. An early day motion on the government’s Psychoactive Substances Bill, meanwhile, brands the document ‘evidence-free and prejudice-rich’.
The ninth annual service user conference in Birmingham sees powerful presentations, heated debate and a rousing closing speech from Big Issue founder John Bird. ‘The skills you used to score and beg – use them.’ he told delegates. ‘Don’t let anyone tell you that you don’t have valuable skills!’ As austerity policies continue to bite, a survey of directors of public health finds that 70 per cent of them expect drug and alcohol services in their area to face cuts.
The bleak news continues as a report by the Recovery Partnership finds that nearly 60 per cent of residential services have reported a decrease in funding, along with almost 40 per cent of community services. The government, meanwhile, delays its beleaguered Psychoactive Substances Act.
The UN convenes its first special session of the General Assembly (UNGASS) on drugs since 1998, with UNODC executive director Yury Fedotov telling the session that the world needs drug policies that ‘put people first’. The event’s outcome document, however, receives a decidedly lukewarm response – despite some welcome language on human rights and harm reduction, the need for consensus renders it ‘watered down’ and ‘generally a huge disappointment’, Transform’s Steve Rolles tells DDN. The seemingly unstoppable flow of new psychoactive substances continues in Europe, with EMCDDA now monitoring almost 600 of them – a sixth of which were reported for the first time in 2015.
In one of the grimmest developments yet in the ‘war on drugs’, Rodrigo Duterte is elected president of the Philippines, vowing to eradicate crime in the country in six months – a plan, he says, that would see him ‘fatten the fishes’ in Manila bay on the bodies of dead criminals, drug dealers and drug users. Closer to home, the Queen’s Speech contains major reforms to the UK’s struggling prison system – ‘the biggest shake-up’ since the Victorian era, says the government – although the Prison Bill’s chief architect, justice secretary Michael Gove, will be sacked the following month. MDMA, meanwhile, is once again European young people’s ‘stimulant drug of choice’, according to EMCDDA, with figures showing increased levels of use in nine out of 12 countries, along with stronger pills. The Psychoactive Substances Act, meanwhile, finally limps into UK law.
As the UK’s Brexit vote sends shockwaves through the world, consensus on the country’s drug legislation continues to shift as a report by the two major public health bodies calls for personal possession of all illegal substances to be decriminalised. A Times editorial on the document goes further, stating that full legalisation should ‘still be the ultimate goal’. Alcohol-related hospital admissions continue their upward curve, and the idea that problems in the prison service are ‘all down to NPS and overcrowding’ is naïve, former governor of Brixton and Belmarsh, John Podmore, tells DDN. ‘It’s looking for a quick fix, and there is no quick fix in this.’
‘The chances of political time and energy being focused on addressing alcohol and drug treatment are negligible,’ Collective Voice head Paul Hayes writes in DDN as he considers Brexit’s implications for the sector. While this may be useful in preventing ‘renewed ideological attacks’ in the short term, he says, the sector needs to come together to ‘find anew narrative, as persuasive to local authorities as previous harm reduction and crime-led narratives have been to central government’.
Another bleak milestone for Scotland as the country records its highest ever level of drug-related deaths for the third year in a row. With over 700 fatalities in 2015 – nearly two per day, and more than double the figure from a decade ago – the statistics are ‘a national tragedy’ and ‘the ultimate indicators’ of the country’s entrenched health inequalities, says Scottish Drugs Forum chief David Liddell. More than 300 NGOs sign an open letter to the UN’s drug control bodies urging them to call for an immediate stop to the extrajudicial killings of suspected drug offenders in the Philippines by president Duterte.
Hot on the heels of last month’s grim figures from Scotland, the ONS reveals that the number of heroin-related deaths in England and Wales has doubled in the space of four years, to more than 1,200. The highest number of deaths, for the third year running, are in the North East, while in the Philippines more than 3,000 people are now thought to have fallen victim to Duterte’s ‘war on drugs’.
The Glasgow City Joint Integration Board approves the development of a business case for the UK’s first consumption room, along with provision of heroin-assisted treatment, generating predictably outraged headlines in some newspapers. Meanwhile, France opens its first consumption room in Paris, with another to follow in Strasbourg.
As the world digests the news that Donald Trump is to become the 45th US president, another set of American voting results see recreational cannabis legalised in four more states, including California.
A year that many people will be keen to see the back of draws to a close, and still no sign of the 2016 Drug Strategy. However, preparations are well under way for DDN’s milestone tenth annual service user conference. With drug-related deaths continuing to rise and resources diminishing, the need for strong, targeted, effective service user involvement has never been stronger. Join us in Birmingham and let’s make a difference!
Justice secretary Elizabeth Truss has announced funding to recruit 2,500 more prison officers as part of the government’s new prison safety and reform white paper. There will also be new measures to test offenders on entry and exit from prison ‘to show how well jails are performing’ in getting them off drugs and giving them basic education and employment skills.
The white paper also includes measures to introduce no-fly zones over prisons to stop drones being used to drop drugs inside the prison walls, as well as extra sniffer dogs. Prisons should be ‘places where offenders get off drugs and get the education and skills they need to find work and turn their back on crime for good’, said Truss.
Deaths in custody rose by 30 per cent in the year to June 2016, while suicides and assaults on staff rose by 28 per cent and 40 cent respectively (DDN, September, page 4). A recent report by the Prison and Probation Ombudsman said that prison authorities must to do more to tackle the role of NPS and associated debts in the rising and ‘unacceptable’ levels of violence in the prison estate (DDN, October, page 4).
RAPt CEO Mike Trace – whose organisation recorded a seven-fold increase in reports of NPS use in prisons last year – said that while it was vital to undermine the prison drug market, more also needed to be done to reduce demand. ‘More than half of new arrivals in prison are daily users of drugs, or dependent on alcohol,’ he said. ‘Most seek to continue using inside and, if a way isn’t found to turn them away from the dealer and towards treatment and recovery, their demand fuels the profits of the gangs, which itself is behind most of the violence, disorder, and health emergencies in prison today. We call on the new secretary of state for justice to tackle the issue by prioritising effective drug treatment in the criminal justice system.’
The call for more investment in treatment was echoed by CGL executive director Mike Pattinson, who also stressed the need for better education, training and employment support, as well as provision of safe accommodation on release. ‘Disappointingly there remains a complete absence in thinking and action about some of the other fundamental concerns that impact upon the prison population and therefore the safety of those being detained, namely sentencing reform and a sensible debate about the role of prisons in a modern society and who should be incarcerated,’ he added.
Behind every drug-related death statistic is a life that could have been saved. It’s our duty to do more, says Dr Judith Yates.
I first met David in the 1980s when, as a small child, his mother kept him away from school all too often. She struggled to cope with life. By the end of the 1990s, in his early twenties, David was a regular attendee at my surgery, prescribed methadone and supported by my drug worker.
One night he banged on the back door of the surgery after 7pm when we were supposed to be closed and trying to pack up and go home. Our gentle-hearted nurse Angela opened the door to ask what he needed and stepped back as he staggered in, fell to the floor, stopped breathing and turned rapidly blue. My quick-witted partner ran to the emergency cupboard and dug out our newly acquired naloxone kit. Naloxone is the antidote to opiate overdose and David was breathing again, although still groggy when the ambulance arrived.
When he returned to my surgery for his routine appointment the following Tuesday he was surprised to be met joyfully by the reception staff who had thought he might have died. On waking in the hospital he had no idea how he got there, how close he had been to death, nor the role played by the surgery team. His was the first life I had known to be saved by naloxone.
It was therefore a shock two weeks ago to see David’s name in the stark ‘drug-related death’ summary I was reading on a clear sunny day in Birmingham. I had trodden a familiar path to our local coroner’s office to review the thick ring-bind folder containing reports of all inquests held in the city during 2016, as part of the preparation for our newly re-formed drug-related death (DRD) local inquiry group.
It seems that David had no longer been in treatment at the time of his death, as only heroin had been found on toxicology. I suppose there was nobody around to administer naloxone on this occasion.
This reviewing of the inquest reports is a miserable job, not only because beneath the terse language of the certificates lie the shocking stories leading to these sudden and unexpected deaths, but also because having been a GP in the area for over 30 years, I have known many of the people who have now come to the end of their lives in ways which might have been avoidable. It is always especially upsetting to find that one of my old patients has died in this way.
Last week, standing at the podium to address the audience at the 21st RCGP/SMMGP Managing drug and alcohol problems in primary care conference, I felt the warm glow of a room full of people who have been working together for all of the 21 years and more, but my subject matter – a review of drug-related deaths in Birmingham – replaced this with an icy chill and a feeling that we must be missing something. I thought of David and the other people I have known who have died suddenly and unexpectedly in this way.
We have all read the headlines telling us that heroin-related deaths have more than doubled in England and Wales between 2012 and 2015 (DDN, October, page 4). Prof David Nutt, speaking at the same conference, asked the question ‘Why are we collecting all these statistics if we aren’t doing anything about them?’ It is only by looking behind the statistics that we can have a chance of understanding what may be the causes and, more importantly, what solutions can be found.
It is shocking that in many parts of the country, as in my city, drug-related death inquiry groups fell victim to the financial cuts in services, and often no longer meet at all. As a result, nobody has been investigating the deaths of people not actually engaged with treatment services at the time of their death. The latest analysis by PHE shows that more than half of people who die in this way have never been involved with drug treatment services, at least since NDTMS records began seven years ago, and more than 70 per cent were not engaged with treatment services at the time when they died (http://bit.ly/2c3k2H6).
We need to learn from each of these tragedies and add to the frequently simple and usually not even expensive actions, which we already know from international evidence contribute to reducing future deaths. These include: low-threshold prescribing (and welcoming rapid re-engagement for those who drop out), supervised consumption facilities offering cups of tea, conversation and a safe hygienic place to inject for the most vulnerable who are not ready or able to come into treatment, and wide access to take-home naloxone wherever it might be used to save a life.
David was only in his late thirties when he died, an increasingly common age for people to suffer accidental overdose. He was of course more at risk because of his age and history, because he had fallen out of treatment, and because he had a history of non-lethal overdose in the past. His death almost certainly could have been avoided.
We have powerful examples of effective analysis and action, for example from the airline industry, the maternal deaths confidential inquiry groups, and the investigations into every road traffic accident death, all of which have found ways to prevent avoidable deaths.
In 2009 airline pilot Captain Sullenberger astonished the world when he made an emergency landing of his plane on the Hudson River, saving every life on board. When asked how he knew what to do, he said, ‘Everything we know in aviation, every rule in the rulebook, every procedure we have, we know because someone somewhere died. We cannot have the moral failure of forgetting these lessons and have to relearn them.’ (Quoted in Black Box Thinking by Matthew Syed, 2015.)
Local inquiry groups are needed now more than ever to look at every fatality and ideally at the near misses as well, to inform our treatment efforts and perhaps even more powerfully to inform people who use drugs how to keep themselves alive and safe into the future.
Dr Judith Yates is writing a guest ‘Post-it’ on behalf of SMMGP, www.smmgp.org.uk
On drugs, like so many people on drugs, Britain is predictable, embarrassing and stuck in the past. Occasionally some bold public figure will admit to once smoking a joint whereupon tradition now dictates that a phalanx of columnists will descend, either to brag about their own boring acid trip in 1982, or to offer terrifying anecdotes about godsons who got hooked on skunk and now aren’t getting into Oxbridge. For the most part, senior politicians simply leave the subject well alone. Two months ago, the all-party parliamentary group on drug reform declared that current policy on medical marijuana was ‘irrational’. The Home Office just shrugged. In the absence of direction, or even debate, British drugs policy drifts, shaped by the whims of police forces. Nobody seems in charge of anything.
Hugo Rifkind, Times, 8 November
The confirmation that a full business case for [a consumption room] is being prepared following a meeting of the Glasgow City Integration Joint Board has generated a predictable gnashing of teeth from those who regard addicts as a criminal underclass undeserving of basic human compassion, let alone state-funded treatment. The critics are only getting warmed up, tossing out phrases such as ‘shooting galleries’ or ‘heroin hotels’, aghast at the prospect of medical-grade opiates being provided under supervision. A few have even offered a taste of the vitriol to come as the plans begin navigate uncertain legislative waters. One right-leaning newspaper warned of a doomsday scenario where ‘pampered users of all ages pump themselves full of freebie drugs’. It is hard to know which addiction is more ruinous: heroin, or this kind of diet of fear, anger and misinformation.
Martyn McLaughlin, Scotsman, 2 November
The long-term aim of drug policy has always been, and should remain, to help addicts recover. But for a small number of vulnerable addicts, safe heroin and a safe place to consume it may be the only answer.
Herald editorial, 1 November
One of the hopes of devolving power to governments in Scotland and Wales was that they would experiment with policies that could spread to the rest of Britain. Glasgow’s promising trial should be watched closely by other cities.
Economist editorial, 5 November
Canada and the US are waking up to the realisation that decades of cannabis prohibition have caused far more problems than they have solved, and it is only a matter of time until such enlightened thinking washes up on shore here.
Addaction’s two-day conference addressed emotional wellbeing while celebrating the value of shared experience, as DDN reports.
‘Learn, share, connect and celebrate,’ urged David Badcock, Addaction’s head of events, opening the charity’s two-day conference on addiction and mental health.
The need to connect soon became a strong theme. ‘I always felt so different from everyone else at school,’ said mental health campaigner Jonny Benjamin – the first speaker to start the conversation about the feelings of isolation that pushed him to the brink of suicide. In his case, the eventual diagnosis was schizoaffective disorder – a combination of schizophrenia and bipolar – but it was not the hospitalisation or the medication that made him want to live. Standing on a bridge in London, contemplating the worst, he was approached by a man who said ‘I’m not going to let you jump’.
‘A few things that he said changed everything,’ said Benjamin. ‘The real turning point for me was him saying to me “look mate, I think you’ll get better”. No one had ever said that to me before.
‘When you’re in that phase, you have no faith left in yourself. So for someone else to put their faith in you – that was what changed my mind… here was a guy willing to listen to me and not judge, and be patient and show compassion. I had hope where I’d never had hope before.’
He explained how he began talking about his mental health without embarrassment. Working with the charity Rethink, he began going into schools, prisons, hospitals and businesses to try to break the stigma – ‘that shame and that silence’ around mental health.
‘I was in a cycle – either drunk, or hungover or both,’ said Sarah Fitzpatrick, describing the painful lead-up to realising she needed to connect. Still drinking and in a violent relationship when she became pregnant, it was the mother she didn’t get on with who phoned social services. ‘When social services took my daughter away, I was very, very angry,’ she said. ‘I thought, “what’s the point?” I’d lost my daughter, my house, everything.’
Connecting with Addaction completely changed her life. ‘I remember my first session – I fell off the chair. After about six weeks I sobered up and was listening more. Joyce, my keyworker, is like my mam. She said “we’re telling you what you need to do, but it’s you who needs to do it.”’
Gethin Jones described his route to disengagement when a troubled and troublesome schoolboy, with his ‘life aged zero to 35 in one big social services filing cabinet’.
‘Never once did a teacher ask me why I acted the way I did. They would say, “Gethin, why are you so disruptive? Gethin, you’re never going to amount to anything.” Those words stuck with me and I started to think, “I don’t want your school. I don’t need your education. I don’t need to be around people like you.’
Sentenced to a detention centre, the frightened 14-year-old child was ‘curled up in a prison bed, in a cell, the blanket over my head, crying into my pillow. I wanted someone to take me away, I wanted to feel safe. Nobody came.’ The belief system that grew within him for the next 20 years was that he didn’t need to have anything to do with anyone – a ‘journey of self-destruction’ that ended in a four-year custodial sentence.
While in prison, he met people who wanted to help him and ‘sowed the seeds that rehabilitation was possible’. But it was a member of the prison outreach team, he says, that ‘connected with me as a human being. Jo never judged or condemned me – she would always be consistent, ask how she could help. She was inspirational to my journey and started to take me through into other services, so they could help and support me.’ With no education, no employment record and ‘no social skills whatsoever’, Jo put him on the path to qualifications and found him a volunteering role.
‘So her support and integrated way of working enabled me to move forward in my life quite quickly. From somebody who felt that they could never amount to anything, I went from two hours a week volunteering to becoming a service manager overseeing a staff team of 40.
‘I’ve heard so many people wondering what they’re going to do about the broken system and lack of support,’ Jones told the audience. ‘But the solution is in this room. All of you have ideas and can think what you can do to make the system better for the people that we support. The next stage is to talk about it, share it – with your peers, your manager, people of influence. Then the most important part is the action – get on and do it.’
Through chairing a panel session, Anna Whitton, Addaction’s executive director of services, wanted to look more closely at why the system wasn’t working for everyone.
‘A young person said to me, “I have nothing to offer the system and the system has nothing to offer me”, she said. ‘It made me think, how do we empower people? How do we integrate and co-design services for the most vulnerable in society? What is it that’s not working?’
‘The system is very much broken, as we’re missing multiple opportunities to intervene,’ said Isabelle Goldie, director of the Mental Health Foundation. This was the case from perinatal services, to teachers missing chances to intervene in class, to adulthood, where one in three GP appointments related to mental health problems. ‘Instead of demonising people, we need to ask what’s gone wrong,’ she said. ‘There’s not enough research about what would make a difference.’
‘People’s lives aren’t straightforward,’ said Paul Farmer, CEO of Mind. ‘People don’t work in silos, but systems often do. Most people don’t “just” have a mental health problem.’ Campaigns such as Time to Change gave people a chance to talk about their experiences with mental health and could be a ‘real powerhouse’ in shifting the narrative, he said.
This narrative also needed to acknowledge the differences between treating women and men, said Katharine Sacks-Jones, director of Agenda, the alliance for women and girls at risk.
‘Women don’t really feature in the conversation about substance misuse and can find that services are designed as default services for men,’ she said. ‘They are a minority in services and often policymakers aren’t thinking about them. But we need to treat them as individuals, and need to understand what shapes their lives… women are sick of telling their story again and again. We need to design services so they don’t have to.’
Sunny Dhadley, director of the Recovery Foundation, brought the essential service user perspective – from both personal and professional experiences. ‘The criminal justice system is seen as a necessary intervention, but this has to change,’ he said. Service users had an ‘absolutely crucial’ role in shaping the system, but he was concerned about shrinking budgets, and the parts of services that could be ‘left to one side’, as well as the detrimental effect on the previously ‘massive service user involvement in the drug and alcohol field’.
Bringing the first day’s programme to a close, was ‘A walk through Addaction’, where the conference was turned into ‘conversation café’ and the round tables in the hall were themed by 16 different projects from all over the country. Delegates ‘speed-dated’ their way around the tables and had the opportunity to discuss projects with presenters, taking up David Badcock’s initial invitation to ‘learn, share and connect’.
Among the final day’s diverse presentations, the theme of service user involvement was resumed by Stephen Molloy, director of the International Network of People who Use Drugs(INPUD). ‘We need to invite and involve people who use drugs into services,’ he told the conference. ‘It’s got to be meaningful engagement of people who use drugs – and not about when they’re two years clean, but about where they’re at.’ Key to this was developing community advisory boards, just as there were for many other medical conditions.
‘People who use drugs don’t have that voice anymore in the UK,’ he said. ‘We used to have it, but those organisations don’t exist anymore. We have to see drug user activism and whether you’re a drug user or not, you have to be part of that community.
‘We’ve become the deserving versus the undeserving and drug-related deaths are rocketing… If we don’t challenge, governments will carry on doing what they’re doing.’ In the closing session, Welsh rugby legend Scott Quinnell brought together the themes and turned them into a rallying cry.
‘It doesn’t matter what you struggle with,’ he said, talking about the dyslexia that gave him the impression he was ‘thick, stupid and lazy’ in school. ‘When you’re told by people you trust, that’s what you become’, with a disastrous effect on self-esteem.
‘So tell people “you can do anything you want in life. Believe in yourself”,’ he said. He had turned around his prospects because he had asked for help – ‘but more importantly, someone asked him ‘how can I help you?’
And that is why you’re so important,’ he told delegates. ‘Put a smile on their face – help them. You are the people making a difference.’
Joanna Sharr of Ridouts answers your legal questions
‘As part of the data monitoring process for our CQC inspection we provided detail of commissioners, local authorities, and other organisations making referrals to our service. Since we did this our personal relationship with a senior individual in one of these organisations has gone sour, and we believe this has adversely affected our rating. How can we challenge this, while avoiding a public argument with the individual involved?’
Joanna answers: The Provider Information Return (‘PIR’) is the information submitted by providers to CQC before CQC’s inspections and is viewed by CQC as an important part of the inspection process. The information provided by services as part of the PIR is used by CQC to help plan inspections and will be considered alongside all other sources of evidence to develop CQC’s inspection report.
Whilst negative comments can adversely affect inspection reports, CQC should not accept such comments and criticisms at face value without seeking to corroborate such evidence before it makes a judgement about a service. Judgements and ratings made by CQC in inspection reports should also be proportionate to the evidence before it and CQC should follow its own guidance in this respect. It is our firm’s experience that CQC can fail to follow its own policies and guidance, which makes it all the more important for providers to challenge CQC’s draft inspection reports through the factual accuracy process.
It would be perfectly reasonable for a provider to challenge comments made by a third party if those comments were unreasonable or were not supported by evidence; both CQC and the individual in question should be accountable for statements that are used to form judgements. The provider could challenge the evidence by requesting copies of the inspection notes, by checking that that the comments are backed up by other evidence in the draft report, or by assessing whether the comments could be countered by other evidence. The provider has five days from publication of the CQC report to seek a ratings review. CQC states that the only grounds for requesting a review are that the inspector did not follow the process for making and aggregating ratings decisions; the review does not offer providers a further forum to challenge the facts or judgements.
In light of the service’s concerns about the deteriorating relationship with one of its commissioners, it would be advisable for the service to focus on maintaining and developing its relationships with its commissioning bodies and third party stakeholders. Ways that relationships with commissioners could be fostered include, for example, holding an open day to address any concerns that commissioners may have or by writing to stakeholders to seek their views. Not only would this encourage an open dialogue but it could also be used as evidence at CQC’s next inspection that the service was driving improvement by seeking feedback. We recommend that this service is prepared for the next inspection by addressing any concerns that CQC made in its last reporting, and ensure that it is compliant in all respects. We would encourage all services to challenge CQC’s findings through the factual accuracy process if CQC’s draft inspection reports do not stand up to scrutiny.
Katalin Ujhelyi, Jerome Carson and Ioanna Melidou share results of a new study.
People with dual diagnosis – co-occurring substance misuse and mental health issues – have complex needs. The duality of their disorders gives augmented symptoms, leaving clients particularly vulnerable and with poorer treatment outcomes. They require the most support, but in fact receive the least, according to Turning Point’s recent Dual dilemma report.
The unmet need of those with coexisting problems was the reason for developing a new treatment programme, within the scope of a PhD research project conducted at the University of Bolton, in collaboration with Lifeline Project. The project involved a group of participants with dual diagnosis issues who attended the Bolton Integrated Drugs and Alcohol Service (BIDAS).
Traditionally, psychology has been preoccupied with what is wrong with us and concentrated on trying to repair it. Positive psychology, on the other hand, is the science of positive aspects of human life and looks for what is right with people. It explores positive experience, positive individual traits, and positive institutions (Seligman & Csikszentmihalyi, 2000).
The field is not intended to replace traditional approaches, but to draw on the findings and methodologies of psychology in general and make it more representative of the human experience (Seligman et al, 2005). According to Seligman’s PERMA Model of positive psychology, wellbeing or flourishing stands on five pillars: positive emotions, engagement, relationships, meaning, and accomplishment (Seligman, 2011).
Positive psychology has been successfully applied in addiction recovery, as well as in the treatment of mental illnesses. However, there is a lack of research relating to dual diagnosis.
Applied to addiction, it can be seen in three areas associated with ‘the pleasant life’ (positive emotions about the past, present, and future); ‘the engaged life’ (having positive traits that are necessary for full engagement, such as hope); and ‘the meaningful life’ (service to, and membership of, positive entities such as family, workplace, Alcoholics Anonymous).
Positive interventions aim to increase positive feelings, behaviours, and cognitions rather than working on pathology and maladaptive thoughts and behaviours (Sin & Lyubomirsky, 2009). According to positive psychology, a lack of mental illness does not automatically mean you have a happy life. While the aim of traditional psychology is to treat mental illness, positive psychology gives a hand to this traditional approach but in addition helps people move beyond survival to achieve their full potential and flourish.
