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The Fear Inside

By
DDN
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A study of people who used heroin in prison gives vital clues on reaching out to this significant and vulnerable cohort. Lana Durjava shares her findings. 
Lana Durjava has a background in forensic psychology and works at HMP Pentonville

Read the full article here in May 2018 DDN Magazine

Recent reports on drug use in prison have highlighted the increased use of new psychoactive substances; however heroin is still a significant concern and tends to be used for longer periods than other drugs such as cocaine and amphetamine. Additionally, prisoners often present with dual diagnosis and polysubstance addiction, which amplify problems associated with their wellbeing and raise concerns for staff and prison security.

Heroin use carries multiple health, legal and social implications, such as increased risk of blood-borne viruses, infections, injecting-related complications, poor health, risk of overdose, social isolation and engagement in criminal activities. In a prison setting it carries additional challenges, with individuals often engaging in riskier behaviour due to contextual factors such as unsafe environment, limited availability of harm reduction services and a climate in which they have to hide their drug use to avoid punishment for failing mandatory drug testing.

Incarceration has an overwhelming impact on everyday life. It brings multiple losses, some of which are irretrievable – loss of liberty, relationships, opportunities, time, and control over one’s own life – and heroin use is one of the means of coping with these losses. The prison environment, with its climate of hostility, suspicion and unpredictability, means regular exposure to feelings of isolation and threats of violence.

Incarceration has an overwhelming impact on everyday life.

The prison population in England and Wales has doubled in the last 25 years due to increases in custodial sentencing and sentence lengths. This has resulted in a population comprising many more prisoners with mental health problems, substance use disorders and histories of self-harm and suicide attempts.

‘Heroin made me bulletproof’

A qualitative study was conducted with former prisoners who had experienced heroin addiction while inside. The aim was to gain better understanding of psychological and social aspects of the phenomenon, and to explore how to support people in this situation to achieve recovery most effectively.

Compulsive heroin use is generally the result of a number contributing factors; however all participants in the study said that one of the main purposes of their heroin use was to regulate overwhelming emotions. Heroin use was an attempt at self-regulation and management of difficult emotional states, with the ever-present theme being an attempt to disconnect from reality and achieve a state of numbness.

‘It kept my emotions stable. Constantly when I was on gear, I’d feel composed, I don’t get angry, I don’t get upset, I just deal with stuff, I feel pretty much invincible when I am on it…

‘It’s not always easy sitting in prison and thinking who’s my missus sleeping with now, who’s trying to play dad to my daughter, what does my daughter think of me, who’s driving my car… Cos you know you lose everything every time you go to prison. You don’t get a chance to sort your stuff out, you just lose everything.’   (Ben)

The conceptualisation of heroin use as an emotion regulator and coping mechanism, which people resort to because they have failed to develop adaptive responses to stress and negative emotional states, is not something new. It matches the self-medication hypothesis, which argues that a person who is more sensitive to emotional distress and who has a lower ability to self-regulate is at greater risk of progressing from experimental to dependent drug use as a means to cope. Indeed, the results of this study showed that participants used heroin to self-medicate.

Ability to self-soothe in times of distress is essential for healthy emotional functioning and to prevent the person from becoming emotionally overwhelmed. Being unable to do this is commonly connected with the problem of internalisation – not learning how to regulate emotions from a primary caregiver at an early stage, which would have allowed someone to practise effective self-care. People who are addicted to heroin have often been described as having disturbed global ego function, turning to the drug to self-regulate.

Generally speaking, a person’s choice of a particular drug is not accidental and different drugs are chosen to cope with different forms of emotional distress. With its characteristic ability to kill physical and emotional pain, heroin appears to be a magic drug, ideal for coping with the pain and loss associated with imprisonment.

‘It helped me deal with emotions I guess, I mean it helped me suppress them. It made me feel numb and that was what I needed at the time cos life was overwhelming otherwise. I felt depressed and all, but then I took heroin and did not feel anything at all. I could forget the mess I was in, I mean I lost my kids and all and I didn’t really care or feel anything about it when I was on heroin.’ (Mark)

‘It’s my obsession’

This study also aimed to explored participants’ relationship with heroin – a relationship that was characterised by obsession and ambivalence and was prioritised above individuals’ interpersonal relationships. Participants manifested a strong attachment to the drug, which was experienced as a secure base and safe haven. They perceived it as an attachment figure, gravitated towards it in times of distress and used it as a source of comfort and safety.

‘…I felt I had no control or power over it and it was running me – my missus once said to me that she had a dream I was having an affair and that affair was with drugs, and that was true. I did not understand that back then but it makes sense today.’ (Simon)

This tallies with previous research on attachment and heroin addiction, which argued that due to its neuro-biological properties, the drug was used to compensate for the absence of satisfying relationships. It was previously shown that heroin is chosen to serve specific emotional and social needs; so one possibility is that people who experience problems in forming close and trusting relationships gravitate towards heroin use. Later on, their heroin use can complicate interpersonal relations and so limit their potential for forming trusting relationships.

The findings suggested that heroin use has a significant impact on object relations – the need for contact with others. Relationships were made based on drugs, disproportionate power dynamics emerged between heroin users and suppliers, a climate of mistrust was created, and the participants tended to isolate themselves and maintain distance from any meaningful interpersonal contact. Prisoners with drug problems often oscillated between feelings of empowerment and disempowerment, based on their level of addiction and drug accessibility.

‘[With the other inmates] it was very basic, there was no friendship or relationship there really, it was just focused on getting and using the drugs, that was as far as it went. You were just talking about what’s happening and who has the money and who has the gear and who will score and where to use it and stuff like that.’ (Adam)

The disparity involved in the power dynamics between heroin users and dealers became particularly evident during withdrawal, when biopsychosocial discomfort induced fear and isolation. Sizeable debts could also build up among prisoners, creating additional complications – often compounded by prisoners’ mental health problems. Certainly the participants in this study reported mistrust of both the authorities and other prisoners, where heroin had the dual purpose of being both ‘a blessing and a curse’.

‘You’ve gotta deal with people who you’re buying it off and they obviously use it as an element of power… Then the obvious violence that goes with it as well, cos things don’t always run smoothly… People rob other people, nick their stuff, people don’t pay people, so it’s kinda like, yeah, looking back I don’t know how I had the energy to do it.’ (Ben)

The study aimed to contribute to the existing knowledge about the psychological and social experience of heroin addiction in prison – an experience that could be summarised as a life of lonely compulsion in a mundane and ruthless environment. While the findings cannot be generalised to the wider prison population, they nevertheless offer a fair indication of the everyday reality of people who experience heroin addiction during incarceration.

British prisons are in a state of perpetual crisis, with endemic drug use, bullying and violence being fundamental parts of daily reality. The prison system currently appears to be mostly about containment and risk management and is characterised by limited resources, staff shortages, lack of meaningful activities and support services that are inadequate in responding to prisoners’ needs.

It is hoped that, with time, an holistic approach will be more consistently adopted that addresses the multiple health, social and psychological needs of the prison population, despite all the contextual pressures and factors that hinder recovery from compulsive drug use and offending. Furthermore, it is hoped that the prison service will employ less punitive strategies in the detection and punishment of illicit drug users – and that custodial sentencing will incarcerate violent offenders, rather than those who are vulnerable, with complex needs, and deemed ‘petty’ criminals.

 

Recovering Through Nature

By
DDN
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Phoenix Futures share the growth of their exciting Purple Camel Project.

Read the full article in May 2018 DDN Magazine

The guiding principles are oriented around growing as much of our own produce as possible

Phoenix Futures we have been working with people with substance misuse issues for over 47 years, offering specialist services across community, prison and residential settings. Our fundamental belief is that every person who is dependent on drugs and alcohol has the potential to rebuild their life.

It is only by focusing on an individual’s wider recovery, however, that lives can be rebuilt and individuals can stay on track. So in addition to our core recovery services we also offer a number of personal development programmes that help service users gain skills, confidence, motivation, employment and reintegrate into their communities. The longest running and most successful of these programmes is Recovery through Nature (RtN).