The new programme – developed by the University of Bolton and Lifeline Project, within the scope of a PhD research project – is providing dual diagnosis clients with an opportunity to increase their wellbeing. It has been shown that individuals with dual diagnosis are less hopeful about their future, struggle more to cope with whatever life throws at them, and therefore experience lower levels of wellbeing (Ujhelyi et al, 2016). The aim of the current intervention is to increase levels of hope, resilience and mental wellbeing through a positive psychology approach.
In a group, participants were introduced to several different positive psychology concepts and learned how these can be integrated into their lives to make them more resilient, more hopeful and happier. In collaboration with the Psychosocial Interventions Service (PSI) at Lifeline Project, participants already engaging in treatment were identified as having a mental health diagnosis and a relative level of stability in regard to substance misuse. The PSI service provided the group with a space and equipment to deliver the sessions, and a member of staff attended to observe and provide support if necessary.
Positive psychology does not equate with a ‘smiley face’ – it is much more than that. It considers concepts that are deep-rooted in different cultures all around the world, but may have been forgotten in terms of benefit to our everyday lives. It also seeks to provide robust empirical evidence as to how these aspects can benefit our wellbeing.
The new positive psychology Intervention consists of 12 two-hour sessions run on a weekly basis, delivered using a psycho-educational approach. Participants are encouraged to engage in group exercises and work in between sessions, acquiring skills and psychological resources that will help them with their recovery.
For people with addictions the work must begin by restoring character strengths. Taking the VIA strengths test – available to anyone at www.viastrengths.org – enables them to discover their top five signature strengths to follow specific objectives. A goal-oriented mindset can then be facilitated through increasing people’s willpower or motivation, as well as their ‘waypower’ – their ability to set and achieve realistic goals while being able to deal with challenges.
What is needed is a radical change in the attitude people have towards life, taking responsibility to find the right solutions to whatever comes up. People need empowerment through increasing their resilience to take control over their own lives, and be given the freedom to accept or reject the opportunities life presents.
Finding what makes life worth living through the deeper appreciation of gratitude, learning about how generating positive emotions in one’s life can build an upward spiral, and recognising the importance of compassion towards oneself and others, are all psychological resources that can provide us with tremendous support during hardship.
Focusing intentionally on our immediate experience and becoming grounded in the present moment through the formal and informal practices of mindfulness will help with the integration of the aforementioned aspects into our lives. And last but not least, we can use mindfulness to put basic nutrition into action to keep ourselves healthy. The end product of learned skills and acquired resources is resilience – the ability to cope with adversity by replacing maladaptive coping strategies.
Although it is too early to draw conclusions, the results of the first pilot study are promising. People’s lives in the group have changed significantly. Based on participants’ feedback, nothing had made them think as much as this intervention before. One participant said: ‘I feel like I have just woken up! I see life in a totally different light!’ Another said: ‘This intervention has changed my way of thinking about myself. I think I shall give myself a little more credit from now on.’ They also felt that the intervention taught them to rely more on themselves: ‘I don’t want to go to the recovery services for the rest of my life,’ and were empowered by the skills and resources they acquired.
The main themes arising from the feedback were ‘I can do this!’ ‘I am capable’, and ‘life is worth living’. Based on the results of the study questionnaires, participants have become more mindful, their dependence on substances has decreased, their wellbeing has increased and they feel more resilient and more hopeful. They have become less anxious and less depressed, and finally, they have more positive emotions and positive experiences. We intend to start a second pilot study in January 2017, which will test an improved version of the intervention.
The authors would like to thank the clients who participated in the programme and Lifeline Project Bolton for their cooperation, and Alcohol Research UK for funding the pilot study. This project would not have been possible without their support.
Katalin Ujhelyi is a PhD student at the University of Bolton, Jerome Carson is professor of psychology at the University of Bolton, and Ioanna Melidou is psychosocial interventions team manager for Lifeline Project.
Sin, N.L. & Lyubomirsky, S. (2009). Enhancing Well-Being and Alleviating Depressive Symptoms with Positive Psychology Interventions: A practice-friendly meta-analysis. Journal of Clinical Psychology (65)5, 467-487.
Seligman, M.E.P., Steen, T.A., Park, N., and Peterson, C. (2004). American Psychologist, 60(5), 410-421.
Seligman, M.E.P. (2011). Flourish: A New Understanding of Happiness and Well-Being. Ney York: Free Press.
Seligman, M.E.P. and Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55(1), 5-14.
Turning Point (2016). Dual Dilemma: The impact of living with mental health issues combined with drug and alcohol misuse. Turning Point UK: London.
Ujhelyi, K., Carson, J., and Holland, M. (2016). Positive Psychology in Dual Diagnosis. A preliminary investigation. Advances in Dual Diagnosis, 9(4), 1-15.
Harnessing service user activism is the key to stopping drug and alcohol services sliding further down the list of ‘targeted outcomes’, says Martyn Cheesman
The world of substance misuse is changing – it’s a case of ever-decreasing circles. The government drug strategy of 2010 outlined the need for a recovery-focused model of treatment and services have been trying to adapt ever since. Don’t get me wrong, the need for a focus on recovery was long overdue; but how can we accurately measure outcomes in an environment that demands instant gratification on dwindling budgets? The big issue is that no single model of recovery is definitive and many of the models that currently exist are no more than a remould of those that have come before them.
So let’s talk about the elephant in the room. Treatment providers are regularly delivering ineffective services that are designed predominately to achieve targeted outcomes, as opposed to supporting the individual needs of service users. The concept of a person-centred approach has unfortunately become more of an ideal than an actual reality, and while there are great managers and service providers delivering creative and innovative projects and programmes out there, ultimately when it comes to commissioned services their hands are tied with the shackles of statistical outcomes.
It is also fair to point out that there is little gain in pointing the finger of blame here. Commissioners have limited resources to employ services and service providers can only present models based on the resources on offer. The sad truth is that social care is woefully underfunded and substance misuse is at the bottom of the pile.
There is a temptation here to concede defeat to the problems that the substance misuse field currently faces. However, if we remain in the mindset of solution focus, austerity can provide an opportunity for positive change. The sticking point is the current trend of risk aversion that dampens creativity and hinders development. The one thing I have learnt in my 11 years working in the field is that risk can be assessed and to a reasonable level calculated.
I have been fortunate over the past year to have a service manager that believes that taking well-calculated risks to further develop creative interventions can breed favourable outcomes, both statistically and tangibly for service users. It takes bravery and a pioneering spirit, but genuine outcomes that benefit communities and individuals are achievable while satisfying the statisticians.
What is required is a collective focus on improving interventions to meet the needs of individuals, by genuinely consulting service users – not just as a supplement to designing services but actually involving them in the fabric of the design process. Not all interventions require financial resources, in fact sometimes quite the opposite. I frequently find in my day-to-day working environment that such incentives often hinder progress or limit interventions under the banner of what an organisation is paid to deliver.
Over the past year I have been coordinating volunteers and peer mentors in the Medway towns for Turning Point. Medway has a significant percentage of its population involved with substance misusing behaviour and, it is fair to say, we are a very busy service. The team of volunteers I manage contribute countless hours, selflessly supporting our service users to access treatment, and have been extremely successful in doing so. What drives them is the passion to see others succeed, promoting recovery and mutual aid to benefit their own community, without the need of a pay cheque at the end of it all.
I am continually amazed and buoyed by their efforts and I believe they set an example that is so often overlooked; a sense of community wellbeing. Over the coming year we will be working with this team of volunteers to secure independence from substance misuse services, supporting them to set up a recovery community in the Medway towns that can survive the inevitable commissioned contract changes and the invariable reinvention of the wheel.
There is a quote attributed to British prime minster Benjamin Disraeli that states ‘there are three kinds of lies: lies, damned lies, and statistics’. If we continue to ‘let the cart lead the horse’, we are only going continue to dilute our ability to achieve genuine outcomes. There are two key elements fundamental to supporting successful recovery that many modern substance misuse services currently lack – empathy and compassion. It’s not that structured services are not important; however, investing in volunteer programmes as part of service provision would go a long way to bringing some balance back to services that are currently on offer, and one step closer to better outcomes for all.
Lee Collingham shares his highlights from the GPs’ conference on managing drug and alcohol problems
Dr Stephen Willott, clinical lead for alcohol and drug misuse at NHS Nottingham City and conference chair, introduced the event’s theme as addressing drug-related deaths, which not only continue to rise in England but are twice the European average.
It was a shock to learn alcohol-related deaths aren’t recorded as DRDs, and Dr Willott appealed for a fresh approach moving forward. The average age of deaths had also risen from 35 in 1995 to 41 in 2016, with evidence proving opiate substitute therapy (OST) was highly effective in helping people get their life back on track. It was also noted that England’s localised agenda is a barrier to not only the widespread provision of naloxone, but also to it being provided to prisoners on release.
Prof David Nutt, former advisor to the ACMD, then talked about how opiate and cocaine-related deaths were at their highest ever, and that there was a need to push for allowing cannabis for medical use in England, as it was in 18 other countries around the world.
He mentioned how alcohol and tobacco, though both legal, were responsible for the majority of deaths, with 80,000 a year dying from tobacco related illnesses and 25,000 from alcohol – compared to opiates being responsible for around 2,000 deaths a year. He also thought the recovery agenda had been the main cause for the rise in drug-related deaths. Next, Dr Cathy Stannard, a consultant in pain management, questioned the use of opiate-based painkillers as the most effective solution for the long-term management of pain. She talked about the importance of getting it right or facing a public health disaster and mentioned that pain was strongly affected by mood, with those affected by anxiety and stress responding less well to the medication.
The morning finished with a choice of sessions on subjects ranging from the future of drug treatment to end of life care. Posters on display included ’seasonal influenza immunisation’, ‘opiate analgesic dependence’ and ‘ the difference between buprenorphine prescribing and methadone for injecting opiate users’. This year’s poster award went to Kathryn Chadwick and Zoe Black from Sheffield Social Care Trust, on leg ulcer management for the problematic user.
Interesting presentations in the afternoon included Professor Ken Wilson from the Cheshire and Wirral Partnership Trust around ‘brains, booze and hospitals’. He explained how brain injury is the biggest concern for problematic drinkers, causing the frontal lobe to shut down and leading to problems with memory.
For me, the highlight of the day was the news from Professor Graham Foster, professor of at Queen Mary University Hospital London, that there is a pot of £70m available for the treatment of hepatitis C. He explained that, from January, there’ll no longer be the need for combination therapy, with the release of a new licensed drug that will not only allow patients to take just one pill a day, but actually cure hep C.
Lee Collingham is a volunteer user involvement worker and advocate.
DDN welcomes your Letters Please email the editor, claire@cjwellings.com, or post them to DDN, CJ Wellings Ltd, 57 High Street, Ashford, Kent TN24 8SG. Letters may be edited for space or clarity.
Vital challenge
Kaleidoscope was one of the original drug services in England, and a pioneer of harm reduction services, campaigning against long waiting lists by providing rapid access to treatment. Over time local authorities improved the services to their own drug using population and the need for our services was reduced. At the same time, however, I saw many small drug services struggling to survive, losing their community based, charitable services to the large corporate drug services. The campaigning voice was beginning to get quieter as services recognised that responding to the demands of the commissioners was more important than meeting the needs of the service user.
So 13 years ago we were offered a route out of England to establish drug services in Newport, South Wales. There were significant problems in Wales with access to treatment and poor treatment outcomes. At the same time there seemed to be a real commitment to tackle the issues of drug and alcohol use that came from government and the local communities, which was incredibly refreshing. In Wales there was a communitarian approach with the concept of co-production key before the term itself was even invented. Recovery was an important element to any treatment service, but so was harm reduction.
Recently ARCH Initiative joined the Kaleidoscope family and I find myself back in England, saddened to see the decline of good service provision across the border as massive cuts to provision take hold. I was however pleasantly surprised to hear of Collective Voice and attended its meeting. Having reflected on this brief experience, I feel deeply troubled.
In Wales we provide services, at some level, to all the 22 counties. In our work there is not a single example where we do it alone we work in partnership. In England I do not get this sense of genuine partnership working and certainly not from Collective Voice. How do I have common cause with any agency that puts commercial prosperity over the needs of service users? How do I work with people who used to be passionate advocates of harm reduction, but because the political winds have changed have tried to emerge as recovery champions?
I see huge cuts to services in England, where the solution has been to make contracts ever bigger, which of course can only be delivered by the McDonalds/Burger King-like services offering cheap, off the hook solutions at the cost of more localised and specialist services. What we need to do is rage against cuts to services, and advocate for innovative community-based solutions that have a passion to serve the needs of people coming to them.
I hope that a new voice can be heard, made up of smaller organisations coming together, offering cost effective service delivery while maintaining their commitment to their values – campaigning services that are able to support government policy when it is right, but to work with the service user community when it is wrong.
When will we south of the border in England follow the successful trail-blazing example set by our Scottish neighbours, with their pioneering and successful approach to the national, and in fact worldwide, drink and drug problems?
In 2011 Scotland introduced naloxone on prison release and it has been massively successful, and we now see an application being made for the UK’s first safe consumption room in Scotland.
It is unbelievable to even contemplate a system where part of the pack you would leave prison with would not include naloxone. Tolerance levels are low so it’s risky to use, and the natural thing to do following release is to stay with old friends, possibly using ones, and to have a hit to celebrate freedom.
The stats and figures citing the harms on society overall from alcohol speak for themselves these days, and we live in a society where alcohol is readily available 24 hours a day on virtually every street corner in the land. It is more affordable than ever, and we are seeing the consequences. It would therefore make a lot of sense to try and manage this risk by introducing sensible price restrictions – as Scotland is attempting to do with minimising unit pricing – as a form of harm minimisation.
In my opinion Scotland’s approach to drink and drug problems is to be commended – it is a liberal and refreshing one. We need to move away from the moral, financial and target-based approach and instead move forward with a harm reduction based, compassionate approach aimed at longer lasting success, rather than a short-term commissioner and government pleasing approach.
Karl Newton, peer mentor
Breaking barriers
Here in Hastings we read with interest Claire’s comments in the dual diagnosis editorial (DDN, November, page 3). Fulfilling Lives is a Big Lottery funded project set up in 12 areas across the country where it is acknowledged that a higher percentage of people with multiple and complex needs and a dual diagnosis are likely to call home.
Agencies here are aware that there is a need to re-engage with the issues that historically act as barriers to access, diagnosis, treatment and recovery for people with a dual diagnosis, particularly when you add homelessness into the mix. It is early days, but the membership of the recently set up dual diagnosis meeting grows, interest is sparked and those involved are keen to examine their part in the process from a solution-based perspective.
Progress is made and alliances formed. Will this result in systems change and more people receiving appropriate treatment? Yes, we believe so!
Few alcoholics and addicts have anything like as much recovery capital to revert to as Amy has in Orkney. Being fortunate does not prevent addiction.
THE OUTRUN by Amy Liptrot
Published by Canongate.
ISBN: 9781782115489, £14.99
Review by Mark Reid.
The dingy confinements of Amy Liptrot’s addiction contrast utterly with the irenic spaces of her recovery. The Outrun refers to the furthest-flung coastline of the family sheep farm on Orkney, where she grew up and where she returns. Once oblivious to its beauty, Amy, like most teenagers, wherever they are, wanted out – to London – only to find no amount of big city bright lights can match the natural luminosity of the islands. Few alcoholics and addicts have anything like as much recovery capital to revert to, as Amy does, 800 miles north. Being fortunate does not prevent addiction.
Of course, when Amy first lived in ‘fantasy’ London she loved being the ‘wild girl’ spending ‘enchanted summer days in the park with beautiful people’ and then ‘Soho nightclubs I’d read about in magazines’. But it’s unsustainable. Soon Amy is making excuses to leave friends in bars ‘to drink faster, alone’. Jobs are lost, as are places to live. Looking for another new flat, ‘I mumbled my story, they chose someone else’. So Amy finds a small room in a Victorian terrace in Clapton. ‘I saw the sash window next to the bed, I knew I’d be able to drink and smoke freely there. I moved in’.
Amy’s recovery is indebted to Alcoholics Anonymous. She accepts there can never be a first drink. She thrives in the trust and bond of being ‘in church halls with misfits drinking tea from chipped mugs, listening to tales of people shitting the bed, laughing our heads off’. Amy strives to embrace the 12-step programme: ‘I need to do more than just not drink’.
Amy does a lot more than just not drink. When The Outrun came out in paperback, the publisher quite rightly pitched it as ‘a nature memoir’, a very fashionable genre. Amy recaptures, and this time truly cherishes, ‘childhood memories of chasing oystercatcher chicks, feeling their soft, hotly beating bodies in our hands, before letting them go’. It’s an idyllic setting for recovery. Once so impatient to leave, Amy Liptrot ‘s coming home radiates how ‘recovery is making use of something once thought worthless’.
Mark Reid is peer worker at Path To Recovery (P2R), Bedfordshire
This year has held more political turbulence than most of us can stomach. Alongside that, the ongoing onslaught on budgets and growing demands on the sector have ramped up the pressure with no easy way forward.
But we mustn’t be lost for words. At the recent Hit Hot Topics conference, American neuroscientist Professor Carl Hart said ‘When there is injustice we need to take risks. When Obama was in office, we went to sleep and claimed victories for things that weren’t victories… You know the score with Trump. It’s better to know the score than to hear pretty lies. Go to work.’
Dr Judith Yates’ article, ‘A name not a number’, demonstrates why it’s our duty to do more. Heroin-related deaths have doubled – yet what are we doing with these statistics? The work of DRD inquiry groups is being stifled by financial cuts, but we know that the vast majority of drug related deaths are of people who are not engaged in treatment – and more than half of them have never been in services.
Simple inexpensive actions, says Dr Yates, can make all the difference, and this is echoed in many moving stories at the Addaction conference. But as Stephen Molloy warned, talking about essential service user activism, ‘We’ve become the deserving versus the undeserving… if we don’t challenge, governments will carry on doing what they’re doing.’
Our next issue of DDN is out on Monday 6 February. Keep in touch at www.drinkanddrugsnews.com and @DDNmagazine
There is an absolute moral imperative on all of us to tackle the ‘outrageous discrimination’ against people with mental health problems, said Norman Lamb MP at a recent conference. I don’t think any of us would disagree with that – the question is, how? As our article shows, the problems are magnified for people from minority groups, and when you add the stigma of a drug or alcohol problem, it’s not surprising that people are not presenting for help. Dual diagnosis has been much talked about in recent years, but are we addressing it logically?
The conference itself was an extremely positive experience, with ideas flying around throughout the day. Participants pledged to network beyond the event, and there was plenty of support for integrating mental health, substance misuse and social care. But it also highlighted the need to reach beyond our sector – it was seen as crucial to engage people at a much earlier stage, which means joint planning with health services and education to catch them before they are at crisis point. Yet who has the time and money to think beyond a day job that’s full to capacity?
We have to talk about this, or it renders our good intentions meaningless. It requires a different way of working and a different level of investment that has to be underpinned by political support – and not just that of our free-speaking shadow ministers. If you have experience of working with dual diagnosis, please share it with us.
A ‘root and branch’ reform of UK cannabis policy is ‘long overdue’, says a new report from Volteface and free market think tank the Adam Smith Institute. A legal cannabis market in the UK could be worth £6.8bn a year and produce annual benefits to the government of up to around £1bn in tax revenue and reduced criminal justice costs, says The tide effect: how the world is changing its mind on cannabis legalisation.
Current policy is a ‘messy patchwork’, it says, with enforcement intermittent and dependent on each regional police force. The government ‘must acknowledge’ that legalisation is the only workable solution, the document states.
The report, which has the backing of cross-party MPs including Caroline Lucas, Nick Clegg, Paul Flynn, Peter Lilley and Michael Fabricant, comes after four more US states, including California, have voted to legalise the sale and consumption of recreational cannabis (see story this page). A regulation model is ‘substantially more desirable’ than either decriminalisation or unregulated legalisation as it is the only way to ensure that the product meets acceptable standards of quality and purity, it says, as well as removing criminal gangs from the equation ‘as far as possible’, raising revenue for the Treasury through point-of-sale taxation and protecting public health.
The document also echoes previous calls for the responsibility for cannabis policy to be moved to the Department of Health, with the Home Office’s role changing from ‘enforcement of prohibition to enforcement of regulation and licensing’. Jailing people for cannabis-related offences in England and Wales costs around £50m per year, the document adds.
‘The global movement towards legalisation, regulation and taxation of cannabis is now inexorable,’ said Volteface’s director, Steve Moore.
‘Today in the UK there is capricious policing of cannabis and no regulation of its sales and distribution. This quasi-decriminalisation of cannabis leaves criminals running a multi-billion dollar racket and exposes teenage kids to criminality. The evidence is now clear that regulated markets for cannabis cut crime and protect vulnerable children. The government’s current policy vacuum is untenable in the face of this evidence.’
‘What does recovery from addiction look like for families?’ is the subject of a ground-breaking research project from Adfam and Sheffield Hallam University’s Helena Kennedy Centre for International Justice, funded by Alcohol Research UK.
The Family Life in Recovery project is the first of its kind in the UK and will be conducted through a series of workshops followed by a detailed survey to map the recovery journey of family members of those suffering from addiction.
The survey will ask: ‘What is the recovery journey for the family member (and the remainder of the family)?’ and ‘What is the family member’s experience of an addict’s recovery journey and its impact on them?’ Results of the survey are expected to be published next summer.
The work follows on from Sheffield Hallam University’s first national UK survey of addiction recovery addiction experiences in 2015, which showed clear improvements in wellbeing in the transition from addiction to recovery. These related to health, employment, offending, risk and substance use, families and social relationships.
‘The Family Life in Recovery survey provides us with a rare chance to build an understanding of what the experience of living with and through addiction recovery is like and what impact it has on a range of family members,’ said project lead David Best, head of criminology at Sheffield Hallam University.
‘This research will help understand the needs that this population has and what can be done to support them in living with addiction and in supporting people to overcome the many challenges of an addicted lifestyle. We have previously shed light on personal addiction stories and now it is the turn of the families.’
‘We know that the journey of recovery has a large impact on the lives of family members,’ added Vivienne Evans OBE, chief executive of Adfam, the charity working with families affected by substance misuse for more than 30 years.
‘We are looking forward to the findings from this research to see how we can better support and advocate on behalf of families dealing with issues surrounding addiction and recovery.’
Service users in London have been discovering their ‘wow factor’ – ways of wellbeing – at a conference coproduced with Central and NorthWest London NHS Foundation Trust (CNWL) and the charity Build on Belief (BoB).
This year’s Engage Conference focused on the simple steps anyone can take each day to improve their quality of life and included a look at dual diagnosis and common physical health problems. The Outside Edge theatre group inspired the audience with their drama, and entertainers were accompanied by a troupe of BoB musicians.
The day also featured awards to service users, recognising their efforts to overcome substance misuse problems and give back to their services and community.
‘Hearing people speaking about their recovery journey to a big audience takes courage and I was humbled and thankful to these people for sharing their personal journeys,’ said Lorna Payne, CNWL divisional director, who presented the awards.
The 2012 alcohol strategy (DDN, April 2012, page 4) had set the policy direction that local areas were still following, head of public services and welfare for cross-party think tank Demos, Ian Wybron, told last month’s What now for alcohol policy? event. The significant exception, of course, was minimum unit pricing, the strategy’s commitment to which was later shelved (DDN, August 2013, page 4). ‘Binge drinking across the UK is in decline and has been for ten years, particularly among 16 to 24-year-olds,’ he told delegates. However, alcohol-related hospital admissions were increasing, and alcohol-related violent crime remained a major issue.
The strategy had contained a great deal on local area partnerships, he said, but the government appeared to have gone ‘very quiet’ on the controversial public health responsibility deal – a ‘very interesting engagement’ between itself, the industry and the voluntary sector. Other elements of a changing policy landscape included the newly revised chief medical officer guidelines (DDN, February, page 4) and the potential implications of Brexit – ‘it feels like there’s an awful lot of uncertainty around alcohol policy there,’ he said. According to Demos’s own research, there were a number of factors that could explain declining rates of binge drinking among young people, he told the event. ‘There seem to have been successes in terms of the health messaging around alcohol, with lots of young people taking those messages on board and moderating their consumption. There’s also a big role for social media, and the sheer amount of time that young people spend on it when perhaps they might otherwise be out drinking. Working with the statistics is always difficult, but one thing they do indicate is that while fewer people are drinking, the ones who are, are drinking more. So what’s needed is a much more targeted approach.’
The think tank’s interviewing had found that young people still did not use units to calculate or moderate their drinking, however. ‘They don’t really understand them, so we do need a new language in terms of consumption – one that makes sense to young people – as well as more emphasis on developing preventative programmes in schools.’ While there had been ‘a lot of effort’ around unit awareness, clearly more was needed, acknowledged the British Beer and Pub Association’s director of public affairs, David Wilson.
The binge drinking figures, however, showed that some policy measures were working, he said. ‘So we need to learn what works and do more of it. The more we can do together – as policy makers and industry – the more effective we can become, rather than having all our debates pitched as stand-offs between the two.’ The industry would continue to develop, and promote, greater choice in areas such as lower-strength products, he said, but this had to be combined with more government help in terms of things like tax policy and advertising rules.
‘We believe that policy – fiscal and otherwise – should encourage and promote low-strength products,’ he said, while one possible opportunity in terms of Brexit was the chance it offered to review beer, wine and cider duties, which are calculated according to alcohol by volume (ABV). In terms of the retailer role in helping to reduce harm, alcohol remained an ‘incredibly important’ category for shopkeepers, said public affairs executive at the Association of Convenience Stores, Julie Byers. ‘Our members have a huge responsibility when it comes to things like ensuring there are no under-age sales.’
Around 70 per cent of convenience store retailers had an age-verification scheme like ‘Challenge 25’ in place, with more than a quarter refusing under-age sales around ten times a week – something that was not always easy for staff working alone in the shop and facing aggression. Her organisation also distributed information to raise awareness of things like proxy purchases – when children persuade older siblings, friends or even parents to buy alcohol on their behalf – and many local authorities and community alcohol partnerships now had campaigns explaining to parents that proxy purchasing was illegal.
‘When people think of the drinks industry they tend to think of huge multinationals, but 90 per cent of it is small and medium sized enterprises – something that’s hugely important to bear in mind when looking at policy,’ chief executive officer of the Association of Licensed Multiple Retailers, Kate Nicholls, told the event. ‘The night-time economy is worth £66bn – it’s big business for UK PLC.’ Her organisation’s members had a vested interest in tackling alcohol-related harm, she told delegates – ‘it’s not good for business if we don’t have a safe night-time economy’ – and partnership was key. Two thirds of alcohol was now sold and consumed away from the on-trade, she said, which meant that ‘top-down policy approaches’ targeting clubs, pubs and bars were not going to achieve the desired results.
‘You can obtain the same end objectives working in partnership,’ she said. Initiatives like promoting lower-strength products and smaller measures would always be more effective than bureaucracy or ‘finger-wagging and lecturing’. ‘We do need to recognise success as well,’ she said, ‘which means we need a clear benchmark of where we start from to work together’. Her members were frustrated, however, that ‘the goalposts seem to keep moving,’ she stated. ‘You need to give the trade the credit where it’s deserved, and you also need to make sure there’s joined-up thinking across government. In our own dealings with government we’ll say “people are drinking less” and they’ll say “ah yes, but now they’re drinking all those nasty soft drinks that are full of sugar instead”.’
‘It’s worth saying that, in any social policy area, to have these sorts of trends in things like reductions in binge drinking is very significant,’ said Portman Group chief executive Henry Ashworth. ‘But we really need to make the effort together to tackle things like the rise in alcohol-related hospital admissions.’ One of the main tasks was to see how local challenges related to the bigger picture, he said – for example binge drinking rates in Newcastle or alcohol-related hospital admissions in Blackpool, both of which were way above national averages. The ‘negative’ attitudes towards the alcohol responsibility deal had also not been helpful, he argued. ‘The drinks industry committed to, and delivered, 80 per cent of alcohol products on the shelves carrying unit and health information and pregnancy warnings – voluntarily.’ Things were now ‘in a different place’ when it came to labelling, however, as, ‘having achieved that 80 per cent figure, the CMO’s guidelines have changed’. There was a ‘plethora of fantastic’ local alcohol partnerships and schemes that were addressing the challenges in a coordinated way, he said. ‘We need to continue to robustly evaluate these partnerships to understand what’s working well. That way we can build more trust between the public and private sectors, the industry and the public health community, and identify and overcome the barriers to effective partnership working.’
When it came to a policy area that was nearly as controversial as the responsibility deal – advertising regulation – the last three years had seen a ‘sharp decline’ in the number of complaints about alcohol adverts, said regulatory policy manager at the Advertising Standards Authority (ASA), Malcolm Phillips. There had also been a smaller decline in the number of alcohol cases his organisation – which enforces the UK’s advertising codes – had decided to formally investigate, he explained. However, the authority knew it could not ‘rely on complaints alone to tell us what we need to know’, and was committed to maintaining a proactive approach towards the issue. ‘A claim often made by critics of advertising self-regulation is that the codes have no teeth, and there’s no incentives for companies to not bend the rules,’ said Diageo GB’s head of alcohol in society, Mark Baird. ‘This is not true. ‘If you spend hundreds of thousands of pounds making an advert and buying advertising slots only to find out you can’t use it – that has an impact, believe me.’
Advertising self-regulation served to complement national laws, he said, and ‘always went beyond’ the legal requirements. ‘Alcohol advertising comes under regular government scrutiny, but it’s very difficult to isolate a single factor – advertising – from all the other factors that influence alcohol consumption,’ he argued. Denmark, for example, had liberalised advertising regulations and seen consumption decline, he said, while the introduction of the Loi Évin – designed to restrict children’s exposure to alcohol marketing – in France in the early ’90s had had limited impact on consumption levels. ‘It’s very, very tight regulation, but under-age drinking is actually on the increase in France, at the same time as it’s declining here.’
In a ‘mature market’, advertising did not increase overall demand, he maintained. ‘So that brings us to the question people always come back with – “If you say alcohol advertising doesn’t work, why do companies spend so much money on it?” Well, of course it works, it just doesn’t work in the way critics and commentators say it does – does Andrex think it can grow the market for toilet paper? The purpose of advertising is to raise awareness of your product, and to steal market share from your competitors. We want people to buy our product, rather than someone else’s.’
OPIUM UP
Afghan opium production has soared by 43 per cent compared to 2015 levels, according to UNODC’s latest Afghanistan opium survey. The increase – to 4,800 metric tons – was ‘worrying’, said UNODC executive director Yury Fedotov. While the area under opium cultivation has also risen by 10 per cent, the most important driver in the increased production is higher yield per hectare, the document explains. The country’s western and southern regions – which together account for 84 per cent of total poppy cultivation – have recorded increases in yield per hectare of 37 and 36 per cent respectively. Document at www.unodc.org
CONVICTION POLITICS
Prisons are failing to rehabilitate offenders and should be radically restructured, according to the final report of the RSA’s ‘Future prison’ project (DDN, September, page 10, and June, page 7). Inconsistent political leadership has created a system that ‘puts public safety at risk’ says A matter of conviction: a blueprint for community-based prisons. Among a range of recommendations in the document is that a new ‘rehabilitation duty’ be legislated requiring prisons and probation services to track individual and institutional progress towards rehabilitation. Report at www.thersa.org
PREVENTATIVE PRIORITIES
Getting people back into work is a key way to tackle health inequalities in the North East, according to a report from NECA (North East Combined Authority). Last year the region recorded the highest number of drug-related deaths in the country for the third year running (DDN, October, page 4) and it also experiences high rates of alcohol-related harm. The document calls for a ‘radical shift’ to close the health and wealth gaps with the rest of the country, including better joint working, shifting the spending focus towards prevention and developing training for primary care staff on helping people with mental health conditions back into the workplace. ‘The entire system needs to shift its priority towards preventing poor health,’ said PHE chief executive Duncan Selbie. Health and wealth: closing the gap in the North East at www.northeastca.gov.uk
HUMAN HARM
Enforcing America’s drug laws has caused ‘devastating’ and ‘unjustifiable’ harm to individuals and communities, says a report by Human Rights Watch and the American Civil Liberties Union. The document is calling for personal use and possession to be decriminalised for all drugs, as well as increased funding to improve and expand harm reduction services. Every 25 seconds: the human toll of criminalizing drug use in the US at www.hrw.org
TROUBLING TIMES
The impact of the government’s flagship ‘troubled families’ programme has been negligible, according to an evaluation report from the Department for Communities and Local Government. Although the programme ‘clearly raised the profile of family intervention country-wide’ and transformed service development in some areas, these achievements did not ‘translate into the range and size of impacts’ that might have been anticipated based on the programme’s original aspirations, it says. In terms of outcome measures like use of drugs and alcohol in the previous three months, there was ‘no statistically significant evidence of any impacts of the programme’. National evaluation of the troubled families programme: final synthesis report at www.gov.uk
CBD CONFUSION
Products containing the active cannabinoid cannabidiol (CBD) for medical purposes ‘meet the definition of a medicinal product’, according to a review by the government’s Medicines and Healthcare products Regulatory Agency (MHRA), but anyone selling CBD products will now need to apply for a licence. Co-author of the recent All-Party Parliamentary report on medical cannabis, Professor Mike Barnes, called the decision ‘confused’. ‘If the MHRA and the UK government now consider that cannabis-derived CBD is a medicine, this is incompatible with the continuing schedule 1 status of cannabis under the Misuse of Drugs Act that clearly states that cannabis has no medicinal value,’ he said. MHRA statement on products containing cannabidiol at www.gov.uk
LOWER THE LIMIT
A coalition of emergency services organisations, road safety charities and health bodies is calling for the drink driving limit in England and Wales to be reduced in order to save lives. Around 240 people die each year as a result drink driving, a figure that has remained unchanged since the start of the decade, while the 80mg alcohol per 100ml blood limit has been in place since 1965 and is higher than almost anywhere else in Europe. ‘With hundreds of lives lost each year, we can’t afford to let England and Wales fall behind our neighbours in road safety standards,’ said director of the Institute of Alcohol Studies (IAS), Katherine Brown. ‘It’s time the government looked at the evidence and what other countries are doing to save lives and make roads safer.’ IAS drink drive video at www.ias.org.uk
FAMILY FOCUS
A joint research project into what recovery means for the families of those with substance problems has been launched by Adfam and Sheffield Hallam University. The ‘Family life recovery project’ aims to map the recovery journey of family members through an in-depth survey and a series of workshops, with the results published next summer. The work would give ‘a voice to a group who are poorly understood and rarely listened to – those who bear much of the burden of addiction and who themselves are affected by the experience’, said project lead, Professor David Best. www.adfam.org.uk
WESTMINSTER WORRIES
Almost a quarter of the homeless people staying in hostels in the central London borough of Westminster are using synthetic cannabinoids like ‘spice’, the local authority has said – a figure that would ‘have been closer to zero just two years ago’. The drugs pose a risk to both rough sleepers and frontline staff, said cabinet member for public protection, Nickie Aiken, and the council is calling for the police to be given increased powers to confiscate them.
Forward Leeds is among local services launching initiatives for Alcohol Awareness Week, 14-20 November. Their Like My Limit campaign aims to reach 17,000 dependent drinkers in the city and tackle more than £26m a year lost to the local economy through hangovers.
Through arranging for its workers to appear at various locations, and an accompanying social media campaign, the service will ask people to keep an eye on how much they are drinking.
‘The amount of alcohol a person drinks can have a significant impact on their health and happiness,’ said Dr Ian Cameron, Leeds City Council director of public health. ‘Our Like My Limit campaign encourages people to keep an eye on their intake and consider making one small change so that they can still enjoy drinking in moderation but feel happier knowing they are not risking their health.’
‘We’re trying to hit people who may not access formal treatment and just help them to become aware of the risks, give them some skills and show them what they can do to prevent drinking too much,’ added Jane Doyle of Forward Leeds. ‘We want to make sure people have an informed choice.’
The campaign was originally launched in 2014 to tackle the rise in the number of adults regularly drinking alcohol at home and putting their longer term health at risk. Top tips include having two alcohol-free days a week, using smaller wine glasses and switching to low alcohol drinks.
Mental health is in crisis – more so for people from minority groups. How do we reach them before they drown? DDN reports from the Minority Mental Health conference
‘There is outrageous discrimination against people with mental health problems… there is an absolute moral imperative on all of us to do something about the situation,’ said Norman Lamb MP.
The shadow Liberal Democrat spokesperson on health was addressing the Minority Mental Health conference, Ending discrimination in mental health: turning the crisis tap off, held in London last month. The event brought together professionals from all areas of health and social care to look at ‘one of the deepest and most discriminatory social failures of our education, social, health and criminal justice services’.
In many cases substance misuse was identified as playing a crucial part in developing mental health problems, while others used substances to self-medicate their mental health issues. In all cases, people were being failed by a complete lack of coordinated care and a health and social care system in crisis.
‘People need diversion [into the appropriate support] when entering the system – but we need to do more than this,’ said Lamb. ‘We need to address the underlying causes of mental health problems, and we need to stop the dreadful flow into the criminal justice system.’
Among the headline statistics, Black African Caribbean men were up to 6.6 times as likely to be admitted as inpatients or detained under the Mental Health Act as the average population. While attending a recent event organised by the charity Black Mental Health UK, Lamb – who has long campaigned for better treatment and understanding of people with mental illness – said ‘the degree of anger, frustration and disadvantage I came across shocked me to the core. I came away feeling something had to be done to address the anger from people in that situation.’
The aim of this latest event was ‘not to call for more research, but to look at what we can do together to turn the crisis tap off,’ said Gill Arukpe, chief executive of the Social Interest Group, created by Penrose and Equinox to support people with a range of needs, including mental ill health and alcohol/drug dependence. ‘Why do so many black people end up in mental health services or prison?’ she asked. ‘Why do so many end up in a crisis situation?’
Ending discrimination needed a change of approach, to look at how we can make a difference to individuals’ lives, said Antony Miller, Penrose’s director of operations. Early intervention was important; The Sainsbury’s Centre for Mental Health said counselling should always be available, but people were having to wait six to nine months for access to talking therapies.
‘What do we do to make people feel they can access services and engage?’ he asked. ‘Early intervention has to be better than dealing with problems when they are fully entrenched.’
We also needed to be much more responsive. ‘It’s not about saying to people, “this is your journey, this is your pathway”. It’s about listening.’
At workshop discussions on ‘the service user’s voice’, a delegate from Camden and Islington Mental Health Trust commented, ‘We need to start listening to the service users who are the experts – take from them what works and go back to them. They are the ones who are feeling it… Just because people have mental health issues or substance misuse issues doesn’t mean they don’t have hope too. We need to catch these issues before it becomes a crisis.’ A director from Norfolk and Suffolk Foundation Trust added: ‘It’s about unity… people can’t afford to be little monoliths, doing things on their own.’
‘We need to understand what’s in front of us – there are people who are not mad, not bad, but need support,’ said Commander Christine Jones, the National Police Chiefs’ Council lead for mental health, addressing the conference on ‘the imperative for change’.
With the prospect of less money in the system, our joint health needs analysis needed to be a lot more sophisticated, instead of applying a ‘sticking plaster approach’ to people in crisis.
We were missing vital opportunities to coach young people ‘at the point when they’re most malleable, most recoverable,’ she said. ‘Damage caused by entry into the criminal justice system at the age of 14 means they’ll be involved into their 30s. Things are easy to spot at an early stage and intervention points can change a life.’
Police had a ‘huge part’ to play in this, as they were often the first contact point, ‘and if they don’t know how to respond, it can escalate’. There were many reasons why people hadn’t come into services before crisis point, including stigma, fear and embarrassment.
Going forward, we needed to think about more efficient options, she said. ‘We need to make decisions at the right place and the right time, to deal with a problem that’s been misunderstood and under-resourced for too long.’
‘It’s about joint working and joint training,’ commented a head of social care at question time. ‘The criminal justice system doesn’t work with local authorities and health as well as it could. If police and health colleagues had more joint understanding, we could move the agenda forward.’
The afternoon sessions were dedicated to ‘solutions’ and Luciana Berger MP offered insights from her visits to mental health projects across the country.
‘It’s worth reflecting that we have made some progress in the last three years, particularly on stigma’ she said, mentioning the recent World Mental Health Day. ‘Mental health is not a sign of weakness – we all have mental health.’
However, the BME community was disproportionately represented in our mental health wards, and the fact that you’re more likely to be sectioned or end up in prison if you’re black was ‘one of the most glaring examples of inequality in our society’. There was a gap in data from both physical and mental health services that was needed to collate a national picture, she said, and government was shirking its responsibility to know ‘so much more’ about BME mental health, to properly develop services.
The financial implications of not helping people early on were showing in mental health costs to the NHS of £105bn every year. Furthermore, Berger’s FOI request to every clinical commissioning group in the country had showed disinvestment in mental health.
The ‘fragmentation of our system’ needed to change to ‘seamless integration of mental health and social care,’ she said, and this relied on everyone working together: ‘If we’re thinking about these mental health issues through the prism of the NHS, we’re thinking about them too late. Our local authorities should be supported in keeping services going.’
Dr Geraldine Strathdee of the Mental Health Intelligence Networks said that there was plenty of data and ‘fantastic analysts working across the system’, but a lack of representative leaders from the target population – the best way to find out about the needs of each area.
‘We need to use data much more effectively and intelligently,’ said Cllr Jacqui Dyer of the Mental Health Taskforce. Everyday discrimination was ‘a great source of stress’, but there was ‘nothing as powerful as true commitment and collaborative work… solutions are possible in every level of the system, but what it takes is collaborative effort.’
And this effort needed to be made at a much earlier stage, according to Maria Kane, chief executive of Barnet, Enfield and Haringey Mental Health
NHS Trust.
‘We need to do services cradle to grave, sperm to worm!’ she said. ‘Turning the crisis tap off is about introducing services much earlier – perinatal services. Those first 1,000 days are key to your mental wellbeing.’
Mental health relied on having ‘somewhere to live, someone to love, something to do,’ she said. ‘We need to line up our services and outcomes to make sure this is what we’re giving to people’.
There were ‘fantastic’ projects going on in many areas, but they depended on short-term funding and needed ‘mainstreaming’.
In the Q&A session at the end of the day, there were questions relating to many aspects of discussion, from recruitment of the right staff to better integration and communication. Asked about the poor experience of many people with substance issues within services, Leo Downey, Equinox director of operations, said referral to the right services could be difficult when mental health and substance misuse were so separate, and suggested that many mental health staff needed more training on substance misuse issues.
‘We need to make sure we don’t keep this conversation to ourselves,’ commented one delegate – a point underlined by the panel’s chair, Antony Miller.
‘It’s about sharing the work now,’ he said. ‘We’ve heard of at least ten projects today that are making a change. We need to stop talking about this and start moving it forward.’ DDN
New alcohol medication Selincro has had a controversial route to market, as Mike Ashton explains.
In 2013 Danish pharmaceutical company Lundbeck was authorised by the European Medicines Agency (EMA) to market Selincro – their trade name for the opiate-blocking drug nalmefene – to reduce consumption among dependent (but not physically dependent) drinkers.
Authorisation paved the way for nalmefene to tackle the bulk of dependent drinking lying below the iceberg-tip of physically dependent drinkers aiming for abstinence – and opened up for its manufacturer a large and potentially lucrative market, provoking accusations of an expensive and inappropriate medicalisation of lesser degrees of dependence based on unproven effectiveness.
To grasp the essence of the controversy, first we have to understand the dubious world of the post hoc sub-sample analysis, the type of analysis on which authorisation was based.
Imagine you have carefully levelled the playing field in a study by randomly allocating patients to a medication or to an identical but inactive placebo. Then eliminating any further bias, you check how the patients do. It can be likened to randomly loading coins with medication or placebo, then tossing them in the air and leaving them to fall – a process over which you have no control once the coins leave your hand.
If the medication worked, you would expect to see, not an even split of heads (healthy outcome) and tails (not so good), but the medication-loaded coins tending to fall on the healthier side. That might happen, but not consistently enough to meet conventional criteria for a significant effect. However, now you have a great advantage: you can actually see how the coins have fallen. You can check the one-pences, the two-pences, the five-pences, the ten-pence coins, the 20-pences, the pounds and the two-pounds. Maybe in one of these subsets there is such an excess of heads that you can pronounce the medication effective, at least among (say) the ten-pence patients. Had you said in advance you would focus on the ten-pence patients, you would have risked another negative finding. But with the data in, now you can see what the outcome actually was.
The conventional criterion for a significant effect is that the difference between the outcomes of medication and placebo patients would have happened less than one in 20 times by chance – a result considered so unlikely that something more must have been involved. Everything else having been equalised, that ‘something’ could only have been the medication.
Now we can see that researchers have an almost sure-fire way to generate a statistically significant finding: slice up the sample in lots of ways until in one subset the magical ‘less than one in 20 by chance’ result emerges. Try more than 20 slices, and a significant finding becomes more likely than not, even if in reality the medication is ineffective.
It is not enough to back-engineer good reasons for after-the-event (or post hoc) sub-sampling, and to deny trawling the data until a ‘significant’ pattern of excess heads was found. The possibility that this could have happened has to be eliminated. Otherwise the analysis can merely suggest the medication might be found effective in another trial limited to these patients, or at least where sub-sampling was planned in advance. Without this, it remains of unproven efficacy.
Authorisation to market Selincro rested on just such an analysis, undertaken in response to unconvincing initial findings in Lundbeck’s trials. Most ways of assessing the primary drinking outcomes had left nalmefene with no significant advantage over a placebo. When it was assumed patients not followed up were drinking at their pre-trial levels, none of the comparisons with a placebo reached statistical significance.
Faced with these results, Lundbeck and their research associates conducted sub-sample analyses which excluded medium-risk drinkers, and those at higher risk who had rapidly remitted even before treatment started – drinkers who tended to stay remitted, leaving Selincro little to improve on. What remained was a higher risk sub-sample who remained at high risk when treatment started. Among these patients, nalmefene had greater scope to reduce drinking, and the results were more consistently positive – but in the process, scientific credibility had been sacrificed.
The EMA’s scientific advisers admitted it was ‘not ideal’, but shrugged off post hoc sub-sampling as common in psychiatric trials due to high dropout. But in this case, high dropout was not the rationale. Instead, sub-sampling had been ‘proposed’ by Lundbeck ‘in order to define a population where the benefit of Selincro would be greatest’. Not just the effect, but the intention it seems was to find a slicing strategy which favoured Selincro. Sub-sampling also helped exclude about half the randomised patients, leaving a small and probably atypical remainder to supply the critical data. Together with multiple reasons for excluding trial applicants, it meant the results could not be relied on as an indication of nalmefene’s likely impact among the generality of drinkers.
Once made, the EMA’s decision initiated a chain leading to its approval for the NHS in Britain. In self-justifying loops, during European authorisation Lundbeck conducted the sub-sampling analysis in order to maximise nalmefene’s apparent impact, which in turn justified authorisation for these kinds of drinkers. This justified a published analysis focused on these drinkers and led to cost-effectiveness analyses based on the sub-sample, leading the National Institute for Health and Care Excellence (NICE) to say the NHS must make the product available for these types of drinkers.
Each link in the chain retained the original analysis’s vulnerability to bias and its questionable applicability to patients in general. To this, NICE added acceptance of the company’s argument that it was neither appropriate nor possible to compare nalmefene with naltrexone, its cheaper parent drug. One strand in the argument (justified by the unreliable sub-sample analysis) was that nalmefene was licensed to reduce drinking, but naltrexone to promote abstinence. In fact, naltrexone usually promotes reduced drinking, and does so among the same types of drinkers.
The other argument which led NICE to discount naltrexone was the company’s assertion that required data was lacking from trials, and that these were so different from the nalmefene trials that comparison would have been invalid. Contradicting their own case, Lundbeck later sponsored and co-authored just such a comparison. Its findings were broadly but not always significantly in favour of nalmefene, but were undermined by the sub-sampling decision. In the three largest of the four nalmefene trials, this gifted the drug an advantage not replicated for naltrexone. The dice were stacked against naltrexone, but only a reader familiar with the source studies would have known.
Eliminating naltrexone from Selincro’s therapeutic ball-park or finding it less effective was vital to Lundbeck. Financially, the company had suffered from the expiring of patent protection, leaving its medications open to competition from cheaper, non-branded, ‘generic’ equivalents. Selincro was meant to help plug the resulting revenue gap, but this would not happen if it too faced competition from generic naltrexone. An indication of how crucial this kind of issue was, in 2013 Lundbeck had paid a 93.8m euro fine imposed by the European Commission after being found to have paid rivals manufacturing generic antidepressants to ‘stay out of its market and delay the entry of cheaper medicines’.
Beyond naltrexone – and beyond this abridged version of the story – is whether any medication is appropriate for the kinds of drinkers at whom nalmefene is targeted. Full story and supporting citations at http://findings.org.uk/PHP/dl.php?file=Palpacuer_C_1.txt&s=dd
Joanna Sharr of Ridouts answers your legal questions.
Our residential rehab has a good reputation but is the target of a negative online campaign by a disgruntled resident. How can we challenge this?