‘Purple Camels’ is a holistic approach to developing sustainable recovery. The guiding principles are oriented around growing as much of our own produce as possible in our gardens and allotments, to be used in our kitchens. We source local produce, if and where cheaper (including environmentally preferable purchasing), and have developed a culture of recycling and being aware of the way we use and save water and the energy for heating and lighting. We look at the use of renewable resources across the spectrum and are aware of pollution.

We called the project ‘Purple Camels’ because camels are able to adapt and survive in challenging environments, and purple is Phoenix Futures’ colour. The programme is part of the organisation’s Recovery through Nature programme – a highly effective therapeutic intervention that engages teams of service users recovering from substance addiction in practical conservation projects, and uses that experience to support their rehabilitation and recovery.

There are two fundamental guiding principles to ‘Purple Camels’. Firstly, the idea must be incorporated into the therapeutic community (TC) process as part of a ‘right living’ ethos, and be service user-led and orientated. It links into the proven, underpinned benefits of eco-therapy, horticultural therapy and our own Recovery through Nature programme and becomes integral to our TC process. Secondly, as an organisation, we are making a conscious effort to reduce our costs in such straitened times, so the intention is that it will save money in the long term and make our approach unique.

Working in partnership with Lane End Farm Trust (LEFT) at Phoenix Futures’ Sheffield residential service brings together our expertise to develop the desired sustainable concept. Our aim is to collaborate on a sustainable food cycle programme by developing the large, walled, Victorian garden at its Storth Oaks site into a kitchen garden of raised growing beds. The intention is to create a vegetable and fruit growing garden that can supply seasonal organic produce for the kitchen at the residential service, and any surplus produce can be sold into the local food community working with the Lane End Farm Trust (LEFT) existing customer network. In addition to the raised beds, we intend to have a poly tunnel on site to extend the growing season and provide better growing conditions to produce a wider variety of produce for more months of the year.

The victorian garden at Phoenix Storth Oaks site

Service users from both PF and LEFT will have access to working in the garden across all stages of the growing season, and trained staff with horticulture and thera­peu­tic horticulture experience will provide guidance and training for service users. As the project develops, we intend to provide basic qualifications for service users who wish to engage in that part of the programme. Other users may simply benefit from the chance to be involved in a real work environment and gain empower­ment through the therapeutic benefits of horticulture.

The benefit to the wider community, including local residents, volunteers and support workers, is access to high quality ethically produced food at fair prices that is grown and harvested by our service users. This ultimately improves community cohesion through inclusive outreach across the local area.  

Work began to transform the gardens with raised beds on 16 April. It was discovered that the quality of the soil was excellent and the decision was made to move the programme forward rapidly, so service users planted the first crop of potatoes on 24 April – potatoes being chosen as the first crop so the soil may be thoroughly worked over when they are harvested.

www.phoenix-futures.org.uk/purple-camel

DDN May 2018

By
DDN
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‘It’s a mismatch between prison and
complex needs’

We need a new dialogue and thinking, says police and crime commissioner David Jamieson, talking about his recommendations to divert people away from the courts and into treatment (page 8). ‘Criminalisation of drugs will be looked back on with as much disgust as criminalisation of homosexuality,’ adds former detective sergeant Neil Woods, speaking at the same NNEF event.

We have long heard the call to stop wasting money on the drug war from healthcare workers – those at the sharp end of human suffering and misery. But when the pieces of the jigsaw join with those from the criminal justice, policy and treatment sectors, there is surely enough to complete the picture that health must come first – and that it is politicians’ duty to take account of the evidence.

The prison population has expanded rapidly and institutions are bursting at the seams. Lana Durjava’s study of people who used heroin in prison (page 6) shines a light on the mismatch between incarceration and complex needs. The motivation is to self-medicate, to shut down responses and deaden the pain – summarised as ‘a life of lonely compulsion in a mundane and ruthless environment’. If they are lucky enough to receive treatment, they are still vulnerable to leaving prison without the support, the right medication, or even a take-home naloxone kit to keep them alive.

So where does this ineffectual policy leave us? In the meantime, our prisoner is trying to block out each day more than the last.

Read the latest issue as a virtual magazine or download the PDF.

Claire Brown, editor 

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

Alcohol treatment at crisis point, says report

By
DDN
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A cycle of disinvestment coupled with reduced capacity and staffing levels means that the alcohol treatment sector in England is in crisis, according to a new report. The situation is putting ‘hundreds of thousands of people at risk’, says The hardest hit: addressing the crisis in alcohol treatment services, which is published by the charity formed from the merger of Alcohol Concern and Alcohol Research UK.

Rapid re-tendering cycles, lack of political support, loss of qualified staff and funding cuts are having a severe impact, the document warns, with the end of ring-fenced public health funding in 2020 likely to worsen the situation further and pose ‘additional risk to the areas of highest need’. It is estimated that there are almost 600,000 people in England who are alcohol-dependent and in need of specialist treatment.

The report highlights a real danger of alcohol services being seen as non essential.

The report is based on the views of more than 150 respondents including service providers, GPs, nurses and others, who reported funding cuts of between 10 and 58 per cent. Almost 90 per cent felt that resources in their area were insufficient, with nearly 60 per cent saying the situation had worsened in the last three years. Community detox and residential rehab were felt to be particularly at risk, and more than 60 per cent of respondents stated that appropriate care for people with both an alcohol and mental health problem was unavailable in their area.

In an era of consistently squeezed public finances there is a ‘real danger’ that alcohol services could come to be viewed as non-essential, the report warns, which risks both ‘creating a false economy’ and damaging ‘the lives of countless individuals, families and communities’.

The report, which was published on the day minimum pricing was implemented in Scotland, calls on the government to develop and implement a national alcohol strategy, and ‘urgently plug the gap’ in treatment funding. It also calls for a national review of staffing to identify the levels of expertise needed at each point in the system. While the use of peer mentors was widely welcomed, there was concern that many were being employed ‘without sufficient training and for economic reasons rather than to improve provision’, the report adds.

Dr Richard Piper: Government must develop a national alcohol strategy.

‘Around 595,000 people in the UK are dependent on alcohol,’ said the charity’s CEO, Dr Richard Piper. ‘It’s clear that the government must develop a national alcohol strategy to address the harm they and their families face, and include treatment at its heart to reduce the suffering of the four in every five who currently do not access the services they need. This report shows very clearly what action is needed and we urge policy makers, practitioners and service providers to join together to implement these recommendations to help the hundreds of thousands of people who are in desperate need of support.’

Meanwhile, people on higher incomes are more likely to drink regularly, according to statistics from two new reports. Almost 80 per cent of those earning £40,000 or above reported drinking alcohol in the previous week, compared to 58 per cent of all adults. For people earning under £10,000 per year the figure was 47 per cent. The total percentage of adults who reported having consumed alcohol in the previous week was largely unchanged from the previous year but almost 10 per cent lower than a decade ago, say Adult drinking habits in Great Britain: 2017 and Statistics on alcohol, England 2018.

Royal College of Physicians comes out for decriminalisation

By
DDN
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In what is being seen as a landmark move, the Royal College of Physicians (RCP) has issued a statement backing drug decriminalisation. After a meeting of its council the RCP has signalled its formal support for the Royal Society of Public Health’s Taking a new line on drugs report from two years ago (DDN, July/August 2016, page 4) and the ‘evidence-based recommendations’ it advocates.

Among the recommendations were for the personal possession of all illegal drugs to be decriminalised, and for a transfer of responsibility for drug policy from the Home Office to the Department of Health. ‘The RCP strongly supports the view that drug addiction must be considered a health issue first and foremost’ the statement reads, adding that the organisation had been ‘alarmed’ by the rising rates of drug-related deaths seen in recent years (DDN, September 2017, page 4), as well as increasing numbers of drug poisonings and hospital admissions with a primary or secondary diagnosis of drug-related mental and behavioural disorders (DDN, March, page 5).

The statistics ‘demonstrate a clear need for physical, psychological and social support and care for people addicted to drugs’, says RCP, adding that diminishing resources in the field were ‘of critical concern’. The royal college ‘seeks urgent action to prioritise and increase investment in public health services and workforce in order to meet rising population need’ it states. The RCP, which has a membership almost 35,000, is the most high profile medical body so far to back drug law reform.

Shirley Cramer: This shows how far the debate has moved forward.