The advent of social media and the ability of individuals to make online reviews has placed significant power into the hands of those who may wish to damage a service’s reputation. Even if your contract with the service user has regard to the use of social media while resident, engaging contractual provisions does not remedy the underlying issue.
This is a sensitive issue and should be handled with care; if dealt with in a heavy-handed manner, not only could the service be perceived to be unreasonable, but the online campaign could easily escalate to cause further damage to the service’s reputation.
For whatever reason, the resident did not seek to raise their concerns with the service directly but went to social media to vent their concerns. Perhaps the resident did not feel that their issues would be taken seriously, but they should be reassured by the service that they are. We would therefore treat the online campaign as a complaint.
A service’s formal complaint procedure should involve particularising the concerns and recording them, exploring the issues and possible resolutions and ultimately responding to the complaint. It may be helpful to include the resident’s family (or advocate if there is any capacity issue) in any discussions to ensure that the resident feels supported throughout the process. The service should discuss the outcome of the matter with the resident and ensure that the situation is resolved to the resident’s satisfaction. This will also help evidence CQC’s key questions, ‘well-led’ and ‘responsive’ in any future CQC inspections.
The resident should be encouraged to raise any future concerns or complaints with the service directly. The service could request the resident removes their negative comments from social media and ask that the resident desists from using social media to vent any future concerns about the service, particularly if the matter had been resolved to their satisfaction.
There will always be cases where, no matter what a service does, a resident will simply be unhappy and will seek to maintain their damaging course of action online. If that happens, and all conciliatory routes are exhausted, the service may wish to consider its contractual options to serve notice to the resident. This course of action will not necessarily quell the negative social media campaign and may lead to an increase in posts. We would advise taking specific legal advice regarding contractual remedies and the implications and subsequent actions that could be required if the matter cannot be resolved amicably.
Joanna Sharr is a solicitor at Ridouts LLP, a practice of health and social care lawyers, www.ridout-law.com
A legal challenge from the Scotch Whisky Association (SWA) and others against the Scottish Government’s plans to introduce minimum unit pricing for alcohol has been rejected by Scotland’s Court of Session.
Although the government has said the drinks industry ‘must now respect the democratic will of the Scottish Parliament’ and the ruling of the court, the association has not ruled out an appeal against the decision. ‘We will study the details of the judgement and consult our members before deciding on next steps, including any possible appeal to the UK Supreme Court,’ said SWA chief executive David Frost.
The ruling is the latest development in the long-running saga of the Scottish Government’s attempts to introduce the legislation. The Alcohol Minimum Pricing Bill – which set a 50p minimum price per unit as a condition of licence – was finally passed by the Scottish Parliament a year and a half after the previous Alcohol etc (Scotland) Bill had its provisions for minimum pricing removed (DDN, June 2012, page 12).
The subsequent four years, however, have seen the proposals referred to the European Court of Justice following the SWA’s legal challenge (DDN, June 2014, page 4). While the European court’s initial ruling was that minimum pricing could potentially breach EU free trade laws (DDN, October 2015, page 4), the case was then referred back to the Scottish courts for a final decision.
The Scottish government has called the court’s latest ruling ‘a landmark’ moment. ‘I am delighted that the highest court in Scotland has reinforced the initial judgment in our favour from 2013,’ said public health minister Aileen Campbell. ‘This follows the opinion of the European Court of Justice, which ruled that it was for our domestic courts to make a final judgment on the scheme. This policy was passed by the Scottish Parliament unopposed more than four years ago. In that time, the democratic will of our national parliament has been thwarted by this ongoing legal challenge, while many people in Scotland have continued to die from the effects of alcohol misuse.’
NHS Health Scotland said the decision was ‘an important day for public health in Scotland’, while Balance North East called it ‘a victory for democracy and for some of the most vulnerable people in society’. While SWA states that it continues to believe that MUP is a restriction on trade and that ‘there are more effective ways of tackling alcohol misuse’, a recent report from the Alcohol Health Alliance found that products like high-strength white ciders – typically drunk by dependent and underage drinkers – were now on sale for as little as 16p per unit. Cuts in alcohol taxes had allowed shops to sell alcohol at ‘rock bottom prices’, it warned.
Scotch Whisky Association and others v Lord Advocate and Advocate General for Scotland at www.scotland-judiciary.org.uk
Glasgow could become the site of the UK’s first consumption room, after the Glasgow City Joint Integration Board officially approved the development of a business case.
A full business case for both a consumption room and heroin-assisted treatment will now be drawn up, and formally considered when the board meets in February. Any facility established in the city should also offer wraparound services such as counselling, primary health care and advice on issues like housing and welfare, however, according to a working group established by the local alcohol and drug partnership (ADP) (DDN, July/August, page 4). This would help maximise engagement with the target population and increase ‘the potential for harm reduction’, the group said.
The working group reviewed how existing consumption room services operated in places like Europe, Canada and Australia, as well as considering feedback from stakeholders. A detailed costing of the facility will now be carried out, alongside a consultation with local residents and businesses to identify a location.
There are an estimated 5,500 people who inject drugs in Glasgow, according to NHS Greater Glasgow and Clyde, with around 500 ‘very vulnerable’ people injecting in public places around the city centre. Last year the city saw a spike in new HIV infections – 47 compared with the ‘previously consistent’ annual average of ten – and also recorded more than 150 drug-related deaths, while police and community safety teams regularly deal with problems associated with discarded needles.
The ADP said it would now develop a ‘robust’ case to support the development of the service, which is likely to prove controversial. ‘Today’s decision marks real progress towards delivering a service model that meets the needs of this small, but very vulnerable, group,’ said the partnership’s vice chair Dr Emilia Crighton (pictured). ‘We are now one step closer to catching up with other countries in the way we tackle this problem. This public injecting group has high rates of hospital admissions, incarceration and homelessness. While conventional treatment and services are effective for the majority of people, we believe this facility will make a major impact in reducing health risks and the resulting costs for this group.’
Although the ultimate goal was for users to remain drug free, until people were ‘ready to seek and receive help to stop using drugs it is important to keep them as safe as possible while do they continue to use drugs’, she stated.
Meanwhile, France’s first consumption room has been opened in Paris by health minister Marisol Touraine and the city’s mayor, Anne Hidalgo. Located in a hospital near the Gare du Nord, the facility is a partnership with harm reduction organisation Gaia-Paris and employs a multi-disciplinary team of 20, with staff expecting around 200 visitors a day. Touraine called the centre a ‘breakthrough for public health in our country’ and ‘an innovative and courageous response to a health emergency’. A second facility in Strasbourg is also expected to open before the end of the year.
There are more than 200,000 people in the UK living with hepatitis C, but only half of these are diagnosed and as few as 3 per cent are receiving treatment.1 If left untreated, hepatitis C can cause serious or potentially life threatening complications like liver cancer.2 The majority of people living with hepatitis C are from disadvantaged or marginalised communities.
People who inject drugs or have injected them in the past are at the highest risk of becoming infected with hepatitis C. This highlights the importance of ensuring those affected are receiving appropriate support and guidance, to encourage timely diagnosis and the best possible care. Peer support can play a vital role in helping people in this way.
A hepatitis C diagnosis can feel daunting for people suffering with drug or alcohol addiction and taking the first step towards finding support can be challenging. Peer worker Tim Palin knows this first hand, having had direct experience beating his own drug addiction and hepatitis C. Tim now provides support to people trying to make a recovery and acts as a campaign ambassador for I’m Worth…, an empowerment programme for people with hepatitis C in the UK.
On his journey to recovery, speaking to peers allowed him to understand that he was not alone and gave him the chance to connect with people who offered a more personal perspective as they had been through similar challenges and overcome difficult times in their lives.
‘It was incredibly important and valuable for me to have someone to turn to when I was diagnosed. The diagnosis was a shock and the course of treatment I was given was really tough. Having people to talk to who had gone through similar experiences made the journey easier,’ says Tim.
Peer support meetings offer a safe and confidential environment for people trying to beat addiction to discuss thoughts, feelings and experiences related to diagnosis, treatment and recovery. They can give people on the road to recovery information about accessing care, point them towards organisations that may be able to support, and offer tips and guidance on how to stay positive.
‘I really appreciated the support I received from the staff at Telford After Care Team which helped me immensely at a time when I needed it most. Now that I no longer use substances, I take pride in being a peer worker and helping others who are going through similar experiences,’ says Tim.
No matter what is stopping someone from getting the care they need, a support network can play an important role in recovery.
‘Opening up about my past experiences and hepatitis C diagnosis was such a relief, and with the right support I was able to work towards a more positive future,’ says Tim. ‘There are so many organisations and groups that can provide support and guidance for these difficult times – the first step is reaching out.’
Tim is a campaign ambassador for I’m Worth…, which aims to address the stigma that many people with hepatitis C face, encouraging and empowering people living with hepatitis C to access care and services no matter how they were infected. You can view his story, alongside others at imworth.co.uk/ambassadors.
The I’m Worth… campaign has been developed and paid for by Gilead Sciences Ltd, a science-based pharmaceutical company. Content development has been supported by input from numerous patient groups with an interest in hepatitis C in the UK.
For more information on the campaign and to access materials designed to support people living with hepatitis C please visit www.imworth.co.uk
The media’s treatment of the troubled families programme, whose evaluation has recently been made public, cannot have cheered David Cameron in his last week as an MP. History does not look likely to be kind to his great social policy. We should, however, be grateful to the former prime minister for his quixotic attempt to do the right thing on a massive scale. Because in doing so he exposed the fallacy which has dominated social policy since 1945: the idea that the government is infinitely capable of solving social problems.
Danny Kruger, Spectator, 29 October
Heroin ‘shooting gallery’ to open in Glasgow for addicts to get hit as kids play in CRECHE. Express headline, 31 October.
Shocking moment two women ‘inject drugs while slumped in a doorway in broad daylight’ just yards from a PRIMARY SCHOOL
Mail headline, 25 October
The lessons of a failing national policy need to be learnt. The approach of harm reduction was born – under a Conservative government – in response to the threat of HIV. It saved countless lives. When focus shifted away from harm reduction, deaths began to rise. We welcome the incorporation of drug-related deaths as a measure in the outcomes framework. However, if death rates are an accepted measure of system performance, the current trend is surely evidence of system failure.
BMJ editorial, 17 October
The problem faced by people with addiction is not that they are unaware of the negative consequences of their condition, but that they can’t see a way out. If we want to end the opioid crisis, we need viral videos of recovery, not overdose.
Maia Szalavitz, Guardian, 7 October
Yesterday, the National Institute of Economic and Social Research issued a report concluding that the troubled families programme had failed… All that money (£1.4bn), time and effort – for what? Just so a handful of people could show off at dinner parties and perhaps enjoy a glowing editorial in The Guardian. Like the controversial charity Kids Company founded by Camila Batmanghelidjh (another bottomless money-pit my husband opposed), the troubled families programme was kept going at massive taxpayers’ expense to salve the consciences of politicians cowed by half-baked notions of political correctness.
DDN welcomes your letters. Please email the editor, claire@cjwellings.com, or post to DDN, CJ Wellings Ltd, 57 High Street, Ashford, Kent TN24 8SG. Letters may be edited for space or clarity.
Letters
Painful isolation
I was very pleased to see your piece on support (or lack thereof) for those of us struggling with addiction to prescription and over-the-counter drugs (DDN, October, page 10). People often refer to mental health – rightly, in my view – as a ‘Cinderella service’ but it seems to me the same could be said for support for people whose problems are with legal substances, despite the truly heroic efforts of people like David Grieve.
In my experience the problem is not only that GPs are happy to dish out repeat prescriptions for the sake of a quiet life, and that there’s little in the way of specialised support, it’s also the attitude you can face when attempting to access generic drug services or attending groups or meetings – the general feeling can often be that, as you didn’t buy your drugs from a dealer, your problems are somehow not nearly as serious or important.
More money for specialised support would obviously be very, very welcome, but it’s hard to see how that’s going to be a priority at the moment, and the BMA’s proposed national helpline would also be a useful first step. But until we can address this hierarchical attitude that exists in some places then I’m afraid we’ve still got a very, very long way to go.
Name and address supplied
Foul language
At the Conservative Party conference, a lesser reported fact is that Liz Truss, the new justice secretary (and Lord Chamberlain) referred to ‘junkies’ with the phrase ‘homes burgled to feed a junkie’s habit’.
I am furious that she would use such a derogatory term on a national platform, and depressed to see the lack of notice the press took of her comments. The most vulnerable people in our society have blame heaped on them for a range of complex social and emotional problems, which are very far from simple to understand, let alone resolve. To determine (extremely simplistically) that crime is down to ‘junkies’ flies in the face of even the government’s own evidence. The ‘modern crime prevention strategy’ illustrates clearly the significant falls there have been in shoplifting and burglaries – something which Ms Truss conveniently forgot, because it didn’t fit with the narrative of the day.
We all need to do more to tackle stigma, and calling out language like this is the very least we should all do.
The evidence on rising drug deaths points to the need for a public health model, according to speakers at the Drugs, Alcohol and Justice Cross-Party Parliamentary Group
Drug poisoning accounted for one in six deaths among people in their 20s and 30s in 2015 in England and Wales – figures that included accidents and suicides and drug misuse and drug dependence, according to Vanessa Fearn and Neil Bannister of the Office for National Statistics. Data from the coroner showed that drug-related deaths (DRDs) had reached the highest level since records began, with the North East showing the highest DRD mortality rate and the East Midlands the lowest.
Deaths involving heroin or morphine had doubled in the last three years and there had been a ‘dramatic rise’ in male DRDs – some attributable to an increase in heroin purity.
Initiatives to gather and review regional evidence had shown that increased availability of heroin had ‘clearly had an impact’, combined with an ageing cohort of users, who were becoming ‘iller, frailer and less able to withstand the rigours of a drug-using lifestyle’, said Rosanna O’Connor, director for alcohol, drugs and tobacco at Public Health England.
At least half of the people dying were not currently in treatment, so some were likely to be chaotic. The increase in problems with prescription medicines was another contributing factor.
‘Until the needs of this ageing group are met, these figures may continue to rise,’ she said, adding that ‘Deaths map onto areas of high health inequality.’
PHE had developed principles for action, which included applying a ‘whole system approach’ to meeting people’s needs and addressing both mental and physical health, alongside drug use. Recent initiatives included getting a DRD indicator into the public health outcomes framework and giving commissioners advice on naloxone provision.
As so many people dying were not in treatment, how could we protect outreach services to ensure they reach them, asked John Jolly, chief executive of the treatment charity Blenheim. ‘The capacity of treatment services to deal with other than their typical cohorts is being reduced,’ he said.
‘We need engagement in all places where people butt up against the criminal justice system,’ said O’Connor.
Ed Morrow, PR and campaigns manager at the Royal Society for Public Health, explained that public health had previously been ‘a bit reluctant to get involved with the discourse around drugs – but that’s changed’.
‘There’s too much government fixation on measuring use, but we have to remember that a lot of people use without having problems,’ he said. ‘We need to give people the information to make informed decisions.’
There were 80,000 people a year involved with the criminal justice system relating to drugs (not just incarcerated) and this had a ‘major effect on their lives’. Transferring responsibility for the drug strategy from the Home Office to the Department of Health would be an ‘important symbolic move’, he said.
Decriminalisation could help to counter the damage caused by disinvestment in outreach work and the RSPH was also keen on the idea of a wider public health workforce – ‘people who have an opportunity to work with problematic drug users’.
Steve Rolles, senior policy analyst for Transform Drug Policy Foundation, had worked with RSPH on their approach and hoped that ‘this has paved the way for other public health bodies to look at these issues’.
‘It’s not a marginal issue anymore,’ he said. ‘Big lumbering conservative institutions are supporting these initiatives.’
Political support was accompanied by a growing bank of evidence. ‘We know that criminalisation has a direct effect on risk – it makes people harder to reach,’ he said. People were more likely to use alone or to share equipment.
In the 90 supervised injection facilities across the world, there had never been an overdose death, making them both effective and cost effective, said Rolles – ‘Yet still in the UK we don’t have a single one.’ We could create one through localism, he pointed out – ‘we don’t need to change the law to open one’.
Now that naloxone is officially ‘out there’, CGL are among those searching for the people most in need of it. DDN reports on their naloxone outreach services.
Guy Phillips is preparing for his nightshift as an outreach worker in Newham, east London. In his rucksack he will carry needles, a first aid kit, condoms, information leaflets – and four naloxone kits, plus a training kit. His mission is to give naloxone to ‘anybody that needs it’ and to offer friendly advice and a route to further help.
Phillips is employed by CGL but coordinates his shifts to do joint outreach with East London NHS Foundation Trust and homeless charity Thames Reach, to find the people in most need. ‘I’ll have my lists of people I want to see and they’ll have their list of people they want to see, so we’ll form a plan before we go out,’ he says. Shifts vary to try to cover all hours within a fortnightly period, and can be as early as 4am to 8am.
Many of those they will be trying to reach will be rough sleepers ‘who might be walking around, about to bed down somewhere’; others will be tuned into the night-time economy – sex workers, who don’t keep hours that fit in with regular drug services.
Some of the people they meet are glad of a friendly face and interested in hearing about naloxone – particularly if word has already reached them of this life-saving drug. Others are more difficult to engage – the sex workers for example, who may be earning £400 a night, can buy as much heroin as they want, don’t need methadone, and can’t see the need to talk to a drugs worker.
Looking at those most at risk, ‘It’s difficult to say who’s most likely to overdose, but imagine the effects of rough sleeping on people, in terms of being out in the cold and not having the facilities we normally have, plus the likelihood of having a lowered immune system,’ says Phillips. So the night’s naloxone outreach schedule focuses on rough sleepers. ‘I’ll ask them if they want to have naloxone, and if they say no, I’m going to have to persuade them it’s a good idea,’ he says. He might get the reply ‘I’m only smoking’, and will have to dig deeper to find out if they are taking anything else. ‘Most people who die of overdose die because they’ve used more than one substance – and each drug can multiply the effect of the other substance,’ he says.
A brief chat will often reveal they are taking ‘all sorts of drugs at all sorts of times – methadone, buprenorphine, alcohol, anything that suppresses the central nervous system’. Then there’s ‘quite a bit of persuasion to do, because people think they don’t necessarily need naloxone, and I have to explain that they do’. When he’s got their attention, Phillips runs through what an overdose can look like and what can happen throughout the course of it. ‘Then there’s obviously telling them how to use it, which is a mechanical thing. They can say whether they’ve understood or not, and have a go with my test kit to learn how to use it.’ He tells them that each shot will last for 20 minutes and that people can go back into overdose afterwards – which is why there are five shots in each syringe. He also cautions them that ‘people can be quite angry with you for administering it’ while coming round.
The other important part of the message is that ‘if in doubt use it – because you can do no harm. And also call 999’ to get the ambulance on its way. The whole intervention – the information, training session, Q&A – has to take place quite quickly. ‘You’ve got to get the information out and it’s got to be quite snappy.
You might be on the street, or in an exposed situation; there might be people walking by. You might be in the darkness, doing it by torchlight, and you also need to consider your own safety because you’re crouched down.’ There are also ‘a lot of places to go and people to see’ on each shift. While the immediate benefits of the naloxone are obvious, the other important reason for using it in outreach is to connect with people and offer them the lifeline into services.
Unfortunately this rarely happens immediately, says Phillips. ‘You wish they’d say “I’m going to change my ways today” but this rarely happens. So it really is about mounting a campaign, visiting people more than once and persuading them, giving them leaflets, increasing their awareness, showing that your door’s open and that you’re a nice kind organisation.’ At CGL’s head office, Stacey Smith is director of nursing and clinical practice and explains that the organisation created a naloxone strategy and turned it into a project management process.
The purpose was to spread naloxone training and distribution far and wide – from all frontline workers and community partners to anyone who might need it, whether in services or not. ‘We thought, we need to really get passionate about this, because the formula is so simple when you think about it. It’s given, it saves lives, and people have a second chance,’ she says. So when the law changed, allowing wider distribution, CGL were ready. ‘Naloxone champions’ had been trained within every project and the initiative was being taken out to pharmacies, community groups, rehabilitation centres, shelters, lifeguards, toilet attendants, to ‘saturate the high-risk areas with naloxone’.
The overall aims, just as for outreach, are ‘obviously to cut down on death – and the other is to get people to feel that they can come into services, no matter what state they’re in or what they’re using’. Smith is encouraged by the 261 people who have reported back to them that they have administered naloxone, but says ‘the potential for life-saving is a lot higher’.
It’s the second year of the naloxone outreach strategy now, ‘so we’re looking at areas where people are not actually getting into services – people that are just on the brink and feel that services maybe aren’t for them,’ she says. This includes districts with ‘extensive homeless populations’, as well as talking to hospitals to make sure people who have been admitted with an overdose are discharged with naloxone, and working with prisons around giving naloxone on release.
‘There’s no closed door on how we can get naloxone outreach to people,’ says Smith. ‘We talk to the police about them carrying it, and we talk to all sorts of people who have contact with our service users to try to get as much out there as possible.’ It’s not just about the naloxone, but about ‘the whole harm reduction message’, she says. ‘We’re trying to make it a whole health and wellbeing approach, rather than just “here’s naloxone”.’ Among the community partners, she says pharmacies have been an important link to people who may need naloxone, ‘as they often see people way before we do’.
The superintendent of a community pharmacy in Birmingham agrees with the benefits of the naloxone outreach programme. She explains how her colleague had received training and knew exactly what to do when a client in the tattoo parlour next door overdosed and staff ran into the pharmacy for help. The pharmacy colleague took a naloxone kit and saved his life. ‘The guy was in the right place at the right time, which was really very lucky because he only came round after the second injection,’ says the superintendent. ‘Had I been in the branch, I’d not been trained to do this. All of us pharmacists should be aware of what we can do with these injections. We’re trained to give the EpiPen – adrenaline for anaphylaxis. But to my knowledge this programme for the drug users is not a general programme, and I think it should be. ‘Let’s hope the programme can be extended – without it that guy wouldn’t be here now.’
Karl Price is someone who would wholeheartedly agree with that. As one of the ‘success stories’ he says he ‘wouldn’t be sitting here today’ if it wasn’t for naloxone. He had three life-saving injections to reverse overdose, when he was in ‘the power of addiction’. ‘I’ve had a friend that’s died and a partner that died – accidental overdoses because the person at the time is not thinking that they’re using too much, or that they’re at risk of overdose,’ he says. ‘But if I’d had a naloxone kit with me, my partner would probably still be here today.’ DDN Tell us about your naloxone initiatives – email claire@cjwellings.com
From the many books on addiction, George Allan selects a guide that makes a worthy handbook for both students and experienced workers.
From confessional memoirs to detailed analyses of complex research, substance issues have an extensive and diverse literature with plenty of books describing ‘treatment’ options in broad terms. There are, however, remarkably few that take an in-depth approach to examining how interventions are actually applied in practice: one such book is Treatment Approaches for Alcohol and Drug Dependence: An Introductory Guide.
The authors eschew preliminaries, such as methods of social control and theories as to why problems develop, and dive straight into the practicalities of working with people. After addressing general skills, assessment, goal setting and motivational interviewing, they lead the reader through all the well-evidenced interventions.
Cognitive therapy, behavioural self-management, relapse prevention and pharmacotherapy are explored, along with brief interventions, assertiveness skills and the other components of an holistic approach; self-help groups, dual diagnosis and case management are also addressed. There is a liberal sprinkling of tools and handouts for service users, and the writing style is characterised by clarity and accessibility.
There are weaknesses: more is needed on working with relatives in their own right and there is little on the implications of parental use for children. Nevertheless, this text was right at the top of my reading lists for students; it was the bar that I set for myself when I sat down to write a text book of my own. Although it is described as an ‘introductory guide’, experienced workers will find much in it to help them refresh their practice.
Of course, reading is no substitute for hands-on work under skilled supervision, but just as the Highway Code is a prerequisite for competent driving, so a detailed guide to applying interventions is the essential starting point. This book provides the necessary knowledge.
The authors are Australians but the UK shares with Australia similar assumptions regarding the nature of problematic substance use and how to address it, so any differences are marginal. The past decade has seen the emergence of the recovery agenda and the rise of a plethora of different psychoactive substances so it is hoped that a third edition of this book is in the offing.
Jarvis, T., Tebbutt, J., Mattick, R. and Shand, F. (2005), Treatment Approaches for Alcohol and Drug Dependence: An Introductory Guide is published by Wiley.
George Allan is chair of the Scottish Drugs Forum. He is the author of ‘Working with Substance Users: a Guide to Effective Interventions’ (2014; Palgrave).
Colleagues pay tribute to a worker who used his experience to help those in trouble.
Tributes have been paid to charity worker Darren Walters, who died in May aged 44 following a heart attack. Darren turned his life around following issues with drugs, and contributed to shaping the future of prison healthcare in Lancashire.
Darren, from Accrington, spent 20 years in and out of prison for a variety of offences after becoming involved with drugs at the age of 15. After linking up with Red Rose Recovery, a charity that helps people deal with substance misuse issues, he managed to start a new life.
Through his work with the charity, Darren came into contact with the NHS where he was able to advise on the way healthcare in prisons should be delivered. NHS England’s health justice commissioning manager for the North (North West), Simon Smith, said: ‘Darren has first-hand experience of the delivery of prison health services. He was able to use his unique perspective and bring a sense of realism to how we develop these health services.’
Darren brought the benefit of a service user perspective to a multi-agency panel, reviewing tenders alongside doctors, nurses and other health professionals, and stakeholders such as local authorities and the National Offender Management Service.
Speaking at the time, he said: ‘If my input makes a change for all the right reasons, I can take great satisfaction from that.’
Three residential rehabs in different locations understand that whatever the location, what matters is providing a range of interventions and treatments, with each one tailored to the individual.
Addiction can affect individuals from all walks of life, and each person has their own unique story. Because of this all of our programmes are uniquely tailored to the person. Each client receives a thorough physical and psychological evaluation, taking into account their medical and addiction history in order to create the best possible care package. Looking beyond their addiction, our qualified assessors will study diet and nutritional requirements, and screen for conditions associated with addiction such as liver disease.
We offer a rapid detoxification programme, which can quickly and safely withdraw a client from their drug of addiction, through to a full 12-step therapeutic programme based on the Minnesota Model. This 12-step programme is presented in a contemporary way, focusing directly on the addiction and looking at issues of denial, unmanageability in life and getting through the very early stages of living without alcohol or drugs.
With more than 30 years’ experience of treating addiction, our team has medical and therapeutic staff, including some who are in long-term recovery themselves. Each client is allocated a key worker to help understand and clarify the programme, and ensure that stress is kept to a minimum while working towards recovery. Though no two people are the same and every client will have an individual plan, many of the sessions come as part of group discussions providing an opportunity for mutual support and learning.
We take an holistic approach, with yoga and art classes helping stress management, while providing cognitive skills and mindfulness applications to provide the tools to help build a new, healthier life in long-term recovery.
Following the programme, a strong emphasis is placed on aftercare with clients learning how to spot signs and triggers that can lead to relapse. A support team and helpline are in place, as well as strong links with local fellowship groups for those that need them.
This 17th century former hunting lodge of the first Earl of Essex is based on the outskirts of Watford, and just 15 minutes from central London by train.
In a relaxed and safe environment within a secluded walled garden, all 13 single rooms are equipped to a high standard, providing clients the opportunity to engage with the therapeutic process.
If you would like treatment for addiction for yourself or someone you know, please call 0800 500 3129.
Our residential rehabilitation centre in Blackpool is able to treat a range of addictions including drug, alcohol and behavioural addictions such as gambling addiction, sex addiction and eating disorders.
With a medical team on hand to observe patients’ progress in recovery 24 hours a day, patients receive the full assistance and support during detoxification. Our Blackpool centre offers luxury rehabilitation, and patients travel here from all corners of the UK.
The centre is designed to promote a feeling of relaxation during treatment, with an atmosphere that promotes learning during rehabilitation and aids the detoxification process whenever uncomfortable withdrawal symptoms arise.
If you would like to discover how our Blackpool centre is able to aid your journey into recovery please call today on 0125 353 0553.
The La Paz Step One recovery centre is situated on an exclusive two-acre Mediterranean estate in Javea, on the Costa Blanca in Eastern Spain. We firmly believe that travel generates an enthusiasm for new possibilities and that removing yourself from harmful distractions back home will aid your recovery. The beautiful town of Javea has scenic mountain ranges on one side and white sandy beaches on the other. There are some incredible views of the sparkling blue ocean from our estate.
La Paz Step One provides clients with a high-end environment in which to concentrate on their treatment and recovery, rather than being distracted by any domestic concerns. The centre combines luxurious bedrooms, healthy gourmet food prepared by our in-house chef, and facilities including a cinema, sauna and swimming pool. With a maximum capacity of only 12 guests at a time and a staff to client ratio of two to one, you have our undivided attention.
Whether you’re making that call for yourself, or on behalf of somebody else, we will be able to provide all the help you need. Call today on 0800 011 1242
It’s easy to take notice of those who shout the loudest, but where would we be without the everyday heroes who just get on with things? The article about Pat Lamdin’s retirement (page 16) is not just an appreciation of a jolly good bloke – the piece is bursting with frustration at the sector’s failure to cherish and retain good people.
Also in this issue – including our joyous cover picture! – we celebrate Recovery Month, take the opportunity to look at the origins of the term ‘recovery’, and note that in commemorating Recovery Month and International Overdose Awareness Day, communities are sharing the same goals, campaigns and demonstrating a unity of purpose that defies being categorised as belonging to one ‘movement’ or another.
The number of heroin-related deaths in England and Wales has doubled since 2012, from 579 to 1,201, according to the latest ONS figures.
Last year saw the highest number of drug-related fatalities ever recorded with 3,674 poisoning deaths, of which 2,479 exclusively involved illegal drugs. Scotland also recorded its highest drug death toll in 2015, at 706 (DDN, September, page 4).
Although the government is keen to stress that the figures come against a background of falling rates of overall drug use, deaths involving cocaine also reached an all time high at 320 – up from 247 the previous year. Deaths involving amphetamine also reached their highest-ever level, and those involving ecstasy the highest in more than a decade.
Overall most drug deaths were again among the over-30s, with the North East of England the region recording the highest number of deaths for the third year running and males almost three times more likely to die than females. Although, as in Scotland, the number of deaths involving NPS remained relatively small, the substances could ‘present a more significant problem in the future, especially as not enough is known about the long term effects of their use’, stressed Public Health England (PHE).
An independent expert group convened by PHE and the Local Government Association (LGA) has published a list of recommendations to try to address the rising death rate, including improving access to treatment – especially for ‘harder to reach’ populations through outreach work and needle and syringe programmes – and coordinating a ‘whole-system approach’ that includes mental health, housing and employment support.
‘Drug use is the fourth most common cause of death for those aged 15 to 49 in England and we know that the majority of those dying from opiates have either never, or not recently, been in treatment,’ said PHE’s director of drugs, alcohol and tobacco, Rosanna O’Connor. ‘Reassuringly, overall drug use has declined and treatment services have helped many people to recover but there is a need for an enhanced effort to ensure the most vulnerable can access treatment.
There is considerable variation across the country, with some regions showing large increases in recent years. PHE will continue to support local authorities in delivering tailored, effective services where people stand the best chance of recovery.’
The ‘shocking’ statistics raised serious concerns about both government policy and the state of the treatment sector, however, said Release executive director Niamh Eastwood. ‘Since 2010 we have seen a worrying implementation of abstinence-based treatment under the government’s ideologically-driven “recovery” agenda. This goes against all the evidence for best practice in drug treatment, and is contributing, we believe, to this shameful rise in deaths. Such a hostile environment means people simply don’t want to access treatment.’
There was also ‘an increasing tendency among local authorities to simply offer treatment contracts to providers who can deliver the service for the lowest cost,’ she continued, with healthcare standards ‘being overlooked’ for financial reasons. ‘The Home Office’s pursuit of a “tough on drugs” strategy and refusal to acknowledge the evidence for best practice in drug treatment is quite literally killing people.’
Deaths related to drug poisoning in England and Wales: 2015 registrations at www.ons.gov.uk
Understanding and preventing drug-related deaths: The report of a national expert working group to investigate drug-related deaths in England at www.nta.nhs.uk
QUITTING TIME
The smoking rate in England has fallen to its lowest ever level, at below 17 per cent, according to figures from PHE. Last year saw 500,000 smokers successfully give up, with cigarette sales in England and Wales dropping by 20 per cent in just two years. ‘There is more help and support available now than ever before,’ said deputy chief medical officer Dr Gina Radford. ‘The introduction of standardised packs removes the glamorous branding and brings health warnings to the fore, and e-cigarettes, which many smokers find helpful for quitting, are now regulated to assure their safety and quality.’
HEP OPTIMISM
Another ‘potential curative’ drug for people with hepatitis C is to be made available on the NHS, according to new guidance published by NICE. Elbasvir/grazoprevir has shown cure rates above 90 per cent in some patient groups, says the document, and ‘provides considerable health benefits to patients without some of the adverse side effects associated with earlier anti-viral treatments’, according to director of NICE’s centre for health technology evaluation, Professor Carole Longson.
MENTOR MERGER
Two leading drugs education charities are merging this month. Mentor UK, known for its work preventing alcohol and drug misuse among children and young people will join with Angelus, the only UK charity dedicated to highlighting risks from new psychoactive substances. The organisation will be called Mentor UK, with Michael O’Toole as chief executive. ‘This merger is a great match of expertise – it is going to give fresh impetus to the prevention agenda,’ he said.
STAND AND DELIVER
A three-year substance misuse delivery plan has been launched by the Welsh Government, including better collaboration between mental health and substance services and more work to reduce blood-borne virus transmission. ‘We want to ensure everyone can access the support and information that they need,’ said minister for social services and public health, Rebecca Evans. The country has also seen a 14 per cent increase in the distribution of take-home naloxone kits, according to figures from Public Health Wales. The kits were reportedly used in more than 430 poisoning events in 2015-16. Substance misuse delivery plan 2016-2018 at gov.wales; Take home naloxone 2015-16 at www2.nphs.wales.nhs.uk
OVERDOSE ACTION
CGL has issued more than 6,000 naloxone kits and successfully trained 5,500 service users, carers, family members and others in how to use them since February this year, the charity has announced. CGL is currently the only commissioned drug service in the UK to have a national approach to distributing the overdose-reversing substance. ‘Our commitment to distributing naloxone as widely as possible and to training people on how to use it correctly has resulted in 241 lives being saved,’ said CGL’s director of nursing and clinical practice, Stacey Smith. ‘We are committed to reducing drug-related deaths and naloxone plays a major role as part of an overall preventative package of care.’
MEDICINAL MESSAGE
A report calling for medicinal cannabis to be legalised has been issued by the All Party Parliamentary Group for Drug Policy Reform. Cannabis: the evidence for medical use is based on a seven-month inquiry, testaments from more than 600 patients and a review of international evidence. ‘Many hundreds of thousands of people in the UK are already taking cannabis for primarily medical reasons,’ said the group’s co-chair, Caroline Lucas MP. ‘It is totally unacceptable that they should face the added stress of having to break the law to access their medicine.’ Report at www.drugpolicyreform.net
MAMBA BAN The European Commission is proposing an EU-wide ban on MDMB-CHMICA, also known as Black Mamba. Nearly 30 deaths have been recorded in eight member states, says EMCDDA, with the substance – already banned in the UK under the Psychoactive Substances Act – also linked to incidences of violence and aggression.
GROWING MARKET
Bodybuilders are increasingly turning to dealing steroids to fund their own use and ‘maintain their social status in the weightlifting community’, according to a report from Birmingham University. ‘While many government agencies and sport officials have suggested that substances are sold largely by organised crime groups for financial gain, the findings showed that the majority of performance and image enhancing drugs within bodybuilding subcultures were distributed by individuals for social reasons or to support their own training,’ it says. Social suppliers available at www.bcu.ac.uk
WIDER IMPACT
More than half of Welsh adults have had negative experiences in the last year as a result of someone else’s drinking, according to a report from Public Health Wales. Almost one in five had felt physically threatened, while 5 per cent had suffered actual physical violence and the same percentage had been concerned about a child’s wellbeing. ‘This report shows how alcohol can harm not just the drinker but also those around them,’ said the agency’s director of policy, research, and international development, Professor Mark Bellis. ‘Some of these harms are due to drunken violence but others result from accidents, threats or even financial problems when too much household income goes on one person’s drinking.’ Alcohol’s harm to others at www.wales.nhs.uk
STRATEGIC SUPPORT
A new support pack for commissioning specialist interventions for young people experiencing substance problems has been issued by PHE. ‘Patterns of drug and alcohol use by young people often change, which means that services need to be flexible and respond effectively to changing needs,’ says Young people – substance misuse JSNA support pack 2017-18. Available at www.nta.nhs.uk/uploads/jsna-support-pack-prompts-young-people-2017-final.pdf
PRISON PAUSE
Justice secretary Liz Truss has raised doubts about whether the wide-ranging prison reforms set out in the Queen’s Speech (DDN, June, pages 5 and 7; September, page 10) will now go ahead, telling a meeting of the justice committee last month that, ‘I am not committing to any specific piece of legislation at this stage’. Meanwhile, a report by the Prison and Probation Ombudsman has said there is ‘an unacceptable level of violence’ in English and Welsh prisons. Establishments should have a coordinated approach to identifying risks of bullying and violence, it says, including ‘the impact of new psychoactive substances and associated debt’. Learning lessons bulletin at www.ppo.gov.uk
FAMILY FAVOURITES
Adfam’s annual Family Voices competition is now open, with a top prize of £150 and two runner up awards of £100. Friends and family who have lived through someone else’s substance misuse are invited to submit an original piece of writing or poem, with the winning entries read by a guest speaker at the charity’s carol concert on 1 December. ‘While it is often difficult to talk about this subject, it can be helpful to write about it, and entries are of a consistently high standard,’ says Adfam. Send your entry (up to 500 words) to carols@adfam.org.uk by 31 October.
TIME TO GET INVOLVED
A ‘global campaign week’ against the actions of Philippines president Rodrigo Duterte is being organised by The Asian Network of People who Use Drugs (ANPUD) and the International Network of People who Use Drugs (INPUD). Peaceful demonstrations will begin at Filipino embassies and consulates around the world from Monday 10 October, and people are also encouraged to help raise awareness on social media. More 3,000 people are estimated to have fallen victim to Duterte’s ‘war on drugs’ since he took office in May (DDN, September, page 4).
Full details of how to take part at www.inpud.net. See news focus, page 8.
RISING CONCERNS
Concerns that decriminalising drugs or introducing legally regulated markets would automatically lead to increased levels of use are ‘poorly supported by empirical research’, according to a report from Transform. Overall levels of use should also not be considered as ‘an accurate indicator of levels of drug-related harm’, argues Will drug use rise? Exploring a key concern about decriminalising or regulating drugs. Available at www.tdpf.org.uk
NEW CHALLENGES
Drinking levels among European teens are falling but there are challenges around new substances and ‘new addictive behaviours’ such as online gambling, according to the European school survey project on alcohol and other drugs (ESPAD). While illicit drug use is stable it is ‘still at high levels’, says the report, which is based on a survey across 35 countries in partnership with EMCDDA. Report at www.espad.org
The president of the Philippines, Rodrigo Duterte, has been taking the ‘war on drugs’ to extremes that have shocked the world. DDN asks what, if anything, the international community can do to stop the man known as ‘the punisher’.
When Rodrigo Duterte was elected president of the Philippines in May and vowed to ‘eradicate crime’ in the country within six months, those who voted for him may have had some idea of his likely approach.
His long stint as mayor of Davao City in the south of the country saw human rights groups accuse him of tolerating or even supporting the extra-judicial killings of offenders, and he stated on the campaign trail that he intended to ‘fatten the fishes’ in Manila Bay on the bodies of dead criminals. Unsurprisingly, his short presidency has so far been characterised by astonishing brutality.
More than 3,000 people – mainly drug dealers and drug users – are estimated to have fallen victim to Duterte’s ‘war on drugs’, and while just over a third of these are thought to have been killed by police, human rights observers believe the others could be the victims of the president’s open call for vigilante action against those suspected of drugs offences. Known as ‘Duterte Harry’ and ‘the punisher’, Duterte has now asked his people for a six-month extension to fulfil his crime reduction pledge, as he ‘cannot kill them all’.
While the killings have inevitably provoked international outrage it has so far been met with defiance. Duterte has threatened to pull his country out of the UN, while seeking closer economic ties with China and Russia, and his response to US criticism of his actions was to call Barack Obama a ‘son of a whore’. As he also continues to enjoy very high approval ratings among his electorate, it’s hard to see what can be done to end the violence.
In August an open letter signed by more than 300 NGOs implored the UN’s drug control bodies to call for an ‘immediate stop’ to the killings. The United Nations Office on Drugs and Crime (UNODC) executive director Yury Fedotov said that his agency was ‘greatly concerned’ by the reports of extrajudicial killings and that he joined the UN secretary general’s condemnation of the ‘apparent endorsement’ of them (DDN, September, page 4). While the UNODC stood ‘ready to further engage with the Philippines… to bring drug traffickers to justice with the appropriate legal safeguards in line with international standards and norms,’ he said, the killings contravened ‘the provisions of the international drug control conventions’ and did not ‘serve the cause of justice’.
Given the circumstances, however, did that go far enough? ‘The UNODC statement could have been more strongly worded,’ Bangkok-based senior policy officer for the International Drug Policy Consortium (IDPC), Gloria Lai, tells DDN. ‘The statement by the INCB [International Narcotics Control Board] was stronger in that president Werner Sipp called on the Philippines government to “issue an immediate and unequivocal condemnation and denunciation of extrajudicial actions against individuals suspected of involvement in the illicit drug trade or of drug use, to put an immediate stop to such actions, and to ensure that the perpetrators of such acts are brought to justice in full observance of due process and the rule of law.”’
Statements by UN special rapporteurs on the right to health and on extrajudicial, summary or arbitrary executions have also been strong, she points out, but there’s more that international drug control bodies could be doing.
‘Policy makers and officials in the Philippines – ranging from the police to the judiciary to health officials to political representatives in the congress and senate – might welcome technical assistance in developing and implementing evidence-based and humane drug policy responses,’ she says. This help could cover the health and welfare of detainees in ‘horrifically overcrowded prisons’, the more than 700,000 people who have surrendered themselves to the authorities ‘mostly for using or having used drugs, or simply being arbitrarily placed ona published list of so-called drug suspects’, as well as provision of drug treatment and harm reduction services. It could also address some ‘alarming legislative proposals’ including one to re-instate the death penalty, abolished a decade ago, and another to lower the age of criminal responsibility from 15 to nine.
Agencies such as UNAIDS and the World Health Organization (WHO) could also offer advice and guidance on drug policy issues, she continues, particularly in terms of contributing evidence to policy debates in the Philippines that helps to counter ‘baseless and false claims’ about the extent of the country’s drug-related problems ‘made by the president and other officials’. Among these are that people who use shabu (crystal meth) ‘suffer from brain shrinkage and become no longer human’, she points out. The UNODC could also extend its practical assistance, as it has done with Myanmar, she adds.
In the meantime, however, the killing is showing no sign of letting up, and with Duterte asking for his six-month extension to ‘finish the job’, what, realistically, could other countries be doing to address the situation?
‘They could try to boost incentives for shifting this approach, for example by raising concerns and supporting alternative humane and effective approaches in UN drug policy and human rights forums,’ she states. ‘But one perspective is that Duterte has continued to incite murder because it has served him well in gaining popular support and winning the presidential election, so he has little incentive to change this approach.’
The lawful pharmaceutical industry in the United States is the most insidious, vile and addiction-provoking monster of its type on the planet. Until it is properly confronted and curtailed, the migration of addicts from legal highs to heroin hell will continue at its fast and furious rate. My real wrath [is] aimed squarely at every politician and doctor who has enabled this horrendous scourge on society by encouraging Americans to medicate themselves in such a disastrously excessive and unnecessary manner.
They’ve created a real life Walking Dead.
Piers Morgan, Mail, 9 September
The NHS has never been good at engaging with excluded populations and delivering services to challenging individuals. Offenders, the homeless and people with fragile mental health, as well as drug users, often have no GPs, make themselves unwelcome at A&E departments, and miss appointments, and the complexity of their health needs is ill-matched to a system structured around specialities. Too often the very people who need the NHS most are those least able to navigate its various pathways.
Paul Hayes, Guardian, 9 September
While [Rodrigo] Duterte’s obsessive war on narcotics may be horrifying to an international audience, for many Filipinos – even those ambivalent to his presidency – a ‘some action is better than no action’ stance has made a welcome change of pace… Duterte’s victory came as the Philippines’ drug problem was becoming so endemic that a firebrand, cartoon character of a president taking a sledgehammer to the issue became a reasonable gamble… Duterte’s mass execution of the low hanging fruit in the Philippines drug trade will serve only to highlight how drugs have filled the vacuum created by successive governments. Filipinos did not vote for Duterte; they voted for a jab at the establishment that has, for the past five decades, consistently let them down.
Joanna Fuertes-Knight, Guardian, 16 September
Why do suckers always fall for the claims of ‘medical cannabis’? Its advocates are invariably mixed up with the lobby for general legalisation… Cannabis may make some people feel better, but so did Thalidomide. A drug correlated with severe mental illness may just not be the ideal miracle cure.
Taking painkillers can mask issues that are nothing to do with physical pain, says Dr Steve Brinksman.
Like many modern GP group practices, ours has GPs with specialist interests. One of mine is rheumatology and it was in this role that I met Maria. She was 43 and had been diagnosed with rheumatoid arthritis four years ago. She had a lot of joint pain and was started on co-codamol 30/500 (30mg codeine and 500mg paracetamol in each tablet) She was taking these regularly, so slow release dihydrocodeine was added in and titrated up to 120mg twice a day with Oramorph (liquid morphine) for breakthrough pain.
After seeing a consultant rheumatologist she was started on methotrexate, a disease modifying anti rheumatoid drug (DMARD), and was being seen in our clinic so that this could be monitored.
On examination I could find no signs of active joint inflammation and noted this had been the same the last couple of times she had been seen. When the possibility of reducing her analgesia had been suggested before, she said she still needed it. When I asked her about this, she told me that she felt much better in herself when she took her medication and worried that she would be ‘bad’ if she didn’t. She explained that she had previously had bouts of low mood and panic attacks, which had eased since starting her painkillers, and that the Oramorph was now mainly used when she was anxious.
There wasn’t time to explore this further, but she agreed that I could book her another appointment to follow this up. A week later she told me about growing up in a home where her father had been very controlling and frequently demeaned and verbally abused her mother, and to a lesser extent her. Her panic attacks had significantly worsened after the death of her mother eight years ago and she agreed that the opioids were not really being used for her RA pain now but to deal with her mental health issues.
A referral for CBT was arranged and we discussed how best to deal with her medication. She felt it would be difficult to slowly reduce what she was currently taking as she felt out of control with the Oramorph, and the decision was made to start her on buprenorphine. This has been titrated and she has stabilised on 6mg, which we are going to start slowly reducing while continuing her CBT.
Maria is a reminder that opioids are not only good painkillers but have psychological effects as well, and life events that can increase the risk of illicit drug use can also make dependence on prescribed medication more likely. The key is assessing these at the outset and using ongoing monitoring to try to avoid strong opioids from readily ending up on repeat prescriptions.
Steve Brinksman is a GP in Birmingham, clinical lead of SMMGP, and a member of the Opioid Painkiller Dependence Alliance, www.opdalliance.org
The stakes have never been higher. This year’s Recovery Month and Overdose Awareness Day activities brought service users and recovery communities together with one clear goal
‘Get political’: The Recovery Walk
During the last 12 months we have seen unprecedented levels of disinvestment in treatment and recovery support services and the highest levels of drug-related deaths ever recorded. Despite Recovery Month this September, we celebrated the gains made by those in recovery, just as we celebrate improvements made by those who are managing other health conditions.
Taking part in September’s Recovery Month reinforces the positive message that behavioural health is essential to overall health; that prevention works, treatment is effective, and people can and do recover. More people than ever before across the UK organised local events, celebrating the fact that recovery from addiction to alcohol and other drugs is a lived reality in their lives and that demand for our advocacy and training services has continued to grow.
As austerity continues it is becoming apparent that the state can no longer guarantee effective, high quality treatment for all and we are hearing of funding cuts to services in England of up to 40 per cent. There has never been a more important time for recovery communities to stand up, speak out and become politically engaged. We need to highlight the fact that every day in the UK people in long-term recovery from addiction to alcohol and other drugs volunteer their time to help others and make their communities better places to live. They are truly one of the greatest assets local communities have.
We received significantly less sponsorship funding for the UK Recovery Walk than in previous years and yet it was the biggest and best so far, with more than 6,000 people in long-term recovery and their friends and families. A special thank you to all of this year’s sponsors and our amazing team of more than 300 volunteers who enabled us to be custodians of the famous UK Recovery Walk. We look forward to seeing you next year in Blackpool!