‘We are delighted that the Royal College of Physicians has voted to endorse our position on drug policy reform,’ said RSPH chief executive Shirley Cramer. ‘That such an influential medical body has put its weight behind a public health and harm reduction approach to drugs, including the decriminalisation of personal possession and use, goes to show just how far the debate on this issue has moved forward – and how far behind the curve many politicians in the UK still are.’

There was now a growing consensus that ‘criminal justice approaches’ to drug harm had failed, she added. ‘It is critical that the health community speaks with a united voice on this issue in order to drive meaningful policy change, and so we hope other medical colleges will soon follow the lead of the RCP.’

RCP statement at www.rcplondon.ac.uk/news/rcp-supports-royal-society-public-health-report-drug-policy

More support for children of alcohol-dependent parents

By
DDN
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The government has pledged to increase support for children living with alcohol-dependent parents. The plans include faster identification of at-risk children – including those having to undertake ‘inappropriate care responsibilities’ – and are backed by £6m funding from the Department of Health and Social Care (DHSC) and Department for Work and Pensions (DWP).

Among other measures announced are increased outreach provision to help improve take-up of alcohol treatment, faster access to mental health and other support services for children of dependent drinkers, and early intervention programmes to reduce the number of children taken into care. Priority for the latter will be given to areas where more young people are affected, says the government, with progress monitored by Public Health England (PHE).

The funding package also includes £1m for ‘national capacity building’ by NGOs, and a £4.5m ‘innovation fund’ for local authorities to improve outcomes for the children affected. Public health minister Steve Brine has also been named as a dedicated minister with specific responsibility for the issue.

It’s estimated that there are around 200,000 children living with alcohol-dependent parents in England alone, while in 2017 the NSPCC revealed that its helpline had received 25,000 contacts raising concerns around substance use near children in the previous three years – an average of nearly one per hour (DDN, March 2017, page 5). The agency also made more than 20,000 referrals to external agencies such as children’s services and the police over the same period.

‘All children deserve to feel safe – and it is a cruel reality that those growing up with alcoholic parents are robbed of this basic need,’ said Brine. ‘Exposure to their parent’s harmful drinking leaves children vulnerable to a host of problems both in childhood and later in life – and it is right that we put a stop to it once and for all. I look forward to working with local authorities and charities to strengthen the services that make a real difference to young people and their families.’

‘The consequences of alcohol abuse are devastating for those in the grip of an addiction – but for too long, the children of alcoholic parents have been the silent victims,’ added health and social care secretary Jeremy Hunt. ‘This is not right, nor fair. These measures will ensure thousands of children affected by their parent’s alcohol dependency have access to the support they need and deserve.’

‘Today’s announcement, committing £6 million to support children of alcohol dependent parents, is both welcome and vital,’ commented Dr Richard Piper, chief executive of the charity formed by the merger of Alcohol Concern and Alcohol Research UK. ‘This very positive initiative would have even greater impact in the context of an over-arching national alcohol strategy.

‘Such a strategy would embed this initiative within a comprehensive approach: preventing people from sliding into harmful drinking, tackling the causes of problem drinking and helping those affected by dependency to beat their addiction and live their lives again. If linked to a comprehensive alcohol strategy, this initiative would be a turning point, improving the lives of thousands of children and adults in need of support.’

Universities and colleges ‘failing to protect’ students from drug harms

By
DDN
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Educational institutions are failing to protect their students from the ‘potential harms of drugs’, according to a report from the National Union of Students (NUS) and Release. The document is based on a review of the institutional support available at more than 150 universities and colleges, as well as a survey of over 2,800 UK students.

Forty per cent of students said they would not feel comfortable disclosing information about their drug use because of fear of punishment – this acts as a barrier to getting appropriate support, the document states. In the 2016-17 academic year there were more than 500 incidents of students being reported to the police for possession of drugs, with 21 people permanently excluded for possession for personal use. ‘Policy responses that focus solely on disciplining students fail to recognise the complex reasons that lead people to use drugs,’ says the report, and risk adding to the marginalisation of certain groups.

Almost 60 per cent of respondents reported either using drugs currently or having done so in the past, with most saying they do so only occasionally. More than 30 per cent of those who have used drugs said they did so to deal with stress, and more than 20 per cent to self-medicate for mental health issues.

Institutions should make sure that a range of appropriate support – including harm reduction advice – is made available to students, the document stresses, and students should not be ‘disciplined for drug-related behaviour that does not constitute a criminal offence’. Any institutions that wish to apply a more punitive approach should do so through a ‘formal warning’ system, it adds, and students should not be ‘reported to the police or permanently excluded from their studies for simply possessing a drug’.

‘We are deeply concerned about the punitive approach taken towards student drug use in some institutions and the appropriateness of support that is offered around drugs in most cases,’ said policy researcher at Release, Zoe Carre.

Zoe Carre: Deeply concerned about punitive approach

‘The fact that at least 21 students were permanently excluded from their studies for simply possessing a drug, and one in four students caught with drugs for their own personal use were reported to the police, is archaic and harmful – this type of approach prevents people from seeking support if they need it. The reality is that students take drugs and educational institutions must have policies and procedures in place that protect the student population. This can only be done by providing vital harm reduction information, so that they can make more informed choices and be as safe as possible.’

NUS shares the research here

Download the report Taking the hit: student drug use and how institutions respond here

‘All or nothing’ – are 12-steps right for everyone?

By
DDN
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The 12-step fellowships are a life-saver for some – but for others, the concept of total surrender can do more harm than good. Alex Boyt makes the case from his own experience.

I was first arrested for drugs in 1973, did my first three rehabs by 1987, and having been told early on I had a progressive and terminal disease that needed a permanent 12-step solution, I did about 3,000 Narcotics Anonymous meetings over the next 28 years. Though twice in my life it had played a central part in pulling me out of extreme injecting drug use, I was never convinced by the requirement to surrender and admit powerlessness.

photo by Nigel Brunsdon

The notion that I would always be an addict because I once had a problem felt very limiting to me. The relentless echo chamber of the fellowship however had me trapped, afraid that to question the need for a 12-step remedy would lead me back to jails, institutions and death.

The continuous references to God and prayer had always been an irritant, but what really began to grate on me was the requirement to swallow and regurgitate the ‘fact’ of suffering from an endless incurable illness that meant eternal vigilance. The sense of belonging was undeniably valuable, but it was conditional on acknow­ledging the 12-step programme as a God-given gift for which one must be grateful.

Within the 12-step environment you cannot have conversations about healthy ways to disengage, since leaving is the first step to relapse. Stories of people doing well without NA meetings were rarely mentioned and then dismissed as rare excep­tions, or otherwise as people who had never really had ‘the problem’ in the first place.

‘I began to discover that endless
disease was not seen by all as
the optimum route to wellbeing.’

When I started to work in the addictions field in 2005 however, I began to experience a wider world of addiction and recovery and to discover that endless disease was not seen by all as the optimum route to wellbeing. I came across research papers and data, witnessed the tensions between harm reductionists and abstentionists, and began to build a picture of reality that made more sense to me.

I found support groups for people trying to leave 12-step fellowships, heard of counsellors who specialised in helping de-programme people from the fellowship mindset and I caught up with people I knew from Narcotics Anonymous in the ’80s and ’90s – many of whom had long given up meetings and were doing fine, abstinent or not.

I embarked on the process of disengaging myself, though the years of exposure to fellowship mantras had me wondering if, somehow, I was being deceived by a mind I had been taught I could not trust. When I met fellowship people, there was often a look of concern in their eyes and I found myself being defensive and feeling a little uneasy… I thank my therapist for supporting me through the transition.

Nonetheless, as I continued my journey it became clearer that the 12-step model, sold to me as the one true route out of addiction – though it suited some – did not hold up so well to closer inspection. Although you can, of course, find numbers and evidence to support any stance, I found the large American NESARC study that showed most people with a drink problem recovered without any intervention (12-step or otherwise) and many without abstinence.

I started to look at success rates which could be measured in different ways; many of the headline numbers put AA success rates at around 10 per cent, though better for those that stuck around longer.

‘The 12-step environment is no magic
bullet… recovery in its various
forms takes place elsewhere.’