Annemarie Ward, Faces and Voices of Recovery UK. View FAVOR UK’s short film challenging negative stereotypes and stigma at www.facesandvoicesofrecoveryuk.org
‘Let’s connect’: Recovery community
The fifth annual Lufstock event took place for three days, bringing families of the recovery community together for a camping weekend. The 250 people who attended connected as a community, creating strong friendships and lasting memories.
This followed Lancashire User Forum (LUF)’s ten-year anniversary event in Preston, attended by service users, volunteers, treatment providers, and other interested parties. It was broadcast live by BBC Radio Lancashire’s Sally Naden and Brett Davison, but the format of this special occasion was devised by the service users. As part of a packed agenda, we hosted the spoken word artist, Steve Duncan, who composed a unique poetry performance especially for our anniversary.
Not only was the event a resounding success; it also provided an open forum where professionals were scrutinised in regard to the landscape of the LUF over the next ten years. It built on the notion of hearing the service user’s voice and having a positive impact on all recovery communities.
The games link to the five ways to wellbeing and offer an exciting platform for people in treatment and recovery and those working with them to have fun and build on the principles of connecting with each other in new ways without substances. They offer a chance to learn new skills and ways of communication, while giving time, effort and money to worthwhile causes.
They show what recovery can feel like and create momentum through forming a giant conga through the ‘festival of colour’. And most of all they show that there’s nothing better than being active, getting out and about,and feeling alive, when you’ve been stuck in a rut like Groundhog Day.
The day had a strong family theme, supporting active recovery in community and family structures. Health professionals from across services came to deliver information on cancer awareness, smoking cessation and healthier eating, as well as offering prizes. There were activities for the children – although everyone let their inner child play out on the day!
Competitors took part in canoeing, climbing and many other events on giant inflatable arenas at the local activity centre. Teams of ten from all parts of Yorkshire and Lancashire entered events throughout the day, creating a spirit of competition combined with support. The weather was fantastic, which drew in the local crowds to cheer everyone on. There was music and live entertainment throughout, with an amazing festival of colour at midday, involving all the teams.
Money from the day was raised for the Aurora cancer charity and presented to them at the New Beginnings open day and graduation on 28 September.
Drug fatalities have overtaken fatalities due to road accidents for the first time, representing a public health issue of growing proportions. In response to this, and to International Overdose Awareness Day on 31 August, we held three events in Greater Manchester, with a particular focus on raising awareness that naloxone saves lives.
An awareness event in HMP Manchester saw 25 inmates with a history of opioid use take part in animated discussions. All participants signed up for training on naloxone and will as a result receive kits on leaving prison. This generated much discussion among prisoners, wardens and other prison staff, with the goal of normalising overdose prevention as part of the prison’s regime.
A mixture of commissioners, service providers and frontline workers attended a similar event chaired by Hayden Duncan of Emerging Futures. Hayden recalled the successful deployment of naloxone across the West Midlands during his time as Public Health England regional manager, and challenged the North West, ‘the home of harm reduction’, to step up and take action in relation to drug-related deaths.
Finally, a public awareness event was held in the centre of Manchester. Undeterred by lashing rain, members of the Greater Manchester Recovery Federation (GMRF), and other activists, collapsed in the street and came back to life to reveal ‘Naloxone Saves Lives’ t-shirts – simple but effective, generating a great deal of interest, and basic information on naloxone was also distributed.
All good – but what emerged at every event was just how little awareness there is, not just about naloxone, but overdose prevention itself. Even those who have experienced one or multiple overdoses lack the basic knowledge to prevent drug-related deaths. Perhaps even more shocking, many of the actions people would take in overdose situations could actually make matters worse.
Despite legislation designed to widen the availability of naloxone, its distribution is patchy. Many treatment services are stepping up to the mark, but most overdoses occur among populations who are not currently engaged in treatment. Many people lacked a basic understanding of what naloxone is and what it does; however, offsetting this was the sheer willingness of people to learn about, be trained in and carry naloxone.
Perceived divisions between those who support a harm reduction or a recovery approach should not get in the way of this. These divisions are largely political and do not represent the view of recovery communities who, as part of their own health and wellbeing, have a desire to support people in any way they can.
Resources are tight, those outside treatment services may be seen as harder to reach and there are many competing issues around the health agenda. However, we have recovery champions, peer mentors or volunteers in every treatment service, many active recovery communities around the country and staff within services more than willing to go the extra mile. Why are we not mobilising this huge resource?
The events in Greater Manchester were a success on many levels – awareness was raised, myths were busted and people were engaged. A Greater Manchester Naloxone Action Group was born and will push the agenda forward. However, to make a dent in the figures we need to see a more proactive approach nationally, and people could do worse than look to the West Midlands for how to do this.
Michaela Jones, in2recovery; and the Greater Manchester Recovery Forum
Train your staff to empower service users with life-saving naloxone, says David Swain
In the 1838 report to the House of Commons on causes of death, the coroners in England and Wales for the preceding year recorded that a third of all deaths were shown to be attributable to laudanum and other opium preparations. These were either by accidental overdose or substitution for another medicine, and needless to say, caused a ripple of concern among politicians.
In 2014 the Office for National Statistics recorded a total of 3,346 drug-related deaths across England and Wales, 1,786 of which were attributable to opiates and which sadly represented an increase from the previous year. However, the figures for Wales revealed a slightly different story, with drug-related deaths in Wales falling by 16 per cent from the previous year.
Why were things different in Wales? The reasons might include a greater acceptance of harm minimisation as the first step to recovery, thereby encouraging users not yet ready to embrace abstinence to engage with services. However, one major factor has undoubtedly been the national take-home naloxone (THN) scheme. Started in 2011, it has systematically trained service users, their families and professionals (such as hostel staff) to identify signs of opiate overdose, apply basic life support and administer intramuscular naloxone. Its take-up has been huge and THN is now an established part of the Welsh treatment landscape. Its ethos continues to be, in the words of Sarz Maxwell, consultant psychiatrist in Chicago, a desire to ‘flood the streets with naloxone’.
Of course, there are always naysayers: ‘Surely naloxone will encourage users to engage in more risky behaviour knowing that the antidote is available?’ There is no evidence that this is the case. ‘What if they give it to someone who isn’t in opiate overdose?’ In the absence of an overdose, the medication is inert. ‘Aren’t we just condoning drug use?’ Oh, please.
If handing out naloxone challenges the sensibilities of some, let’s look at what we’re achieving. Of course there is the obvious gain in lives saved, but there’s the sense of control being handed back to people who feel they have none, and the power to save a life.
Gearing up services to be able to train clients and their families to understand and be able to use naloxone is a simple matter, but it requires trainers who are able to deliver properly. Pulse Addictions provides take-home naloxone training for staff, either as a standalone session or as part of its course on risk management in substance misuse. This comprehensive training will enable staff to empower their clients to respond in emergency situations, reducing the tragedy of drug-related deaths.
In the concluding article in a three-part series, DDN looks at much-needed services offering information and support
Buying codeine-based cough medicine from the chemist was David Grieve’s path to addiction. At the time, manufacturers combined codeine with ephedrine – ‘a similar effect to amphetamines’, he says, and by the time he realised he needed help he was seriously ill.
Struggling through treatment with very little help, he set up the support service Over-Count to help others who find they have a problem with over-the-counter medicines. Back in 1993, when he started it from his front room, it was a tiny organisation with no funds. Sadly, he says, the situation hasn’t changed much – but the problem of opioid painkiller addiction has grown out of all proportion.
‘Since we started Over-Count in 1993, the amount of people we’ve helped is getting on for 80,000,’ he says. ‘About 1,000 people a year are coming in presenting with addiction to painkillers.’ They range in age from 18 to 69, and three-quarters are female. ‘About 95 per cent of the products they are addicted to are codeine-based painkillers,’ he adds, with Nurofen Plus overtaking Solpadeine Plus as the pill of choice. ‘The reason is quite simple – Nurofen Plus has 12.8mg of codeine in it, compared to 8mg, so you get more for your money.’ The amount of tablets being taken varies from six to 74 day – ‘a dose that would kill me and would kill you’. In this case, the woman gradually increased her intake to 12 tablets six times a day, with a couple more doses in the night, and came to Over-Count ‘as a last resort’.
In this extreme case, Grieve gave the woman a letter to take to her doctor, to help her get immediate medical support and liver function tests. For others, the support begins in different ways and through the offer of a withdrawal programme, which ‘has an 86 per cent chance of succeeding’ and leaving the patient drug free for at least six months.‘If you can do six months, the chances are you can carry on drug free,’ he says. The reason for the success rate, he believes, is that ‘it feels personal and you’re not just ignored and left to get on with it.’
Working constantly to prepare the individual programmes and respond to clients, Grieve does not have the time or money to continue his research or expand his database on the problem as much as he would like to. He is also deeply frustrated that his ten years of lobbying for a centralised information database and standardised treatment appears to have come to nothing, and warns that the problem will ‘increase beyond recognition’ over the next five years.
Director of DrugWise, Harry Shapiro, is equally surprised at the slow response to the issue. ‘I did various Hansard searches and the subject has never come up – there aren’t even any parliamentary questions on it,’ he told DDN. ‘It’s completely ignored as a public health issue.’ This is a situation he hopes to help change through the All-Party Parliamentary Group for Prescribed Drug Dependence, which considered his paper on opioid painkiller dependence and will dedicate its next meeting specifically to the topic, later this month.
The BMA is also holding stakeholder meetings, gearing up to lobby the public health minister to fund or run a national helpline – but he acknowledges that the mechanism can grind exceedingly slowly and that there’s ‘not a huge amount happening on the policy front’.
In the meantime, support organisations are developing the knowledge to offer much-needed help. Among these, DrugFam has the families’ interests at heart, offering them a seven-day-a-week helpline, groups, and one-to-one support. ‘It’s about raising awareness so that they’re not isolated and alone,’ says chief executive Sarah Bromfield. ‘Families don’t always identify this as something they can get support for. So we need to raise awareness around GPs and the health services and around substance misuse agencies as well.’
Their latest initiatives, including developing leaflets, information brochures and a toolkit, came about as a result of an increasing number of calls to the helpline around the issue. ‘We felt it was important that we did something about it,’ she says. ‘There are a lot of hidden families not getting the support they need.’ They have also joined the Opioid Painkiller Alliance, a group of organisations from the pain and addiction communities, which is campaigning for better screening, support and information for patients who are at risk of developing dependence.
DrugFam’s information is being developed through talking to family members who are going through these issues and looking for common themes. An important element will be to help them tackle stigma, as well as the behaviours associated with any other addiction – ‘so we need to help families at an early stage to put the boundaries in place and look after themselves,’ she says.
Annemarie Ward, chief executive of Faces and Voices of Recovery (FAVOR) UK, agrees that being able to deal with stigma is a vital tool for both patients and families in tackling addiction. ‘Opioids, whether prescribed, bought over the counter, or bought on the streets, don’t discriminate,’ she says, ‘but people certainly do, which prevents people from reaching out for help when they most need it. Like most people with substance use disorders, those with opioid dependence take their problems underground and don’t seek help early because they’re worried about the ramifications for their careers, or they’re ashamed to tell their families and friends.’ There are plenty of ways to challenge this stigma by offering compassionate support, both to the individual and to their loved ones, she says. ‘Simply being kind and non-judgemental to people who are in an incredibly vulnerable situation can go a very long way.’
Last month’s Opioid Painkiller Addiction Awareness Day (22 September) highlighted that there is a long way to go to start tackling this problem seriously – not just because of growing numbers of people affected. Searching for activity related to the campaign reveals very little and there was a lack of cohesive action to get the message across to the public and find those in need of help.
Over this series of three articles we have seen that progress for this patient group is hampered by lack of reliable data, inconsistency in professional practice and protocols, underfunded initiatives and a lack of political will to grasp the agenda and move it along. On the plus side, there are individuals, groups and services out there that are working with a passion to raise awareness and offer a lifeline to those who are addicted.
This article has been produced with support from Indivior, which has not influenced the content in any way. More information on opioid painkiller dependence at www.turntohelp.co.uk
Since 2008 ‘recovery’ has been at the heart of British drug treatment policy. As Mike Ashton reports, it has been used as both an inspirational call to overcome addiction and a justification for limiting treatment
Though the term has a long history associated especially with 12-step-based approaches, the modern ‘recovery’ era in Britain can be dated to May 2008, when governments in Scotland and England presented it as a new dawn, which would reinvigorate treatment services stuck in the rut of preventing harm and crime rather than redeeming and regenerating lives.
In an ‘age of austerity’, commentators have noted that the ambitious rhetoric was not matched by the ‘intensive support over long periods of time needed to become drug free’. Though incorporated in genuine patient-centred advocacy, at a political level, in England ‘recovery’ helped legitimise not intensification, but withdrawal of support, as long-term treatment became stigmatised as impeding recovery. This article offers a reminder of that part of its origins which lay in the imperative to cut public spending and curtail addiction treatment – not to do more, but to spend less. Neglected in the dazzle of the recovery vision, these origins remain active in today’s conceptualisations and uses of the term.
So dominant has recovery become, that it lies at the heart of the treatment themes in Britain’s national drug policies. It features in the titles of both the English and the Scottish strategies, while the Welsh strategy committed the nation to ‘focus our efforts on helping substance misusers to improve their health and maintain their recovery’.
What these strategies meant by ‘recovery’ was not spelt out, but the broad themes were clear: some of the most marginal, damaged and unconventional of people were to become variously abstinent from illegal drugs and/or free of dependence and (as Scotland’s strategy put it) ‘active and contributing member[s] of society’. Scotland’s ambition echoed those of the government in England dating back to the mid-2000s for more drug users to leave treatment, come off benefits, and get back to work – and become an economic asset rather than a drain.
At first, under Gordon Brown’s Labour government this ambition verged on the brutal. In February 2008 Labour’s UK drug strategy seemed to threaten drug users reliant on benefits with penury if they failed to ‘move successfully through treatment and into employment’. The backdrop was the credit-crunch crisis dating from August 2007, followed in April 2009 by a promise by Conservative Party leader David Cameron to usher in an ‘age of austerity’ to cut the budget deficit.
Though transition out of treatment and into employment was close to what later became ‘recovery’, of the six times that word was mentioned in the 2008 strategy, all but one referred to recovering financial assets from drug dealers, not recovery from addiction. South of the Scottish border, ‘recovery’ had yet to be discovered, but already preparations must have been underway to make it the dominant theme in the May 2008 Scottish strategy. That month too, in England the initial stress on reintegration through employment, enforced by withdrawal of benefits, had in senior government circles morphed into a more appealing label: ‘recovery’.
In this, Labour was not just catching up with Scotland but also with the Conservative opposition. In July 2007 David Cameron’s ‘New Conservatives’ had released the fruits of their addictions policy think-tank. In contrast to Labour’s strategy, ‘recovery’ was the banner for its overarching philosophy. For treatment in particular, ‘The ultimate goal… should be recovery and rehabilitation through abstinence.’ It required ‘radical reform’ entailing a move away from substituting legal for illegal drugs and ‘facing the fact that abstinence is the most effective method’. Not much survived of what would have been an expensive shift to residential rehabilitation and the structural reforms the report saw as needed to pursue recovery. But recovery itself, and the associated abstinence objective and denigration of maintenance prescribing, became embedded in Conservative thinking – and with the advent of David Cameron’s government in 2010, in national policy.
The strands later to be woven into the English version of recovery had, however, been gathering several years earlier, prompted in the mid-2000s by the felt need to make economies in addiction treatment and contain public spending – especially the welfare benefits on which the patients overwhelmingly relied. Though total funding was increasing, per patient funding had been falling for several years when in 2005 an ‘effectiveness’ strategy developed by the National Treatment Agency for Substance Misuse (NTA) complained of the ‘lack of emphasis on progression through the treatment system’ leading to ‘insufficient attention… to planning for exit’. Foreseeing a time when funding would be less available, the agency’s board was told that ‘Moving people through and out of treatment’ would create space for new entrants ‘without having continually to expand capacity’.
Opposing the previous stress on retention – the yardstick on which services were then being judged – in 2007 this new emphasis on treatment exit was given an unwelcome boost when the prevailing crime-reduction justification for investing in treatment was challenged by the BBC on the grounds that treatment should be about getting people off drugs. There was no gainsaying the seemingly incriminating fact that in England in 2006/07, just 3 per cent of drug treatment patients had been recorded as having completed treatment and left drug free. The shock of that challenge and the economising turn away from retention to treatment exit fed through to the following year’s national drug policy. Announcement of a three-year standstill in central treatment funding until 2011 – a real-terms cut when the caseload was expected to rise – further focused attention on squaring the circle by getting more patients to leave as well as enter treatment.
By then firmly linked to the term ‘recovery’, in 2014 the emphasis on treatment exit remained in government circles, eliciting a robust defence from the Advisory Council on the Misuse of Drugs (ACMD) of long-term opioid substitution therapy for heroin users. The following year the Conservative Party’s election manifesto made it clear that the council’s message had been rejected, continuing in the name of ‘full recovery’ to condemn ‘routine maintenance of people’s addictions with substitute drugs’.
Harm reduction measures can be seen as controversial within the wider population, but isn’t confronting public fears an essential stage in moving the agenda on? DDN reports
‘How radical can harm reduction be?’ asked Dr Ingrid van Beek at the City health 2016 conference in London. Van Beek was part of the team that established what still remains Australia’s only drug injecting facility, in King’s Cross, Sydney in 2001. The fact that no other Australian facilities have been set up in the last 15 years makes the King’s Cross site appear more radical than it really is, she argued.
The site was chosen as there was a large amount of street use in the area, and was established as an extension of needle exchange services. While these services are now seen as mainstream, with more than 90 countries providing needle exchanges, establishing safe clinical settings for people to inject drugs is still sometimes seen as ‘a step too far’.
‘What did you think was happening with all the needles being given out?’ was a question van Beek had asked politicians and local residents also opposed the scheme. Lobbying against a backdrop of cheap heroin, rising drug-related deaths, and an increasing amount of visible street users, she had finally persuaded politicians to confront the problem and agree a trial period for the new facility.
Despite the scheme being the most evaluated medical facility in the world, with its positive outcomes in reducing both fatal overdose and street use validated by independent assessment, its trial status remained for nine years before it finally became a permanent service.
It’s not enough to just present the evidence, van Beek told delegates – you also have to engage with the values and morals of those who oppose it. Shutting it would ultimately have resulted in an increase in overdose deaths, something that opponents needed to be reminded of. ‘I think we should keep people alive, and make no apology for it’, she said.
Harm reduction facilities are never more needed than in times of austerity – but unfortunately the short-term costs could prohibit establishing these interventions, said Dr Konstantinos Farsalinos, of the Onasis Cardiology Centre in Greece. Providing delegates with a perspective on Greece since the financial crisis, Farsalinos talked of the massive reduction of GDP and huge increase in unemployment, which had especially hit young people and the poor, and had seen an associated rise in drug and alcohol use, accompanied by more cases of blood-borne viruses and mental health issues.
One of the problems was that effectiveness of harm reduction services could often only be proven over the long term. Coupled with a lack of public sympathy for some client groups, this could make it hard to secure initial funding, said Farsalinos.
Professor Neil McKeganey of the Centre for Substance Use Research urged caution around seeing harm reduction as a universal panacea. Interventions should be limited by both evidence of cost effectiveness over a long term, and also the moral and political limitations required by the wider population, he said.
Harm reduction was not a call to arms but an important societal movement, said McKeganey, and it was important that it was judged with the same critical measures used on any other health intervention.
One of the main challenges according to Jamie Bridge, of the International Drug Policy Consortium, was that ‘people who use drugs are now widely seen as criminals, not as people who need support’.
Campaigns such as Support. Don’t Punish were proving successful at bringing grassroots partners into the debate and gaining the attention of the media – both vital in reaching new audiences and influencing policy.
Drug policy had been ‘a public health disaster around the world’, he said, and decriminalisation was the only way forward.
Why wait for the death toll to rise, asks Nigel Brunsdon
With overdose deaths recorded every week in the UK, safer spaces were disappearing fast but needed more than ever, Nigel Brunsdon told the National Substance Misuse Conference, Breaking down barriers.
Needle exchanges were closing all over the country and transferring to pharmacies, and the lack of political will to open consumption rooms in the UK made no sense: ‘There have been zero deaths in them anywhere in the world, and they’ve been open since 1986,’ he said. Slowing slides of filthy and unhygienic spaces full of needle litter, close to where the conference was being held, he added ‘Birmingham has an overdose fatality every week’.
Beyond reducing deaths, the facilities were also shown to reduce blood-borne viruses and increase access to treatment, housing and other forms of engagement.
‘We have the highest levels of drug use ever and many people who’ve never been in treatment,’ he said. ‘So why aren’t drug services clamouring to do this?’
More reports from the NSM conference in next month’s issue.
Pat Lamdin has just retired after years as a drugs worker. His legacy was an important one, say Neil Hunt and Sean Tanzey, for he put his clients’ welfare and happiness above targets, audits and outcome monitoring
Old fat bloke retires; so what? Happens every day, why does it matter? It matters when people like Pat Lamdin retire, because we’re not making them like that any more.
When the careers of people devoted to public service come to an end there is something of a bias towards publicly honouring the accomplishments of people who have long since ‘progressed’ and moved on from their original vocation: typically, to a series of successively better paid, higher status leadership roles.
Other exceptional careers, however, are based on deliberate and sustained efforts to avoid promotion (despite regular encouragement) because promotion would inevitably be a distraction from a calling and particular talent for working with people experiencing problems with alcohol or other drugs.
Pat Lamdin’s practice warrants celebration in these pages for this reason. He worked directly with this population until he retired – not because he was someone who lacked ambition, but because his simple yet worthy desire was to continue doing the work he had chosen to do many years earlier. Doubtless this was one of the reasons he always seemed so bloody good at it.
It takes an unusually dedicated person to choose to do this and spend pretty much their entire working life in counselling rooms decorated in the bland ‘shabby magnolia and woodchip chic’ historically favoured by the voluntary sector. If you doubt this, just ask yourself how many retirement parties you have attended for people who have worked more or less continuously in such ill-paid positions.
Regarding which, Pat never had much time for the treatment sector’s seemingly endless enthusiasm for semantic navel gazing about what to call its workforce or the people it aims to help. He seemed less bothered than most about whether his job title said he was a psychiatric nurse, counsellor or prescribing or recovery worker. Or whether the people with whom he spent most of his time were now called patients, clients or service users. Probably this was because, whatever terminology was used to describe it, he always had an unswerving sense of what his work entailed – meeting people on their terms and helping them as best he could
As numerous colleagues from across the years would attest, Pat was an exceptional colleague who had as much time for the administrators as for the chief executive. When practitioners and the occasional researcher sought his advice, this would frequently be as wise as it was blunt.
What special qualities does Pat have? This is an important question. When talents like Pat’s leave the workforce due to retirement (or other causes) it is vital that they are replaced by new practitioners with the skills necessary to those who need help. All that can be done here is to refer to a couple of aspects of how Pat worked.
You know those rare people you meet who immediately engage with you fully and often leave you feeling curiously better about yourself? Well Pat is one of those. Perhaps the capacity to do this is that thing known as ‘unconditional positive regard’ (UPR), which many aspiring counsellors first learn about in An introduction to counselling skills? But establishing the therapeutic alliance is a profoundly important skill that a good practitioner develops throughout their working life. Pat would cheerfully tell anyone who would listen that no care plan ever saved a life, but skilled workers could do. And, he would say, if you were still listening, you don’t give workers skills by just giving them a manual to work from.
The treatment field has a mountain of controlled trials comparing ‘this therapeutic model’ versus ‘that therapeutic model’ and the only consistent finding is that interventions tend to be much of a muchness. As it turns out, the variable that explains the largest difference in outcomes is ‘therapist factors’, ie what that person is like and how they treat you.
This is why people with this remarkable talent for UPR are so valuable in the workforce. After all, it isn’t a giant leap of logic to suppose that, if a practitioner immediately enables a client to feel genuinely valued, safe, and perhaps a bit better about themselves, then perhaps they’ll feel more ready to talk about something they find incredibly difficult for the very first time, or stick with doing something that is very difficult to do, or go away and attempt something they didn’t believe they could do?
He was walking proof that being a corpulent, 6’1” bloke with a pink Mohican and an ear expander big enough to pass your granny through (plus her handbag) is no barrier to engaging with people at any stage of their life, if forming the therapeutic alliance is uppermost in your mind.
There seemed something about this combination that almost instantly reassured people who were nervously attending their appointment. It says, this is someone who seems unlikely to be judgemental, or shocked by any revelations, however shameful. On the contrary, it’s easy to imagine his own past might contain a few demons and a little shameful behaviour too. Or maybe quite a lot. Though whether that is true, it’s probably not the sort of thing to reveal in an appreciation of someone’s career.