The peer support, collective direction and structure of 12-step fellowships are a perfect combination for some. But it could be argued that for the population as a whole, 12-step intervention is little better than doing nothing. What is clear is the 12-step environment is no magic bullet and that significant amounts – if not more – recovery in its various forms takes place elsewhere.

Another piece of research that resonated with my experience was the Miller et al study, showing that when you want to find the main predictor of relapse, belief in the disease model is a significant factor. The ‘all or nothing’ measure of success and failure within the total abstinence framework is a two-edged sword. If you convince someone that any use is a calamity and that any attempt at self-control is futile, it can be a dangerous combination. A beer on a sunny afternoon will wipe all the clean time and status within the support group and bring the shame of failure bearing down, so there is very little more to be lost in returning to problematic use.

Now someone who has never come across the disease concept would very likely, well, just have a beer. The powerlessness message may help those who are totally abstinent, but is more likely to harm those who are not.

If we throw into the mix people who have been persuaded off their psychiatric meds by well-meaning amateurs in the name of being ‘clean’, then risks begin to increase. If you function well and are happy with total abstinence of the purest kind, then great, and hats off to you. But it is rarely right to tell someone with a whole personalised set of trauma and resources to follow your path.

Those on methadone may not be ‘clean’ in some people’s eyes, but it is the number one evidenced intervention in reducing drug-related deaths, which are at an all-time high. Those on medications are often being kept safe by them, but all too often are subject to stigma within the 12-step environment, and pressure mounts to stop taking them.

‘Telling someone with problematic drug
use to get clean can be like telling
a homeless beggar to get a job.’

Some say that addiction is an equal opportunities affliction, but that is demon­strably false. The data shows that deprived communities have the highest rates of addiction, and the privileged have better rates of recovery. Too often I hear celebrities extolling the virtues of 12-step recovery – and that is all very well If you are successful, with significant internal and external resources. But telling someone with problematic drug use to get clean can be like telling a homeless beggar to get a job.

Last time I wrote an article discussing the merits of the 12-step environment the letters pages were hot for months, attacking and defending me, and I was reluctant to take the flak again. Nonetheless I write this for two reasons.

Firstly, I say to those for whom it works well: be gentle with others. The chances are that they may well find a way to recover without the fellowships, so go easy on the ‘all or nothing’ rhetoric. You may mean well, but it does not help everyone.

Secondly, for those who do not feel the fellowship environment is right for them, either initially or after some time, there is nothing wrong with exploring other options. If my son had a problem, the 12-step solution would not be my first choice.

I was thinking about those I know with drug histories who have died too early – either accidentally or who have killed themselves – and you know what? It’s the ones who have been told they are powerless and have failed without abstinence that make up the majority who have gone. I don’t hold this up as evidence; just an observation from my experience.

The six 12-step rehabs I went through were sometimes a godsend and at other times served only to reinforce my sense of failure. The fellowships have been a great resource for me at critical times, and the weird cult-like structures have been useful to turn things round. But the premise of endless disease has not felt healthy for me in the long run.

I know many people who consider the 12-step model a life saver for which they are very grateful. I know others who used it for a while and then happily moved on. But I also know too many who have felt diminished by their experience.

I will end with a word of caution. A support structure is a big deal; if you leave one, don’t do it without putting something else in place. And if you choose a beer on a sunny afternoon after a period of 12-step abstinence, the sense of failure is more likely to do the damage than the thing you consume.

Whatever you choose, I wish you well.

Alex Boyt has worked until recently as a service user coordinator in London and is still actively involved in drug policy debate

International study supports low UK alcohol guidelines

By
DDN
-

The UK’s comparatively low threshold for recommended safe drinking levels has been supported by a major new study.

As international low-risk drinking guidelines vary substantially, Risk thresholds for alcohol consumption – published in the Lancet – studied almost 600,000 people without previous cardiovascular disease across 19 countries, to attempt to define ‘thresholds associated with lowest risk for all-cause mortality and cardiovascular disease’.

The ‘minimum mortality risk’ was found to be around, or below, 100g of alcohol per week – or 12.5 units, as one UK unit is defined as 8g. Drinking above that level was found to increase the risk of heart failure, stroke, fatal hypertensive disease and fatal aortic aneurysm.

In the US, an upper limit of almost 200g per week is recommended for men – roughly twice the UK level – while guidelines in Italy, Portugal and Spain are almost 50 per higher still. Many national guidelines, however, recognise that drinkers are willing to accept some level of risk.

‘These data support limits for alcohol consumption that are lower than those recommended in most current guidelines,’ the study states. ‘Exploratory analyses suggested that drinkers of beer or spirits, as well as binge drinkers, had the highest risk for all-cause mortality.’

People drinking at the current UK guideline levels – which were revised just over two years ago to 14 units per week for both men and women (DDN, February 2016, page 4) – would face little increased risk. However, drinking above two units a day means the ‘death rates steadily climb’, according to Winton Professor for the Public Understanding of Risk at Cambridge University, Prof David Spiegelhalter. ‘This is a massive and very impressive study,’ he said. ‘The paper estimates a 40-year-old drinking four units a day above the guidelines has roughly two years lower life expectancy, which is around a twentieth of their remaining life. This works out at about an hour per day. So it’s as if each unit above guidelines is taking, on average, about 15 minutes of life, about the same as a cigarette.’

The widely reported study – which acknowledges that ‘self-reported alcohol consumption data are prone to bias’ – has led to headlines such as ‘Glass of wine a day could shave years off your life’ (Independent) and ‘Deadly cost of that extra drink’ (Mail).

‘This research adds to a growing number of studies supporting current UK guidelines for lower risk drinking,’ said Dr Tony Rao of the Institute of Psychiatry, Psychology and Neuroscience at King’s College, London. ‘It also highlights the need to reduce alcohol-related harm in baby boomers, an age group currently at highest risk of rising alcohol misuse.’

Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599,912 current drinkers in 83 prospective studies at www.thelancet.com

PCCs lead the call for change

By
DDN
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It used to be that senior police, like politicians, would only speak out on drug policy from the safety of retire­ment. These days, however, serving PCCs are taking an increasingly leading role in the call for change, as DDN reports.

A few short years ago most people would probably not have predicted that it would soon be the police who – as Release recently said – were ‘leading the way in the debate for drug policy reform’ (DDN, March, page 5). But that’s exactly what seems to be happening.

The charity was responding to the latest call by a police and crime commissioner (PCC) to implement radical measures to cut drug-related death and crime rates – in this case West Midlands PCC David Jamieson and his plans for prescribed heroin, diverting people from the courts into treatment, and ‘considering the benefits’ of consumption rooms.

‘Despite the good work being done by many, collectively our approach to drugs is failing,’ said Jamieson, whose region sees half of all burglary, robberies and shoplifting committed by people with drug problems, at huge cost to the public purse. He intends to have as many of his plans as possible in place before he leaves office in 2020, plans that also include training and equipping the police with naloxone and implementing safety-testing of drugs in the region’s night-time economy.

His call had the backing of the PCCs’ membership body, the Association of Police and Crime Commissioners (APPC), and follows similar announcements from North Wales PCC Arfon Jones – whose annual report included plans for a consumption room pilot and to look at decriminalisation as most drug use ‘is recreational and causes no harm’ (DDN, October 2017, page 5) – and Derbyshire PCC Alan Charles. The first PCC to put his head above the parapet, however, was Durham’s Ron Hogg.

Arfon Jones: ‘There’s no difference between addiction to lawful or unlawful substances – what makes a criminal is the law.’

It’s now over a year since Hogg announced that he’d asked local public health departments to look at options for introducing heroin-assisted treatment to allow people to ‘stabilise their addiction in a controlled environment’ (DDN, March 2017, page 4), although he’d been a vocal critic of government drug policy as far back as 2014.

Initiatives such as consumption rooms, heroin-assisted treatment and drug testing in nightclubs are no longer just backed by campaigning organisations like Release and Transform, but by august bodies such as the Royal Society for Public Health (DDN, March, page 4 and July/August 2017, page 4) who see them as part of a logical move towards a more evidence-based policy. But why is it that increasing numbers of PCCs are calling for radical reform? The obvious answer is that it’s they and their officers who are witnessing the failure of current approaches on the frontline, so it’s little surprise that they might want to try something new.

This mood was very much in evidence at last month’s meeting of the Drugs, Alcohol and Justice Cross-Party Parliamentary Group, which heard from Hogg, Jamieson and Jones as well as Derbyshire PCC Hardyal Dhindsa – who also serves as the APPC’s alcohol and drugs lead – in a roundtable discussion on ‘advancing an evidence-based approach to drug policy’.

Ron Hogg: ‘We cannot continue with prohibition, we’re just putting millions of pounds into the pockets of organised crime.’

‘It’s time for us all to show some leadership on this – it’s about us doing the right thing,’ Hogg told the group. ‘We cannot continue with prohibition, we’re just putting millions of pounds into the pockets of organised crime. It’s a crazy waste of money – policy has failed.’

In his 30 years as a drugs officer he’d seen only worsening problems, he said, and the background of constantly shrinking budgets meant that it was ever-more vital that money was spent as wisely as possible. While it was his call for heroin-assisted treatment that had unsurprisingly made the headlines, this was only ‘one small aspect’ of what needed to be done, he said – and one that would also help to cut out a ‘pot of money’ going to organised crime. ‘We must not criminalise addicts, but those who deal,’ he told the meeting. ‘We need to treat drug users in a different way to how we do at the moment.’

His Towards a safer drug policy document from July last year advocates a fundamental review of the Misuse of Drugs Act, and of UK drug policy in general. The Act’s effectiveness has never been formally evaluated, it argues, ‘despite overwhelming indications of failure’, while the current legal framework is both confusing for the public and fails to ‘correlate with evidence-based assessment of relative drug harm’. Any review should also ‘consider all international experiences in order to ascertain a more effective way forward’, it adds.

David Jamieson: ‘Despite the good work being done by many, collectively our approach to drugs is failing.’

David Jamieson’s report from earlier this year, Reducing crime and preventing harm, shares many recommendations with Hogg’s, such as diverting people from the criminal justice system, but also proposes a move that could help win over those elements of the press not traditionally receptive to drug policy reform – taking money from organised criminals to help fund drug services. ‘Those profiting from the misery of drug addiction should pay for treatment,’ it states.

Jamieson told the meeting that when his team had started to look at the situation in their area some ‘killer facts’ had emerged – not only were there more than 22,000 people using heroin or crack cocaine but ‘children are affected, social services – the costs are enormous. Half of all burglary is to feed a habit, and the cost on all public services five years ago was £1.4bn – just in the West Midlands. All the shootings in my area are drug-related. It’s time to have a grown-up conversation about drugs.’

The first step had been to draw up his report, he said, emphasising the links between criminality and drug harm, and the cost to public finance, and making sure it was a ‘workable and pragmatic’ policy document. ‘We want to put it into action, and we’ve had enormous support – including from the media, as it talks about saving costs to the public purse.’

The main reason that the drugs issue was one that had traditionally not been led on was that it was simply seen as ‘too difficult’, Dhindsa told the group. The fact that the ‘war on drugs’ clearly wasn’t working had had little impact on government policy, he said, ‘but by joining up with different groups, we can make positive steps in the right direction’.

Hardyal Dhindsa: ‘The fact that the “war on drugs” clearly isn’t working has had little impact on government policy.’

The meeting also heard from a mother whose son had been lured into ‘county lines’ activity by a drug gang, a growing trend that has seen a huge increase in the number of modern slavery case referrals for minors (see news, page 4). This was something that needed cross-departmental action, stressed Dhindsa. ‘The issue is vulnerability – it’s easy income that then becomes something much worse.’

Arfon Jones told the meeting that while as a police officer he’d only been able to make ‘a small dent in the criminal business model’, like other PCCs he was now in a position to genuinely influence policy.

‘We need recognition that addiction is a disease and not a crime,’ he said. ‘We need recognition that there’s no difference between addiction to lawful or unlawful substances – what makes a criminal is the law.’

Prohibition did not work, he said, as was evidenced by the fact that towns and cities were ‘swamped’ with new psychoactive substances (NPS) despite them having now been illegal for almost two years (DDN, June 2016, page 4). Regulation could not only help protect children, but help control the high potency levels found in the vast majority of cannabis currently being sold (DDN, March, page 5), he argued.

‘We need to recognise the difference between use and misuse of drugs, and we have a way to go to recognise how important harm reduction is – people will only go into treatment when they’re ready.’ When it came to recreational use, however, money was ‘better spent on those who have a problem’, he stressed. ‘Why do we punish and criminalise people who cause no harm to others? These people need diverting into an educational programme, in the same way as for a speed awareness course.’

‘I’m really passionate about changing this agenda,’ Hogg told the group, and while his calls for a new approach had originally met with little support, that was now changing. ‘It’s incumbent on those who have influence to change policies,’ he said. ‘I can still see their faces – when I go to tell a mother, brother or sister that someone has died. It’s human misery and tragedy, and it’s our duty to do something about it.’

Government to set up county lines ‘coordination centre’

By
DDN
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The government is to establish a £3.6m National County Lines Coordination Centre as part of its new Serious Violence Strategy.

The strategy identifies ‘the changing drugs market’ – in particular, around crack cocaine – as ‘a key driver harming our communities’. Last year saw a 23 per cent increase in the number of people seeking treatment for crack (DDN, December/January, page 5) as well as a two-thirds increase in the number of minors reported to the authorities as potential ‘modern slavery’ victims – due in part to rising number of ‘county lines’ gang referrals (DDN, April, page 4).

The strategy ‘stresses the importance of early intervention’ and also includes announcement of a ‘serious violence taskforce’ with representatives of local government, the voluntary sector, the police and others. Around half of the recent rise in robbery, gun and knife crime is the result of improvements in police recording, the document claims, while ‘for the remainder, drug-related cases seem to be an important driver’.

Drug dealing through gangs will be tackled in the new strategy.

The number of murders where either the suspect or victim were known ‘to be involved in using or dealing illicit drugs’ increased from 50 to 57 per cent in the year to 2016-17, with crack cocaine markets having ‘strong links to serious violence’, it states. The document also sets out how ‘a small minority of people [are] using social media to glamorise gang or drug-selling life, taunt rivals and normalise weapons-carrying’.

At the document’s launch home secretary Amber Rudd stated that the view that increases in violent crime rates were partly the result of insufficient police on the streets was ‘not supported’ by evidence, while changes to the provision of youth services as another potential factor was also ‘far too simplistic’.

County lines activity had become ‘an increasingly popular way of dealing drugs around the country’, she said. ‘This involves gangs grooming and using children and vulnerable young people to traffic drugs using dedicated mobile phones or “deal lines” into new locations outside of their home areas. The wider the reach of the gang, the further their violence, drug dealing and exploitation spreads. So this is the situation we are faced with. And what we’re talking about here are murders, torture and other types of extreme violence.’

Amber Rudd: new centre will provide ‘vital intelligence’ about drugs markets

As well as helping police to arrest perpetrators the new coordination centre would increase protection for vulnerable people who had been drawn into county lines networks, provide ‘vital intelligence’ about drugs markets and support the police to shut down mobile phone numbers used for dealing, she stated, adding that she also stood ‘fully behind’ the appropriate use of stop and search.

‘We need to engage with our young people early and to provide the incentives and credible alternatives that will prevent them from being drawn into crime in the first place,’ she said. ‘We will take the comprehensive approach necessary to make sure that our sons and daughters are protected and our streets are safe. As a government we will never stand by while acid is thrown or knives wielded.’

Harm reduction in Belfast

By
DDN
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Belfast’s injecting drugs crisis has prompted a call for action – to bring a drug consumption room to the city as quickly as possible. Report from Chris Rintoul.

There has been a marked rise in people who inject drugs in Belfast city centre over the last two years. This is shown by a dramatic increase in discarded injecting equipment – in back streets, car parks, public toilets, toilets provided by shops and public transport stations, as well as a number of disused buildings. Further evidence is an increase in the numbers of people begging, accessing needle and syringe provision, and presenting for treatment for heroin dependence, which has been accompanied by sensationalist media reporting and frustration among members of the business community.

On 20 February a conference was held at Queens University Belfast. Called Responding to injecting drug use: an exploratory conversation, it was delivered by Extern, a social justice organisation providing services throughout Ireland, and co-sponsored by Queens University and the Belfast Drugs and Alcohol Coordination Team. More than 130 people attended, from diverse perspectives and agencies including the media, politicians, city councillors and the health and social care field.