Strangely, this Renaissance prince of the liberal humanities wasn’t universally popular. If managers required Pat to attend a meeting, he would take gleeful pleasure in requiring them to listen to what he had to say. Over and over again. Our clients deserve workers with skills beyond completing paperwork. Groups are highly difficult treatment approaches, not a cheap option beginners can run unsupported. Data is a tool, not an objective. Not music to every manager’s ears.
But let’s salute a contribution made over four decades, across the NHS and voluntary sectors. As a seasoned marathon runner, Pat knew about staying the course, in mental health, homelessness and substance misuse, which demonstrates a level of commitment and resilience few sustain at the client-facing level.
Committed, because although the work can be hugely enjoyable when you work with people who at times can be wise, witty, heroic and much more (such as the epically strange); it also requires being a witness to a relentless flow of lives blighted by tragic and traumatic events with the intractable problems that follow.
Resilient, because when you are an expert at your craft who has studied extensively to obtain the necessary qualifications and also acquired the subtler, sophisticated understanding that can only be obtained by spending thousands of hours talking to hundreds of people… well it can be bloody annoying when policies and procedures seem to be constantly changed for no discernible good reason by people you sometimes suspect haven’t a clue what your work entails. Or because your employer has suddenly changed, though your clients haven’t. Or the irritation of dealing with the ‘bean counters’ and the ever-increasing demands on your time from their array of clinical audits, activity monitoring forms, outcome tools and other performance monitoring data, much of which seems ill-conceived, irrelevant and a hindrance to doing your work in the way clients need.
When Pat left, some of his clients wept. No manager did.
Combining her two key interests brought Hannah Feeney to The Alcohol and Drug Service (ADS) as an advanced social work practitioner.
I came into social work by accident at age 19 when I had completed my A levels and was trying to work out what I wanted to do with my life. I was advised that doing a counselling course would equip me with communications skills that would benefit me in any job, so off I went to complete a ten-week course.
This was my first experience of listening to people who were in emotional pain and started my pathway towards working with people who were facing adversity and needed professional support.
When I began a degree in social work, I don’t think I really understood where it would take me. But I came to learn that it is a profession that engages with people at some of the most complex and challenging periods of life where hopelessness, fear, isolation and distress are common – not just for the individuals, but also in their families, children and wider communities.
I was inspired by the area of substance misuse services very early on, through completing a specialist module and practice placement. I saw the widespread impact of addiction and was humbled by the sheer determination people had to find to achieve independence and wellbeing.
I started my first job in a drug intervention programme – a qualified social worker, employed as a drug and alcohol worker. I used social work skills on a daily basis to engage with people, assess their needs, and help them to plan their care and achieve their goals, but was discouraged from sharing my professional identity due to a belief within the organisation that service users would not engage with social workers.
I began to see the lack of understanding in society of my profession, and the misconception that all social workers were people to be suspicious of. Being part of someone taking control of their life and thriving in recovery was rewarding and I knew I had made the right decision to work within this sector, but I was keen to retain my professional identity.
In 2006 I had the chance to take on a role that incorporated the two things I had developed a real passion for, and I became employed by a local authority as a specialist social worker for substance misuse.
This gave me an opportunity to focus on developing my social work skills further, and over the next six years I saw the substance misuse field change and grow following the introduction of the recovery agenda. As services have been recommissioned and austerity has hit, service providers have been reconfiguring their staffing, leadership structures and their use of peer support and mutual aid, while supporting people to build recovery in their communities.
The social work profession has also seen huge reform, new legislation and workforce challenges, bringing it closer to the substance misuse sector than ever before. There is now a real opportunity for social work to support the recovery agenda with its underpinning principles of empowerment, self-efficacy and community cohesion.
I currently work as the social work lead for The Alcohol and Drug Service (ADS). Like many providers, ADS has employed social workers for many years but began thinking closely about its workforce several years ago as it formed partnerships with NHS trusts. Leading on the social care element of the services they provide, ADS made a decision to use the skills and accountability of social work professionals to lead the frontline workforce, developing reflective practice within their teams and contributing to the skills development of others.
My role is therefore to build and lead a social work structure across the organisation’s partnerships that is robust and enables career progression, is in touch with national policy and governance and is constantly developing and adapting to the change that reform brings.
Alongside the strategic element of my role I am responsible for enabling, monitoring and evaluating continuing professional development (CPD) from social work placements, through the assessed and supported year in employment (ASYE) and into post-qualifying learning and development. As a practice leader for the social work professionals that ADS employs, I thoroughly enjoy watching them thrive in their professional roles within our services. One of our social workers said, ‘As a recognised social worker I have begun to bring other areas of my training into my work, including reflective practice and the confidence to challenge other professionals… it is greatly appreciated that we are recognised in the sector that we work in.’
The social work team at ADS are now spread among our services, supporting the holistic approach required for effective recovery-focused services. We engage with and contribute to a number of university social work programmes and fast-track schemes, giving our social workers opportunities to develop other skill sets that are valuable to them and the organisation. ADS holds a strong belief that social work as a profession has a key role to play in the future of substance misuse services and I feel great excitement about what this could mean for our workforce and the wider substance misuse field, for social work – and ultimately for the people who need and use our services.
Trends come and go and nowhere more so than in the shifting world of addiction management, says Dr Julia Lewis.
The pendulum seems to swing from one paradigm to another with the supporters of each frequently baying for the blood of their opponents. Some support abstinence as the only sensible goal, and berate the so-called ‘medical model’ with its alleged transfer of dependence to state-endorsed substances, while others shout loudly in support of what they claim is a more inclusive harm reduction approach. But what if there was a model that encompassed all these laudable ideas and then took things a stage further?
In 2007 the World Health Organization called the management of chronic disease (such as asthma, diabetes and hypertension) ‘one of the greatest challenges facing healthcare systems throughout the world’. Out of these concerns developed the chronic disease management (CDM) Model defined by the Disease Management Association of America as ‘a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant’.
Various researchers have argued that this model can be applied to the management of addiction, as evidence suggests that addiction has a similar profile to other chronic diseases. For instance, more than half of patients entering publicly funded addiction services in the USA achieve and sustain recovery after multiple episodes of treatment over several years, and addiction is associated with chronic physiological changes; a relapsing, remitting course; comorbidity; a need for ongoing care but with variable adherence to that care; and the absence of a ‘cure’.
Current models of addiction treatment provision in the UK frequently follow an acute care model, concentrating on the management of complications of use as opposed to the underlying condition, and lacking essential coordination of care across health and social care systems. However, managing addiction solely through these acute episodes of brief stabilisation and detoxification can contribute to the frustration of service users, their families and the public regarding prospects for permanent recovery.
Also, as a chronic disease with biological, genetic and physiological elements, addiction should be addressed via a case-managed combination of treatment modalities, personalised to the assessed needs of the service user, providing an integrated pharmacopsychosocial approach to treatment.
In contrast, the CDM model bases care on the service user’s needs, values and decisions, rather than reacting to problems. Nevertheless, transferring the CDM approach to the management of addiction requires a move into a recovery-oriented system and the recovery management (RM) model has been developed to combine these two treatment paradigms. So, what are the essential features of an RM model of addiction treatment?
The model is easy to access and geared to developing motivation. The care planning process focuses on the whole life of the service user, not just the problems caused by their use, and supports their right to manage their own condition. The clinician is seen as an educator, providing long-term support, and a comprehensive care plan brings together services best placed to address their needs. Interventions are evidence-based and include all relevant modalities, and the emphasis going forward is on self-management, with links to recovery resources in the community and easy access to re-intervention if needed.
It is possible that the RM model provides us with an integrated system of tried and tested addiction treatments but in a way that wraps the management plan around the service user, connects them effectively to other relevant parts of the health and social care system and draws on recovery resources in their community.
Accepting the chronic disease nature of addiction may be a difficult mindset shift for some, but to continue to attempt to address it via a model of acute, ‘one-size-fits-all’, circumscribed treatment not only does a disservice to our service users but also flies in the face of the evidence. It’s time to adopt the new paradigm.
Creating a shift in thinking from the traditional acute care models to the RM model is underpinned by the following concepts:
Addiction exists in transient and chronic forms. Transient forms may resolve spontaneously or with brief interventions alone. Chronic forms are associated with greater complications, more comorbidity and more obstacles to recovery.
Evidence shows us that, although recovery is an achievable goal, it takes around three to four treatment episodes over a period of eight years for this to occur.
If we see addiction as a chronic disease, we should not see previous treatment as a poor prognostic indicator, convey to service users the expectation of complete recovery after one treatment episode and punitively discharge service users who relapse.
Many people discharged from addiction treatment find themselves caught between recovery and relapse for weeks, months or even years, strongly supporting the need for ongoing post-treatment monitoring and support.
Multiple episodes of treatment, if integrated into a recovery management plan, can lead to cumulative effects and multidisciplinary interventions may have synergy.
Dr Julia Lewis is consultant addiction psychiatrist for Aneurin Bevan University Health Board. This article is based on her talk to the SMTPC event, The post-war dream, held in Newport, Gwent.
Drink and Drugs News is the UK’s publication for addiction treatment. Since 2004 we have worked with the NHS, Public Health England and the UK’s major treatment providers to provide informed coverage of all kinds of addiction.
DDN is a free independent publication available in print and online, it is read by treatment providers, health and social work professionals, policy-makers and individuals looking for help for themselves or a loved one.
DDN Residential Directory 2017
As well as our monthly magazine and annual conference, we also produce a comprehensive guide to UK residential treatment facilities.
In January 2019 we will be producing our new DDN Guide to Residential Treatment.
Incorporating the sought-after UK residential directory, this publication will combine personal stories, practical advice, and detailed information to help individuals find the right centre for them.
Choosing the right rehab is a daunting prospect raising lots of questions:
What is 12-step – and is it right for me?
What other treatment options are available?
Home or away – what country or location would suit me best?
How long will the programme be?
Do I need detox?
What addictions can be treated?
How much will it cost, and how can I pay for it?
This free guide will help to answer these questions, and provide clear advice that demystifies the jargon and aims to breakdown preconceptions surrounding residential addiction treatment.
Inspirational personal stories will show how individuals who have had successful treatment journeys have achieved long-lasting, meaningful recovery.
While still being a resource for statutory referrers as a pull-out and keep centre section of DDN Magazine, the new publication will have a focus on individuals self-funding their treatment. The magazine will be available to read online, be distributed in health and social care settings, and be available at events and through our magazine partners. Promoted in the national press and media, individuals will also be able to request a free printed copy posted discreetly to their homes.
MAKE SURE YOUR SERVICE IS PART OF THIS NEW DDN PUBLICATION
Promotional options
We have promotional opportunities to suit all budgets including a free listing for UK services – and can offer sponsorship, editorial coverage, display advertising in print and online, and enhanced listings for services.
Space is limited. Get in touch today to ensure you don’t miss out.
Nicole Ridgwell of Ridouts answers your legal questions.
Can I challenge the results of our CQC inspection? And if so, how?
Nicole answers:
As previously reported in DDN, the July 2015 implementation of new comprehensive CQC inspections has brought significant regulatory change to the substance misuse sector. Feedback from the frontline is that this first inspection cycle has been predictably challenging.
At Ridouts, we see inspection reports in which policies are strongly criticised in one location while passing without comment in a sister service. The fundamental problem appears to be the variation in training and knowledge of CQC inspectors. Clients have described inspectors demanding evidence of compliance with NHS standards to which services are not subject, and criticism of services choosing a detox route differentiating from NICE guidance, not listening to the provider’s cogent explanation of why they use a different but equally recognised tool for their client group.
Unfortunately this was foreseeable and, by choosing not to publish ratings at this stage, CQC tacitly acknowledged that this set of inspections was a trial run. That however is cold comfort to the providers faced with critical reports, enforcement action and damaging media headlines.
Providers need to feel confident in their right to challenge. Without challenge, CQC and the public will presume the provider accepts the content.
Preparing for the possibility of challenge is important. In theory, there should be no surprises when a provider receives a draft report. There should be sufficient feedback during the course of the inspection to headline areas of strength, as well as areas for improvement.
While feedback sessions are not an opportunity to debate findings, they should enable staff to begin gathering evidence to challenge and identify areas for improvement, with a view to responding to the draft report. Where feedback is insubstantial, providers must request further detail.
On receipt of the draft report, providers must scrutinise it line by line, identifying not simply factual inaccuracies but negative or imprecise wording and vague criticisms. Although this may seem laborious, it is important to lodge all valid objections. Should matters progress to enforcement action, it will be much more difficult to retrospectively challenge something about which providers were initially silent.
CQC 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.
Providers in all sectors are intimidated by CQC and often feel powerless to exercise their rights. Successful challenges however not only correct falsehoods for individual services but also feed into CQC’s reflections on their inspection process. This contributes to improvements in inspection training, to the benefit of your next inspection and CQC’s understanding of the sector as a whole.
Nicole Ridgwell is solicitor at Ridouts LLP, a practice of health and social care lawyers, www.ridout-law.com.
The Resonance Factor is a new model that puts accountability – and empowerment – centre stage, says Kenneth Robinson
There is nothing special about substance use, and this article deliberately refrains from terminology like ‘addiction, dependence and misuse’. Of course the individual requires support – and at times considerable support – however that is common to all relationship issues. For the drugs professional to make a monster out of it is one of the gravest mistakes in the field of substance use.
There is no simple intervention that has been devised to date to stop an individual from using substances, because substance use is ultimately based on the choice of the individual. There is a limited chance of an individual making changes to his or her life if they are unable learn and understand the very personal and intimate relationship they have formed with substance use – the same as for any individual looking to address any issue. Hence, is it surprising that some clients return over and over again to services if they believe themselves to be a slave and powerless to addiction?
The Resonance Factor model was created with this in mind. The central focus is the exploration of the user’s relationship with their drug of choice, which includes revisiting the discovery of that drug and the experience of the high – a pharmacological fact that tells us that drugs and alcohol affect each individual differently. This enables the service user to consider how they use drugs and alcohol to change the way they think, feel and behave, and who they become when they have used. Let us not believe the ‘defensive’ nonsense of a client who says ‘I enjoyed substances when I first used them but I haven’t enjoyed them for the last ten years!’ In all honesty, does that make sense? If you believe the client to be an addict, sick, ill and the like then it makes perfect sense, but if you wish to understand substance use more deeply and understand the ‘wow’ factor of it all, then ‘I don’t like substances any more’ would not make sense.
The Resonance Factor does not avoid the issues that may have prompted the service user to access treatment – health problems, loss of relationships or children, housing, employment. These form the central platform of our therapeutic work with the client. It does, however, consider these issues to be pathways to and from the central issue that is the pursuit of the high. This singular pursuit, often maintained for many years, becomes the most important relationship for the drug or alcohol user, and is therefore the primary focus of the approach.
For the substance user to use at the expense of everything else, he or she has to create justifications, and maybe more thought and consideration should be given to that. The Resonance Factor is an approach that asks the service user to discover their accountability, while empowering them to make new choices.
The number of heroin-related deaths in England and Wales has doubled since 2012, from 579 to 1,201, according to the latest ONS figures. Last year saw the highest number of drug-related fatalities ever recorded with 3,674 poisoning deaths, of which 2,479 exclusively involved illegal drugs. Scotland also recorded its highest drug death toll in 2015, at 706 (DDN, September, page 4).
Although the government is keen to stress that the figures come against a background of falling rates of overall drug use, deaths involving cocaine also reached an all time high at 320 – up from 247 the previous year. Deaths involving amphetamine also reached their highest-ever level, and those involving ecstasy the highest in more than a decade.
Overall most drug deaths were again among the over-30s, with the North East of England the region recording the highest number of deaths for the third year running, and males almost three times more likely to die than females. Although, as in Scotland, the number of deaths involving NPS remained relatively small, the substances could ‘present a more significant problem in the future, especially as not enough is known about the long term effects of their use’, stressed Public Health England (PHE).
An independent expert group convened by PHE and the Local Government Association (LGA) has published a list of recommendations to try to address the rising death rate, including improving access to treatment – especially for ‘harder to reach’ populations through outreach work and needle and syringe programmes – and coordinating a ‘whole-system approach’ that includes mental health, housing and employment support.
‘Drug use is the fourth most common cause of death for those aged 15 to 49 in England and we know that the majority of those dying from opiates have either never, or not recently, been in treatment,’ said PHE’s director of drugs, alcohol and tobacco, Rosanna O’Connor. ‘Reassuringly, overall drug use has declined and treatment services have helped many people to recover but there is a need for an enhanced effort to ensure the most vulnerable can access treatment.
There is considerable variation across the country, with some regions showing large increases in recent years. PHE will continue to support local authorities in delivering tailored, effective services where people stand the best chance of recovery.’
The ‘shocking’ statistics raised serious concerns about both government policy and the state of the treatment sector, however, said Release executive director Niamh Eastwood. ‘Since 2010 we have seen a worrying implementation of abstinence-based treatment under the government’s ideologically-driven “recovery” agenda. This goes against all the evidence for best practice in drug treatment, and is contributing, we believe, to this shameful rise in deaths. Such a hostile environment means people simply don’t want to access treatment.’
There was also ‘an increasing tendency among local authorities to simply offer treatment contracts to providers who can deliver the service for the lowest cost,’ she continued, with the standard of healthcare ‘being overlooked’ for financial reasons. ‘The Home Office’s pursuit of a “tough on drugs” strategy and refusal to acknowledge the evidence for best practice in drug treatment is quite literally killing people.’
Deaths related to drug poisoning in England and Wales: 2015 registrations at www.ons.gov.uk
Understanding and preventing drug-related deaths: The report of a national expert working group to investigate drug-related deaths in England at www.nta.nhs.uk
Research shows that Korsakoff’s syndrome can occur in many dependent drinkers, yet the condition is rarely acknowledged and understood. Glenn Barnett explains the syndrome, which causes severe memory disorder, and shares a new model to support those affected to help them back to community living.
Throughout this month’s new articles we have some fascinating thoughts on our responses to addiction. Is it a learning disorder rather than a disease, as Maia Szalawitz suggests? Will we listen to new evidence to reshape drug policy, asks David Nutt. And what should be the purpose of harm reduction – as primary goal or to eliminate drug use? Mike Ashton presents both sides of the argument.
Read on for ideas and inspiration, including a look at how some innovative treatment services are responding to the complex problem of painkiller addiction.
Bringing together social work students and people in recovery gave an opportunity to share skills and knowledge, as Marelize Joubert reports.
Attending a substance misuse conference with the theme of recovery gave social work students at Sheffield Hallam University the chance to find out more about drug and alcohol services, listen first hand to peer mentors’ stories about recovery, and hear about what works in services. The conference, hosted by the university’s social work department, also allowed the students to learn about career opportunities.
The rationale for the conference came from research by Professor Sarah Galvani and Debra Allnock that highlighted the gaps in knowledge and skills around substance use education that newly qualified social workers need before qualifying. This is brought sharply into focus by the increasing prevalence of substance use as a significant factor in child protection and safeguarding for both vulnerable children and adults, highlighted by the Social Care Institute for Excellence (SCIE).
A key feature of the day was collaboration with a wide range of social care and health practitioners, peer mentors and volunteers from Aspire, the commissioned drug and alcohol service in Doncaster. Aspire delivered a range of workshops that covered everything from parental substance misuse to the role of medication in assisting recovery. Volunteers and peer mentors were fully involved in the day, with one workshop focusing on the role of ‘champions’ in recovery.
‘We were delighted to be involved in the conference being delivered to student social workers,’ said Stuart Green, Aspire services manager. ‘Aspire delegates were able to offer insight into treatment services and theoretical models of addiction from a hands on approach.’
Research also underpinned the day, with Prof David Best sharing his recent research around recovery, including the importance of relationships and connections. Research has shown that those who experience recovery can become ‘better than well’, he told students.
Best explained how change becomes more possible when research is backed up by the cost savings that could be made in economic and social terms by delivering recovery-based services. He gave an example of the importance of identity and visible recovery by sharing his research around the work in Blackpool by Jobs, Friends and Houses – a service that has the simple and effective idea of providing opportunities for jobs, housing and supportive networks to those leaving prison (DDN, June, page 8).
Michaela Jones added a political and personal context to the concept of recovery, talking about how services and recovery fitted within the current climate of austerity. A further session led by Dr Jamie Irving from the university’s department of criminology and law, introduced the Sheffield Addiction Recovery Research Group (SARRG), which aims to establish Sheffield as a beacon of excellence around recovery in the UK.
Delegates heard how SARRG is peer-led and aims to support recovery-focused groups, and promote recovery-oriented activities and research. Through forging key alliances with local services such as Sheffield Alcohol Support Service, the Amy Winehouse Foundation and the local DACT, the group undertakes research and action to better understand the pathways out of addiction and into recovery.
One of SAARG’s key aims is to help reduce stigma, by supporting partner organisations and helping to provide an evidence base that will inform best recovery practices such as the recovery capital measurement tool but one of its distinct characteristics is the very real partnership between those in recovery, researchers and services. By giving practical examples of some of the recovery-focused events that have been taking place in Sheffield – bike rides, conferences, workshops – he showed how they linked to research around the importance of feeling ‘connected’.
The presence of peer mentors and volunteers as delegates and participants gave meaning to the term ‘visible recovery’, for as well as participating in the day’s programme, they talked to students about their own experiences and felt empowered as ‘community connectors’.
‘The day was a great help in getting the perspective of potential social workers and an insight into what kind of concerns or questions they may have in their future roles, and having the opportunity to dispel certain views or misconceptions about addiction and recovery,’ said one peer mentor.
Student feedback certainly seemed to confirm that they had also gained a lot from the day.
‘Working with people hard to engage made me more aware of the issues of stigma, especially around how government policy drives this, to how a person may hide information due to shame,’ said one, while another commented:
‘Substance misuse can affect anyone for many reasons. Addiction is like a seeping wound and the impacts are significantly detrimental and corroding to the emotional, physical, financial and social wellbeing of the user and their families. I have learned that recovery can be successful with the invaluable support of expert, compassionate, non-judgemental workers dedicated to providing practical and emotional support to individuals in crisis because of addiction.’
E-cigarettes could be the biggest public health intervention of our lifetime, says Dr Chris Ford.
Slightly ambivalent about the conference theme, I went to speak at the Global Forum on Nicotine in Warsaw in June – and had my eyes firmly opened. I got chatting to two people, both of whom were vaping. Eric, now in his late 60s, explained that he was a retired teacher and had smoked since he was 16 years old.
He had tried everything to stop smoking but nothing had succeeded. He had had chronic obstructive pulmonary disease (COPD) for the last few years and one bad night he googled ‘how to stop smoking’ and came across e-cigarettes, known technically as electronic nicotine delivery systems (ENDS). In all his years of trying to stop smoking, nobody had mentioned them to him.
Thinking ‘What have I got to lose?’ he ordered a basic e-cigarette kit and e-liquid and hasn’t smoked a cigarette since. He needed to experiment with different nicotine strengths, temperature control and a variety of flavours before arriving at the right combination – but he hasn’t looked back.
I knew after seeing a film by Aaron Biebert, A Billion Lives that I was on an amazing journey of learning. What struck me was the passion of these consumers and the struggle ahead. I was shown evidence of politicians, doctors and other health professionals speaking falsehoods, not looking at the evidence and taking a dogmatic stance.
The selling of tobacco for smoking is probably the most immoral and insidious form of drug dealing in the world – more than 6m people die every year from it. The companies producing this deadly product are largely based in countries where strict regulation of advertising, selling, and use, is in place – however, about 80 per cent of the world’s smokers live in poorer countries where almost none of these regulations apply. The top three global health problems – ischaemic heart disease, cerebrovascular disease and chronic obstructive airways disease – are directly related to smoking.
E-cigarettes are a highly effective intervention for those who can’t or don’t want to stop using nicotine. The Royal College of Physicians reports that risks using a vaporiser are unlikely to exceed five per cent of those associated with smoked tobacco products (http://bit.ly/244lizV). Yet even in the face of such obvious benefits, we are seeing bans in an increasing number of countries.
There seems to be a ‘war on e-cigarettes’, with vendors being prosecuted and even jailed in countries as diverse as India and Australia. ‘Big pharma’, who have put millions into nicotine replacement therapy, and tobacco companies, who have been left behind in the development, are both supporting the anti-e-cigarette propaganda.
E-cigarettes could possibly be the greatest public health intervention of our lifetime, and everything possible must be done to make them accessible to all. We must ensure that this new, much safer, way of consuming nicotine isn’t just available in the richer countries, leaving the lethal hot smoke mechanisms to be sold in their billions to the poorest in the world.
Scotland has once again recorded its highest ever number of drug-related deaths, at 706 – almost two per day.