 

During the last two years Extern have been working with stakeholders across the city to assist in managing what has rapidly become an entrenched issue. A public expectation that Belfast’s developing heroin ‘scene’ should, could and would be eradicated primarily by law enforcement measures is being replaced with a growing pragmatic awareness that we have to manage what is a health and social issue. As a result, attempts are being made to learn from other cities who have experienced these issues for longer periods.

 

As Extern’s drugs and alcohol consultant, I was able to use my international contacts to attract a world-class group of speakers from the legal, law enforcement, academic and practice fields. Professor Pat O’Hare of Liverpool John Moores University chaired the event, introducing the

keynote speaker, Professor Carl Hart of Columbia University, NYC. Carl’s impassioned presentation outlined the moral case for a baseline harm reduction response for people who inject drugs (PWIDs) in the city centre, with a drug consumption facility (DCR) in an area where drugs are already bought and used.

Next Durham’s chief constable, Mike Barton, outlined his views on how similar problems in Durham could and should be treated, and made particular reference to heroin assisted treatment (HAT) for those who have not benefited from traditional OST medications. His presence attracted a number of high-ranking officers from the Police Service of Northern Ireland and enabled them to consider HAT and the case for a DCR in Belfast.

The next speakers were Niamh Eastwood, barrister and executive director of Release, and Neil Woods, an ex-undercover police officer and now chair of Law Enforcement Against Prohibition (LEAP). Niamh outlined the legal issues associated with a DCR within the UK – both the apparent barriers and potential ways to overcome them. She made clear that there is a legal way forward in the UK to the provision of DCRs, if enough popular support exists and the local police force and politicians agree with the concept.

Neil then spoke of his very personal journey in discovering the wrongs of the ‘war on drugs’, especially the further damage that law enforcement approaches can do to the most vulnerable. His view is that the legal approach rarely ever reduces the supply of drugs for long and drives the market into the hands of the most vicious criminal supply networks.

**********

In the afternoon delegates heard from experts based in Glasgow, London and Dublin on issues these cities have faced in terms of responding to injecting drug use, and the serious problems faced by PWIDs in public spaces.

Kirsten Horsburgh of the Scottish Drugs Forum stepped in at the last minute for Dr Saket Priyadarshi, to inform us of the current situation in Glasgow, in light of recent advice from the Scottish Lord Advocate that any DCR in the city would require a change in the Misuse of Drugs Act (MoDA), effectively delegating responsibility back to Westminster and dashing Scottish hopes.

Dr Magdalena Harris of the London School of Hygiene and Tropical Medicine highlighted issues she encounters in her current research among homeless injectors, particularly the prevalence of skin and soft tissue infections. Then Marcus Keane, head of policy at Ana Liffey in Dublin explained the process he has been involved in to bring a change in Irish legislation, allowing for the first supervised injection facility in Ireland, which will open up later this year in Dublin.

The final session of the day was delivered by Dr Gillian Shorter of the University of Ulster. Detailing the range of DCRs worldwide, she identified different models in operation such as medically supervised or not, injection-only facilities or those which cater for people who smoke or even snort heroin, those that cater for heroin use only and those that permit the use of a wider range of drugs.

The evidence presented left us in no doubt that wherever a local need is identified, there are clear and unambiguous reasons to consider providing a DCR. The lasting impression I have is of a clear win-win-win scenario in providing DCRs – PWUDs can access a humane, health-promoting alternative to street-based injecting; support services gain an opportunity to engage with them by providing what they most need; and the wider public find that the level of discarded injecting equipment reduces and visible heroin use declines.

Charlie Mack, CEO of Extern, closed the conference with an eloquent call to action – to join together armed with the evidence we’d just heard and work to make a DCR happen in Belfast. There was a very strong consensus that we must do this, and quickly, as vulnerable lives depend on us along with our courage and determination.

A number of other cities in the UK are currently exploring the possibility of providing a DCR of some description. I believe that sooner or later one of these cities will find a way by local agreement with stakeholders in their city (rather than awaiting a change to MoDA) to provide one.

**********

My own thinking is that the terminology we use – ‘drug consumption room’ – may be unhelpful, conjuring notions of a libertarian drugs free for all. A more helpful and accurate term is overdose prevention site (OPS), which describes exactly what it is – although it is still limited in that it doesn’t explain that it will allow PWIDs access to wider healthcare and social interventions such as wound care, housing and substitute opioids. Whatever the model, it will undoubtedly prevent fatal overdoses and the spread of BBVs among the people who use it. Terminology is a secondary consideration to the purpose of the service.

Extern want to build on the success of the conference in the coming months. We operate a street injectors support service, an ‘old-school’ harm reduction outreach service, which engages with this very hidden, vulnerable population. Since starting in October 2017, staff have successfully reversed three overdoses with naloxone, provided and removed large quantities of injecting equipment, supplied naloxone and much more. In addition, they have assisted PWIDs to access accommodation and even treatment. What if we were able to offer them an overdose prevention site as well?

We dream big, and will continue to do so until we have exhausted all options available to us to prevent the need for street injecting.

Chris Rintoul is drugs and alcohol consultant at Extern

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‘We did it together’

Tony Duffin describes how through local team work, a small charity helped to change the law to allow supervised injecting facilities.

Catherine Byrne TD, minister of state for communities and the national drugs strategy with Tony Duffin

 

 

Established in 1982, Ana Liffey Drug Project was Ireland’s first low-threshold harm reduction service. As a small charity working in Dublin and the mid-west Region of Ireland, we provide fixed site and outreach services to over 2,000 people each year and have 35 staff, supported by a similar number of volunteers.

From 20 January 2012, we were a leading advocate for supervised injecting facilities and played a key a role in lobbying for the introduction of the Misuse of Drugs (Supervised Injecting Facilities) Bill 2017 – which was signed into law on 16 May 2017 by President of Ireland Michael D. Higgins.

The following four key strategies helped us to achieve our goal of legislative change:

Know your case
Gather the evidence and know the argument both for and against your proposed change. While there was only a handful of detractors, it was important to able to respond with certainty.

Speak to your stakeholders’ self-interest
Don’t just know who your stakeholders are, but also know what their needs are. When we communicated with different stakeholder groups, we always tried to speak to their self-interest and explain how our proposed change would benefit them.

Engage with the media
Engage widely and frequently with traditional media and social media. Early on we were reminded of the old journalists’ saying – ‘good news is not good news’. However, we had newsworthy stories which people wanted to hear. We made our own news.

Ask for help
You can’t do it all on your own – we were attempting to do something that had not been done before. We asked for help at a number of key stages. At the end of the day, successfully introducing the legislation was achieved by civil society, legal, statutory and political champions all working together.

Tony Duffin is CEO of Ana Liffey Drug Project

Making pathways for commissioning

By
DDN
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Commissioners are on a mission to do things better. But how can they take on board the many complex health issues with less money in the pot? DDN reports.

There’s much talk of developing innovative commissioning practice – prompted, in the main, by the need to ‘do more with less’. As part of the refining process, many services are letting go of the specialist posts that would have been central to operations just a few years ago.

In our March issue (page 20) the alliance of NHS providers, NHSSMPA, highlighted the ‘significant decline in registered staff, including nurses, social workers, clinical psychologists and doctors’ and cautioned that some drug and alcohol services had begun relying on limited clinical expertise.

Through a recent suite of documents for commissioners, providers and clinicians, Public Health England (PHE) emphasised the many and varied roles that specialist doctors, nurses and psychiatrists should play in addiction services. These highly trained professionals are, they reminded us, not just there to provide medical treatment in response to highly complex needs – although those are the elements of their roles that cannot be fulfilled effectively by lesser trained and qualified staff.

 

PHE named many other skills that enhance quality and leadership within teams, as well as integrating many public health activities and interventions. Furthermore, they pointed out, specialists can help to coordinate resources in a way that adds cost efficiency to a system stretched to breaking point.