The 2015 figures are 15 per cent higher than 2014’s already record figure of 613 (DDN, September 2015, page 4), which itself was up 16 per cent on the previous year. Scottish Drugs Forum CEO David Liddell said the numbers were a ‘national tragedy for Scotland’ and ‘the ultimate indicators’ of the country’s health inequalities.
The total number of deaths now stands at more than double the amount recorded a decade ago, with males accounting for almost 70 per cent. More than 30 per cent of the deaths were in the Greater Glasgow and Clyde NHS area, and 73 per cent were among the over-35s. ‘One or more’ opiates or opioids including heroin/morphine and methadone were implicated in, or potentially contributed to, more than 600 of the deaths (86 per cent) – a higher figure than in any previous year.
While NPS were implicated in or potentially contributed to 74 deaths, only three were thought to have been caused by NPS alone. The figure for benzodiazepines, meanwhile, stood at 191 deaths and cocaine at 93.
‘The deaths are heavily concentrated in our poorest communities and if you look behind the lives of most people who have died you will find a life of disadvantage, often starting with a troubled early life,’ said David Liddell. ‘Rather than focusing on individuals and blaming their “lifestyle” we need to understand how we as a society have failed and continue to fail so many people.’
The deaths were preventable, he stressed, but less than half of Scots with a drug problem were in treatment or care services at any one time. ‘We know that being in effective treatment protects people against dying of an overdose so we need to look at ways to increase the reach and retention rates of services. We also have to look at the quality of those services. These figures represent a national challenge to our image of ourselves and an opportunity to show that we, as a society, care.’
Addaction Scotland said that it was ‘deeply concerned’ by the figures, drawing attention to the ‘uncertainty of current and future funding’ of services and adding that provision of fixed-site needle exchanges – often the entry point for people to engage in treatment – had fallen.
The statistics were ‘a legacy of Scotland’s drug misuse which stretches back decades’, said public health minister Aileen Campbell. ‘We remain committed to tackling the scourge of illegal drugs and the damage they do to our communities, and to support those who are struggling with addiction.’
Drug-related deaths in Scotland in 2015 at www.nrscotland.gov.uk
The government has published the final version of its revised alcohol guidelines, stating that both men should and women should drink no more than 14 units per week.
The draft guidelines were issued at the start of the year (DDN, February, page 4) drawing criticism from parts of the media both of the levels themselves and some of the language used, such as that there was no safe level of drinking.
Although the guidelines took effect in January the Department of Health launched a consultation to see what the public felt about their ‘clarity, expression and usability’, while Public Health England carried out its own research into reactions to the document’s tone and language. The new report states that the intention is to help people understand the potential health risks and make ‘decisions about their consumption in the light of those risks’, but not to ‘prevent those who want to drink alcohol from doing so’. Chief medical officer Sally Davies drew criticism from some newspapers when she told a commons select committee earlier this year that she takes ‘a decision’ each time she ‘reached for a glass of wine’ – ‘Do I want the glass of wine or do I want to raise my own risk of breast cancer?’
The new document states that for those drinking at or above the ‘low risk level advised’, the risk of dying from an alcohol-related condition would be expected to be ‘at least 1 per cent’ over a lifetime, making it comparable to ‘those posed by other everyday activities that people understand are not completely safe yet still undertake’. However, the expert group was also ‘clear that there are a number of serious diseases, including certain cancers, which can occur even when drinking within the weekly guideline’, meaning there is ‘no level of regular drinking that can be considered as completely safe in relation to some cancers’.
Alcohol Concern chief executive Joanna Simons said the guidelines were based on the views of independent doctors studying 20 years’ worth of evidence and represented ‘the maximum amount we can drink each week with little risk to our health’, calling for a mass media campaign to make sure they were widely understood. Industry body the Portman Group, however, said that while the new document ‘provided much-needed clarity’ it was ‘regrettable’ that it still included a reference to there being no safe level of drinking, while the British Beer and Pub Association (BBPA) said that the guidance did not provide consumers with a ‘fully objective picture’ and failed the ‘common sense test’.
A YouGov survey commissioned by the Campaign for Real Ale (CAMRA), meanwhile, found that more than half the public ‘disagree’ with the guidelines, with more than 60 per cent of respondents believing that ‘moderate alcohol consumption could be part of a healthy lifestyle’ and over 50 per cent disagreeing with the decision to make the guidelines the same for men and women. ‘If the public feels, as our figures suggest, that the guidelines are not credible and lack evidence, the danger is they will increasingly just ignore them,’ said CAMRA chair Colin Valentine.
UK chief medical officers’ low risk drinking guidelines, and How to keep health risks from drinking alcohol to a low level: Government response to the public consultation at www.gov.uk
Korsakoff’s syndrome is a severe memory disorder, associated with long-term alcohol misuse. Glenn Barnett shares a new model to support those affected and help them back to community living.
Korsakoff’s syndrome belongs in a spectrum of disorders categorised as alcohol-related brain damage (ARBD). It is a severe memory disorder associated with excessive, long-term alcohol misuse, and results in the loss of specific brain functions due to the lack of vitamin B1 or thiamine. Post-mortem studies suggest that Korsakoff’s occurs in about 2 per cent of the population and 12.5 per cent of dependent drinkers.1
Finding community support for individuals’ specific needs, especially for younger adults, is a real challenge as there is limited specialist provision available across the UK. The Arbennig Unit – part of Queen’s Court Residential Service in Conwy and run by care provider Potens – was set up in 2002 to support younger adults with alcohol-acquired brain injuries within an appropriate and responsive environment.
Our aim was to provide people with Korsakoff’s opportunities for choice and independence – with the focus being on what the individual could do, rather than what they could not do.
What we quickly realised was that to provide the consistent and predictable support required, we would need to develop a bespoke support model.
A trawl of available literature did not give us what we needed, so we developed the Arbennig clinical support model based on the idea that rehabilitation should aim towards a structured, alcohol-free life.2 So abstinence became the cornerstone of our model.
Based on empirical observation, there is a high probability that Korsakoff’s sufferers’ lifestyles have been chaotic, with little, if any, of the social support networks that people would take for granted from friends and family. In response to this, Potens’ support model looks at involvement of professionals, but does not underestimate the importance of family and friends – in circumstances where these relationships have either not been damaged or can be restored.
The health needs of Korsakoff’s sufferers have often been compromised by poor diet. In addition we have come to understand that underlying mental health issues often become more pronounced after a period of abstinence. So we work in collaboration with a wide variety of health professionals to promote improvements and positive outcomes in both physical and mental health.
James had been a resident of Arbennig Unit since July 2015. Having faced some very personal challenges in the past, he had turned to alcohol to help him cope. This resulted in a need for support around his daily activities and the confidence to live independently in the community.
Read the article or download a PDF from DDN Magazine.
Our admission process is supported by FIM FAM. The functional independence measure (FIM) is an 18-item global measure of disability. It is used to measure disability in a wide range of conditions, with each item scored on seven ordinal levels. The functional assessment measure (FAM) specifically addresses cognitive and psychosocial functions, which are often the major limiting factors for outcomes in brain injuries.
We also use the Addenbrookes’ cognitive examination (ACE), which is a brief neuropsychological assessment of cognitive functions and a development on the mini mental state examination (MMSE – the most commonly used test for cognitive function) focusing on memory.
On completion of assessments, James and the staff worked out priorities for helping to achieve his aim of moving out to independent living. Strength-based support plans were developed to complement findings and to ensure that a full, active and worthwhile programme was developed.
A lot of work was completed around abstinence and the benefits – both physically and emotionally – were reinforced in the context of James wanting to move back into the community and keep hold of a tenancy. This was only successful as we adopted a collaborative approach with specialist input from a multi-disciplinary team of professionals, including support charity CAIS.
An important goal for James was to self-medicate as this would enable him to maintain improvements to his mental and physical health. It would also keep to a minimum visits from a care team, which had been making him feel that his flat was a workplace and not his home.
James regained the confidence and skills to manage his community access. This was completed initially on a one-to-one basis with staff to build up confidence, then support was withdrawn, gradually enabling him to access the community independently.
Family connections had broken down because of his chaotic lifestyle, and he had recently separated from his wife. Staff supported James to contact his ex-wife and re-establish a relationship to the point that they would travel together to see their granddaughter. Staff then supported James to contact his son to let him know how hard he was working and how much progress he had made.
A barrier to improving James’ health had been his inability to eat healthily, due to benefit problems and managing some debts that had spiraled out of control. After some work on budgeting skills and support to ensure he was on the right benefits, James was able to afford healthy meals and enjoyed cooking again.
He completely engaged with the team and worked within the support model with more commitment as progress was being made. Over the weeks, staff noticed James’s confidence growing and skills were rediscovered and built on. He faced every challenge presented to him head on and with the Arbennig staff team conquered each and every one.
James moved out into a supported living tenancy in February 2016. We are confident that as a team we have equipped him with the right skills and instilled enough confidence for him to succeed in his endeavours in the future. He also now has the support of his family, whom he now sees on a very regular basis, to help him succeed.
Like Arbennig, any establishment that supports adults with Korsakoff’s through a rehabilitative process needs a thorough understanding to achieve the progress experienced by James: Korsakoff patients are capable of new learning, particularly if they live in a calm and well structured environment and if new information is cued.3
This forms a key part of Potens’ model for staff supporting residents like James, helping him restore and relearn daily living skills by providing meaningful activities.
For further information on Korsakoff’s or this model, contact him on 07914 607745
(1) Alcohol Concern factsheet updated 2001
(2) Jacques A., Anderson K., (2002) A Survey on assessment, management and service provision for people with Korsakoff’s syndrome and other chronic ARBD in Scotland.
Dementia Services Development Centre. Stirling
(3) The Korsakoff syndrome: clinical aspects, psychology and treatment. Alcohol and Alcoholism vol 44 No2 pp 148-154 2009
UNODC executive director Yury Fedotov has condemned the ‘apparent endorsement of extrajudicial killing’ of suspected drug offenders in the Philippines by president Rodrigo Duterte, stating that it ‘does not serve the cause of justice’. Last month more than 300 NGOs signed an open letter asking UN drug control bodies to call for ‘an immediate stop’ to the killings, around 1,900 of which have been recorded since Duterte took office in May. Known as ‘Duterte Harry’ and ‘the punisher’, the president has encouraged vigilante action against drug users and dealers as part of his pledge to ‘eradicate crime’ in the country within six months. ‘This senseless killing cannot be justified as a drug control measure,’ said IDPC executive director Ann Fordham.
CRYPTO CASH
The UK has the second highest number of online drug vendors, at 338, according to a report from the Rand Corporation – less than half the US total of 890 but higher than Germany’s 225. Total drug revenues on ‘cryptomarkets’ in January 2016 were estimated at between $12m and $21m, says the document, suggesting that they remain ‘niche’ marketplaces compared to the estimated $2.3bn monthly offline drug market in Europe alone. The report finds ‘some evidence’, however, that drugs sold on the dark web are providing stock for offline dealers. ‘The evidence on the full impact of cryptomarkets remains inconclusive,’ said co-author Stijn Hoorens, with some arguing that they reduce violence from the drug supply chain but others believing they offer a ‘new, often young, consumer base easy access to drug markets’. Internet-facilitated drugs trade at www.rand.org
HEP HOPE
Access to hepatitis C treatment is improving, according to PHE’s annual figures, with 2015 treatment rates up 40 per cent on the previous year, alongside access to newer drugs. Around 160,000 people in England are living with the virus, says Hepatitis C in the UK: 2016 report. ‘It’s early days, but with more patients being tested and improved treatments, there is genuine hope that we are seeing an impact on the number of deaths from hepatitis C related end-stage liver disease and liver cancer,’ said publication lead Dr Helen Harris. Available at www.gov.uk
CUSTODY CONCERNS
Deaths in prison custody in the 12 months to June 2016 were up 30 per cent on the previous year, at 321, according to figures from the Ministry of Justice. Self-inflicted deaths rose by 28 per cent, self-harm incidents by 27 per cent and assaults on staff by 40 per cent, spelling out the ‘urgent need’ for prison reform according to the Howard League’s director of campaigns, Andrew Neilson. ‘Prisons are not only becoming more dangerous, they are becoming more dangerous more quickly,’ he said. ‘The high levels of violence and deaths should shame us all, and the new secretary of state for justice and her ministers must set out concrete plans to reduce them.’
Safety in custody statistics bulletin at www.gov.uk. See feature, page 10.
DARK DATA
Hospital admissions for drug poisonings have risen by more than 50 per cent in a decade, according to HSCIC figures. There were 14,280 admissions with a primary diagnosis of poisoning by illicit drugs in 2014-15, up 57 per cent on 2004-05, says Statistics on drug misuse: England 2016, with 45 per cent of admissions among 16 to 34-year-olds. There were almost 75,000 admissions with a primary or secondary diagnosis of drug-related mental health and behavioural disorders, up 9 per cent on the previous year. Figures at www.gov.uk
HEADS DOWN
More than 330 retailers have either closed down or stopped selling NPS since the controversial Psychoactive Substances Act came into force in May, the government has announced. Nationally, 24 ‘head shops’ have closed and a further 308 have stopped selling the substances, while 186 people have been arrested. ‘It’s still early days but the police enforcement approach combined with education and support services for users is helping to reduce the damage that misuse of these substances can cause in communities,’ said National Police Chiefs’ Council lead for psychoactive substances, Commander Simon Bray.
HIV WARNING
The decline in new HIV infections in adults has stalled, says a UNAIDS report, with infection rates now rising in some regions. Eastern Europe and central Asia saw a 57 per cent increase in annual new infections between 2010 and 2015, states The prevention gap. Although more than half of these were among people who inject drugs, allocation of resources for prevention are still ‘falling far short’ of what is needed warns the agency. ‘We are sounding the alarm,’ said UNAIDS executive director Michel Sidibé. ‘If there is a resurgence in new HIV infections now, the epidemic will become impossible to control.’ Report at www.unaids.org
DUAL FAILINGS
People who misuse drugs or alcohol and also experience mental health issues are being ‘denied access to proper treatment’, according to a Turning Point report. NHS services are not set up to support multiple needs and people are consequently ‘falling through gaps’ in care, says Dual dilemma: the impact of living with mental health issues combined with drug and alcohol misuse. ‘So often people with overlapping mental health and substance misuse issues are labelled “hard to reach” when it’s the services that are hard to access,’ said Turning Point chief executive Lord Victor Adebowale.
With NPS problems making regular headlines and a general consensus that the system isn’t working, the UK’s prisons are in bad shape. David Gilliver reports on a major project that could help create something new
Earlier this year the government announced ‘the biggest shake up of prisons since the Victorian times’, with plans for six major new ‘reform prisons’ and unprecedented freedoms for their governors with regard to budgets, education, rehabilitation services and more (DDN, June, pages 5 and 7).
That seems a long time ago now. David Cameron was still prime minister, the UK hadn’t voted to leave the EU, and Michael Gove, chief architect of the reforms, was justice secretary rather than a back bencher. Around the same time, however, RSA launched its own major project to look at how prisons could become fit for purpose for the 21st century and ensure ‘lasting social reintegration’ for ex-offenders.
‘At present, when nearly half of those in prison go on to reoffend within a year, we cannot say our criminal justice system is working,’ wrote Gove in his introduction to the project’s scoping paper, The future prison. ‘When prisoners are prepared to risk their lives taking new psychoactive substances as an antidote to boredom, we cannot say our programme of purposeful activities is working.’
By the end of the year the aim is that the project will have come up with a blueprint for a future prison that places the ‘challenge of rehabilitation’ at the centre, and will also have identified what the government needs to do to ensure the right legislative framework for funding, policy and governance is in place to achieve it.
‘We know what’s wrong – what there hasn’t been is “how do you put it right”,’ says chair of the project’s advisory group, and former prison governor, John Podmore. ‘A lot of the debate is still around “you can’t do anything until you reduce the prison population and get more resources”, and we shouldn’t stop fighting for that, but you have to deal with the problems we have now and start developing a strategy for longer-term improvement. This is about the long-term strategic issues that hadn’t really been considered in a holistic way.’
It also aims to address the dislocation between theory and frontline experience and, ultimately, between ‘prisons and the wider community’. To this end, it points out that in most countries prisons are run by the state, or, increasingly, by private companies, while no one has so far explored a ‘third way’ – not for profit prisons run by the communities they are ‘there to serve’. How much of an appetite for that model is there likely to be, though?
‘The key thing is that without a focus on purpose you end up having technical discussions about the public sector, the private sector, or the not for profit sector,’ says project lead Rachel O’Brien, ‘rather than saying “if you’re judged, incentivised, measured on this, it matters less who the provider is”. Things are so difficult at the moment that what you’re getting is this strange mix of top-down control with very little accountability, so it’s kind of the worst of both worlds.’
The project focuses on core areas like leadership, education, employment, health, risk, rehabilitation, devolution and autonomy. The latter is central, explains O’Brien. ‘So rehabilitation first, but how does greater autonomy support that outcome? A key thing would be much more emphasis on being outward looking, as well as partnership, and that has great implications not just for the governor role but the relationship between the prison and criminal justice boards.’
One area where the system has been falling down is that prison officers, doctors, nurses and teaching staff are simply not having prolonged contact with prisoners, or getting to know them in any meaningful way. ‘Everybody reading DDN knows that the essence of successful drug and alcohol treatment is the case worker,’ says Podmore. ‘You can have all the treatment protocols in the world, all the contractual requirements, but at the end of the day success for the client is someone who gets to know them, works with them, gains their trust, addresses their issues and is central to their rehabilitation.’
On that subject, the scoping paper makes the point that while reoffending rates provide ‘seductive hard data’, the concept of rehabilitation is harder to grasp. Is that a barrier that can be easily overcome when it comes to meaningful reform? ‘I think it’s getting there,’ says O’Brien. ‘A lot of our work actually draws on the recovery area, so when somebody says to me, “It is nebulous, we can’t measure it”, I say, “Well, no more so than concepts like recovery capital, and more so than wellbeing”. A lot of the indicators you would use would be very similar. I think the biggest risk is that we chase the holy grail of reoffending.’
It’s partly about talking about community safety, risk and rehabilitation ‘in the same breath’, she explains. ‘Sometimes it felt like these things are put in different corners, as if they’re a choice, when the evidence is that they’re very closely aligned. We’ve had a very risk-averse, security-driven approach rather than a rehabilitative approach.’
‘It’s the whole issue of what you measure and how you measure it,’ adds Podmore. ‘It’s a very difficult thing, and the drug and alcohol field has had this for years with abstinence and recovery. TheNational Offender Management Service’s (NOMS) primary measure of drug use in prisons is mandatory drug testing, and in the last annual report it went down. Therefore there isn’t a drug problem in prison, because the main measure is showing a reduction. We know that’s palpable nonsense, so why are we still doing it?’
The one thing that’s not measured is leadership and management, he argues, and when it comes to the issue of devolution of justice, there’s a compelling case for splitting the prison service up. ‘There’s 85,000 people in prison, and maybe 25 or 30,000 really need prison in the traditional sense. How many of the 85,000 are we afraid of, and how many are we mad at? Locking people up is very easy to do – getting people out so they don’t come back is the tricky bit, and that’s where we’re failing miserably. So I’d have a kind of federal estate for the long-termers and terrorism and so on – a traditional, centralised system – and then a devolved, local, community prison estate which is looking at people who are going in and out. That will be governors with autonomy reporting to local boards, with devolved, integrated justice.’
So how much of an impact is the new government likely to have on the reforms set out in the Queen’s Speech, or is it too early to say? ‘All I can go on is what [justice secretary] Liz Truss has said to the press, which is that she’s going to push ahead and push ahead quickly,’ he says. ‘The message seems to be that, OK, there’s been a change of people but the policies are in place. That’s not to say there aren’t all sorts of imponderables around budgets and finance, and things you can’t predict. But when you look at the levels of violence and assault and illicit drug use, then something’s got to be done, and done quickly.’
On the subject of drugs, when it comes to the much-discussed impact of NPS, the paper argues it’s inextricable from the question of prisoners’ needs. ‘It goes back to culture, really,’ says O’Brien. ‘There’s no part of the project that doesn’t see on a daily basis the acute impact it’s having on everybody, but however much we get the testing right, or drones or security, we’re not going to change the demand side. All the evidence is that a key part of it is when people are doing nothing.’
It also means that much more effort needs to be put into awareness-raising and education, both on the outside and as people come into prison, rather than ‘waiting until it’s too late’, she argues. ‘It’s not just in-custody education, it’s a broader community approach. It’s about demand, and the inability to adapt to new challenges, which again goes back partly to autonomy. You need the system to support you and share the best evidence of what does work, but governors need to have the flexibility to respond to issues that change very rapidly.’
A key failing is that drug and alcohol service providers simply aren’t being involved in the debate, states Podmore. ‘The response is bring in drug dogs, or chop down trees around the perimeter to stop stuff being thrown in. The people in NOMS who’ve been responsible for the strategic approach to drug problems in prison have never recruited, or sought to recruit, the sort of high quality people I’ve come into contact with in the drug and alcohol field. Whoever’s dealing with the NPS issue is going to be looking at it from a security perspective rather than a treatment perspective. Yes, you’ve got to stop NPS coming in, but you’ve also got to stop prisoners wanting them, and it’s hugely complicated – it’s about education, treatment, the wider regime. My plea to the drug and alcohol network out there is be knocking on the door and demanding more involvement in these issues. The people who know best how to deal with these problems are not being included.
‘I know a lot of the organisations reading DDN are being beaten over the head about winning, retaining and competing for contracts. I know the pain of all that. But I’d like the sector to be saying, “we’ve got much more to offer than you’ve realised and you should be reaching out to us much more”. The drug and alcohol sector understands the problems of people leading chaotic lives, and families, and illicit drug use. It’s not about the setting, it’s people with complex needs, and the sector’s been handling that pretty damn well for years.’
FEBRUARY
MARCH
The number of heroin-related deaths in England and Wales has doubled since 2012, from 579 to 1,201, according to the latest ONS figures. 
ly for our anniversary.
Combining her two key interests brought Hannah Feeney to The Alcohol and Drug Service (ADS) as an advanced social work practitioner.
A participant’s view: Highlights from the GPs’ conference
Lee Collingham shares his highlights from the GPs’ conference on managing drug and alcohol problems
Dr Stephen Willott, clinical lead for alcohol and drug misuse at NHS Nottingham City and conference chair, introduced the event’s theme as addressing drug-related deaths, which not only continue to rise in England but are twice the European average.
It was a shock to learn alcohol-related deaths aren’t recorded as DRDs, and Dr Willott appealed for a fresh approach moving forward. The average age of deaths had also risen from 35 in 1995 to 41 in 2016, with evidence proving opiate substitute therapy (OST) was highly effective in helping people get their life back on track. It was also noted that England’s localised agenda is a barrier to not only the widespread provision of naloxone, but also to it being provided to prisoners on release.
Prof David Nutt, former advisor to the ACMD, then talked about how opiate and cocaine-related deaths were at their highest ever, and that there was a need to push for allowing cannabis for medical use in England, as it was in 18 other countries around the world.
He mentioned how alcohol and tobacco, though both legal, were responsible for the majority of deaths, with 80,000 a year dying from tobacco related illnesses and 25,000 from alcohol – compared to opiates being responsible for around 2,000 deaths a year. He also thought the recovery agenda had been the main cause for the rise in drug-related deaths. Next, Dr Cathy Stannard, a consultant in pain management, questioned the use of opiate-based painkillers as the most effective solution for the long-term management of pain. She talked about the importance of getting it right or facing a public health disaster and mentioned that pain was strongly affected by mood, with those affected by anxiety and stress responding less well to the medication.
The morning finished with a choice of sessions on subjects ranging from the future of drug treatment to end of life care. Posters on display included ’seasonal influenza immunisation’, ‘opiate analgesic dependence’ and ‘ the difference between buprenorphine prescribing and methadone for injecting opiate users’. This year’s poster award went to Kathryn Chadwick and Zoe Black from Sheffield Social Care Trust, on leg ulcer management for the problematic user.
Interesting presentations in the afternoon included Professor Ken Wilson from the Cheshire and Wirral Partnership Trust around ‘brains, booze and hospitals’. He explained how brain injury is the biggest concern for problematic drinkers, causing the frontal lobe to shut down and leading to problems with memory.
For me, the highlight of the day was the news from Professor Graham Foster, professor of
at Queen Mary University Hospital London, that there is a pot of £70m available for the treatment of hepatitis C. He explained that, from January, there’ll no longer be the need for combination therapy, with the release of a new licensed drug that will not only allow patients to take just one pill a day, but actually cure hep C.
Lee Collingham is a volunteer user involvement worker and advocate.