MULTI-SKILLED VALUE
The fact that nurses are such ‘a multi-skilled breed’ is without doubt why they bring such good value to drug and alcohol services, says Ishbel Straker, a clinical director and board member of the nurses’ association IntANSA. Their expertise in therapeutic engagement, assessment and care planning, health care delivery, disease prevention and prescribing works alongside their commitment to the NMC standards – ‘prioritising people, practising effectively, preserving safety and promoting professionalism and trust’.

‘We are ever evolving to meet our clients’ needs and the needs of our services,’ she says. ‘We work with harm minimisation at the forefront of our minds, while giving advice, assessing and treating through a variety of activities such as vaccinations, lung function tests, wound care, blood sugar monitoring, ECGs and sexual health – all of which are measurable outcomes.’

‘Looking at the client from the centre of their needs’ has become the way of working at Change, Grow, Live, says Dr Arif Rahman, CGL’s consultant addiction psychiatrist. Far from dispensing with the psychiatrist’s role, CGL have put it right at the centre of their services.

‘It’s really good for the client as it gives them a specialist assessment that’s holistic. We’re medically trained, psychiatrically trained and substance misuse trained… The whole ethos is about getting people to the best of their potential,’ he says. ‘We can identify, support and manage, and if necessary liaise with other specialists around the aspects of clients’ needs. For example, I’m in frequent contact with a pain specialist, a liver specialist and secondary mental health services.’

HOLISTIC AGENDA 
Many clients find it easier to engage with a substance misuse charity than to access a liver specialist, engage with a mental health team, or ask for testing for blood-borne viruses or screening for respiratory disorders, he explains. So whatever the need, he is in a position to liaise with other specialists to bring care to the client.

He talks about ‘a new way of working’ – not losing skills, but adapting them to take account of updated Models of Care and the client’s journey. He acknowledges that there have been cuts to services and restructuring in a lot of places, but feels positive that a ‘difficult few years’ have given ‘an opportunity for looking at things again’. Psychiatry as a profession is in a good place to contribute to a holistic public health agenda, he states, having several decades ago experienced and adapted to changes that are now happening in health and social services.

Alongside his client assessments, he feels that one of the most important parts of using his expertise is in finding pathways for clients and linking them to colleagues and partner agencies for their health, psychological and social needs.

CREATIVE COMMISSIONING
Chris Lee, a commissioner in Lancashire and a member of the new Faculty of Commissioning, agrees with the need to ‘create robust pathways to make sure the skill set is there across all organisations’ – particularly as the treatment system now has so many diverse stakeholders including CCGs, the NHS (and the prison estate), local authorities, Collective Voice and the NHSSMPA.

While ‘the front door to treatment has changed’ and clients might enter treatment through one of many different routes, the current challenges mean that leading through specialisms is more important than ever, he says. ‘The money’s going out of the system at 100 miles per hour, but the clinical guidelines have been enhanced. So how do you do that with a population that’s got ever-increasing complex needs?’

This, he believes, makes the case for a different and more creative brand of commissioning. ‘If I sit down and write a specification for a tender this afternoon that mentions an addiction psychiatrist, your bid will come back with an addiction psychiatrist in there,’ he says. ‘But you can commission differently. You can say, “you’ll be working with people with complex needs, people with co-existing mental health and substance misuse concerns. You’ll be dealing with people with long-term homelessness issues, people who are long-term unemployed – and you need to be able to deliver both the clinical and psychosocial model.”

‘You’re not saying that you must have a psychiatrist or a psychologist or whatever – you’re saying, “this is the level of complexity you’ll be working with; what team would you put out?” It’s up to the provider to come back and say what they will give you.’

Lee sees opportunity in the need to mix cost-effectiveness with addressing complex needs, and says ‘that’s where it gets really exciting, because you can start playing around with different delivery options’.

Traditional ways of working are not ‘the given’ anymore, right down to the buildings that can constitute one of a service’s biggest overheads. The new way of working can be ‘light and agile’, he suggests – meeting in a coffee shop or a library, using community assets, and freeing up money to spend on staff instead of buildings.

LET’S GET DIGITAL
Service delivery might be able to incorporate digital support – a Skype call, email contact, text support, people filling in their own assessments online, or contact with a keyworker that can be anywhere.

‘Even people with highly complex needs could get some of their support through digital means – you could do doctors’ appointments by Skype for example to save travelling,’ says Lee, adding that there will always need to be a balance between this and traditional face-to-face meetings.

His point is that ‘years ago everyone got the same broad-brush approach, but these days you don’t do it that way. And if the money’s draining out of the system, we can’t afford to be working in old-fashioned ways.’

Furthermore, he believes that commissioners have a responsibility to lead on this open-minded approach: ‘If the commissioner pretends they know everything, you’re robbing yourself of some good ideas,’ he says. ‘The good providers out there have some really innovative ideas.’

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

How treatment services need to adapt to survive

By
DDN
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If treatment is to survive it needs to make a more convincing case and reach out to new groups, argues Paul North.

Seven years ago I, along with several hundred drug treatment workers, sat at CRI’s (now CGL) annual conference and listened to the opening speech by CEO David Royce. The mood was positive. Money was coming into the sector, CRI was growing month by month and treatment centres were, on the whole, robustly staffed.

David stood centre stage and whilst enthusiastically praising staff for their continued hard work and commitment, he delivered a stark warning to the room. The future might not be so bright for drug treatment – we must be careful, prepared and fluid. The money that the sector relied upon might not be ring-fenced in the years to come, and we must be ready to change. It might be that treatment needed to branch out and look for money elsewhere. It was likely there would be fewer jobs, and higher caseloads.

Six years later when I was sat in a council meeting listening to the proposed cuts to the treatment budget in York, the reality of the situation finally hit me. Of the four councillors in front of me, one was unashamedly falling asleep. Another, who despite having taken the time to research the subject, asked questions with next to no passion or concern for the excessive reductions in funding. The whole process was a formality, with no press coverage and no real challenge from treatment, all overseen by a powerless commissioner watching the precious budget slip through their hands like sand.

Having left treatment and now working in policy, I have spent a lot of time considering how this situation can be reversed. How can services reach previous levels of funding? What needs to be done to stop the budget cuts?

In order to answer these questions the first step is to accept a cold hard truth. The public are not concerned by a reduction in drug treatment budgets. The heroin cohort single-handedly created, funded and sustained treatment for years. From concerns around the spread of blood-borne viruses to drug-related offending, providing treatment with money was not a political hot potato – it simply made sense.

 

 

 

 

Years later, heroin deaths are at an all-time high, treatment services have seen record budget cuts and there has been no significant public fallout. While it is easy to blame austerity and government, the truth is that the majority of the PHE budget is happily spent elsewhere – a decision ignored by local communities and the media. As the heroin cohort dies and leaves treatment, so does the money to support them.

The challenge that treatment must confront, and a surefire way of creating funding, is to connect public need with public concern – raising awareness of an issue to attract new referrals, whilst at the same time educating society on the benefits of doing so. This is no small task for treatment and requires innovative outreach. The truth though is that if treatment does not find treatment-naive groups and make a convincing case for supporting them, the government is unlikely to give out funding on the off-chance of success. There needs to be a clear justification for funding, and concern to match it.

Creating public concern often requires a good narrative, and these narratives must also be backed up by data and evidence. The first step then is to prove the need, by evidencing that there are hundreds of thousands of people who require support. All these people who would benefit so much from treatment need to walk in through the front door – these stats then need to find themselves on the desks of commissioners as well as the local press. At a local level, let people know the great work the treatment service is doing and encourage others to get support. Identify a group and prepare them for treatment, get them on NDTMS and prove treatment still has a use outside of the heroin cohort.

The first group that treatment could target is an easy win. Last year, 23.8m opiate prescriptions were dispensed in the UK. Use of painkillers has risen by 80 per cent in ten years and is costing the NHS billions of pounds – there are no doubt hundreds of thousands of people using opiates problematically on prescription. They are easily accessible, in every community across the UK, and reducing their use would save the NHS millions of pounds. Furthermore such an approach would bring significant health benefits, as it is estimated that up to 90 per cent of prescribed opiates are ineffective at addressing chronic pain. Treatment services are essential if such a reliance is to be reduced – without a planned therapeutic intervention a situation similar to that in the US could emerge where those taken off ineffective prescriptions simply seek out illicit opiates.

It is clear that a very strong economic and health argument could be made for engaging this group. Save money, put some of it into treatment and reduce the vast numbers of people on poorly managed opiate prescriptions.

The next key group is the hundreds of thousands of cannabis users that do not enter treatment. Last year we showed in Liz McCulloch’s report Black sheep that cannabis presentations have risen by 55 per cent in ten years. My report Street lottery estimated that this equates to 200,000 cannabis users in the UK. Cannabis represents both the fastest growing cohort of drug users, and the most commonly used drug among young people and adults. As outlined in Black sheep treatment has not yet made a convincing case for engaging this group as we are ignorant of the health and economic benefits of doing so. This group require bespoke outreach interventions and campaigns to engage. Without any effort at all the group has doubled in size in ten years. Imagine what it would look like if treatment made a more concerted effort.

If services around the country looked up from managing the heroin cohort and engaged treatment-naive groups then the money would emerge – the national press would have a story, further educating the public on the changing face of treatment and encouraging others to seek support. The issue of funding services would then likely receive far more public support. Such a strategy would unite public concern with public support, thereby validating funding.

This is not about ditching the important service that treatment provides for the heroin cohort. It is about ensuring in years to come it can continue to do so effectively. Treatment needs to stay well funded and healthy to support heroin users at a time when overdoses are at an all- time high. Those on the frontline of drug treatment know full well the importance of continued support for this group.

This is an exciting proposition for those working in treatment. The chance to explore a new frontier and engage groups who have historically avoided support. A chance to show government the innovation that the sector is capable of and share the life-changing work that has been going on in key-work rooms up and down the UK for years.

To those who are sat with overwhelming caseloads, complex clients and demanding targets, the only way out of that picture is to adapt. The heroin cohort created treatment but if services don’t act they might also spell the end of it. They are no doubt a vulnerable and difficult cohort to work with who need bespoke support, but they are not the key to future funding. If treatment does not grasp this opportunity quickly and make a convincing case for more money then it will disappear into irrelevance, and only have itself to blame.

Graph data from Beyond the tipping point at www.recovery-partnership.org

Paul North is head of communications at Volteface, @Paul_North 

Clinical Eye: Personal development is an investment

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Time spent on your own development is necessary investment, says Ishbel Straker.

It’s that time of year again, when we are appraised and more importantly have the opportunity to appraise ourselves. This is a rare moment in our nursing life, but one which is incredibly valuable. We are given the space to consider how the previous 12 months have gone and how you would like things to pan out over the following 12 months for the benefit of your learning capacity and for client care.

This is a time when we can look at how best we, as individuals can empower ourselves to be the best we can be for those in our clinical spheres. I spend a lot of time thinking about this for the nurses under my care, planning out training and CPD sessions over the 12-month trajectory, considering trends within the addiction field and how we can equip the nurses to best manage them.

It is easy to look at this for others, but if you asked me the last time I considered my learning needs I would be searching for the answer. Why is that? Well, I would suggest it is because we as nurses are a selfless race of professionals. Now don’t get me wrong when I say this, we absolutely have our faults and I could spend days listing them for you but I’m sure you have your own list to look at! I mean selfless because that is what we are conditioned to be throughout our training – to think of our patients before ourselves, to feed our patients before ourselves, to hydrate our patients before ourselves, to toilet our patients before ourselves.

Now this is all well and good. However, there are negative implications to this in the form of our own self-worth and development. We need to reflect on our abilities, the changing demographics and our competency levels within this. We cannot continue to ride on the wave of ‘how we have always done things’, but instead become focused on innovation – which means, as difficult as it may feel, looking inwardly at our own learning potential.

I appreciate that there are financial and time constraints within services, but this year, at appraisal, be prepared with your own ideas and personal development plan. Be what you may feel is a little selfish, because I promise, in the bigger picture, the client is still at the centre.

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

The news, and the skews, in the national media

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Media Savvy

The news, and the skews, in the national media

 

President Trump has declared that his administration is getting serious about the opioid epidemic several times since taking office. But he has repeatedly failed to offer a substantive plan – and he has floated at least a few truly absurd ideas. He did it again this week. The president went on at length about his preposterous proposal to fight the scourge of drugs by executing drug dealers – an idea that many experts say would not stand up in court and would do little to end this epidemic… It was Mr Trump playing his greatest ‘law and order’ hits – as usual, full of sound and fury but signifying nothing.
New York Times editorial, 20 March

It would be wrong to legalise recreational cannabis use, particularly given the evidence that excessive use can cause mental health problems. But that should not prevent scientists and doctors from developing useful medicines to help people who are suffering.
Scotsman editorial, 17 March

So long as we leave decisions on drugs that are both medicines and recreational substances to the Home Office we won’t progress, as they seem unable or unwilling to see beyond their failed ‘ban everything’ strategy.
David Nutt, Spectator, 19 March

Hepatitis C could be the UK’s next big public health success story. But if we want to eliminate it by 2025 we need a concerted and coordinated effort to find undiagnosed patients and treat them. This is the biggest obstacle we face so it requires everyone to join forces, from homelessness and drug and alcohol charities to GPs and public health directors, and from sexual health clinicians to prison staff. I welcome the approach that NHS England is taking to identify those living with the virus and our work must be carefully coordinated to ensure no areas lose out. Vulnerable patients should be automatically tested at their GP, while testing should also be readily available at sexual health clinics and pharmacies – and amongst the prison population.
Steve Ryder, Telegraph, 20 March

Some users might be more susceptible than others to the trap of addiction, but Ant [McPartlin] and others like him are not in the grip of an uncontrollable disease that is to blame for all their woes. They are not victims, and it doesn’t help them to be treated as helpless amoeba at the mercy of their own desire. This whole concept of addiction as a disease originated in the US not very long ago, where it was classified as such so that people could get it covered by their medical insurance policies. If it was a disease, went the reasoning, then you could get treatment for it, and then you could get that treatment paid for. However, it is your choice as an adult whether or not you swallow the drink and ingest the drugs that exacerbate your condition.
Jan Moir, Mail, 23 March

Your letters in the April issue

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DDN welcomes your letters.

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

 

Unwanted interventions
I very much enjoyed Mike Ashton’s look at the chequered history of alcohol brief interventions (DDN, March, page 22). My gut feeling has always been that they’re at best useless, and at worst potentially counter-productive and – while I realise the jury is still out – it’s nice to get even a tiny bit of academic back-up for that. And surely, they’re also at odds with much of the current direction of thought around drug use, as espoused by more and more police and crime commissioners – that it’s best to turn a blind eye to the ‘recreational’ and focus instead on the genuinely problematic.
James Burton, by email

 

Hobson’s choice
‘Find out who your local commissioner is, and let’s bring some new thinking in,’ advises Paul Musgrave in your conference reports (DDN, March, page 12). Well I’ve known who my commissioner is for quite a while. The problem is he doesn’t know who I am, nor does he seem to have the slightest interest in finding out, let alone listening to anything I might have to say. I realise my experience may not be all that representative, but somehow I doubt it. ‘It’s all about choice,’ he says earlier in the article. Fine, but whose choice exactly?
Name and address supplied

More comment can be seen under the relevant feature articles on this website. You can leave your own feedback and opinions at the foot of each article.

DDN April 2018

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‘With yet more evidence, can we justify standing still?’

How far do you have to go to show that something’s a good idea, it’s cost effective, and that it works? We know that safe spaces, such as DCRs, save lives and that supporting instead of punishing is the only humane approach to drug policy.

When leaders on the frontline of law enforcement raise their voices to tell us our current approach to drug policy is not only failing, but a ‘crazy waste of money’, surely politicians must listen (page 6). These are not isolated voices: the Royal Society for Public Health is among many organisations to back harm reduction initiatives such as consumption rooms and heroin-assisted treatment as a move towards evidence-based policy.

Police officers were among the stakeholders to come together at a recent conference In Belfast on injecting drug use (page 8), and talked about the damage that law enforcement approaches can do to vulnerable people. If the support of the local police force is a critical factor in being able to establish DCRs in the UK, then surely we can’t be far off making them a reality in local areas.

We’re all too familiar with the upward trends in drug-related deaths, so when we’re presented with yet more evidence that a policy change would be cost-effective as well as health-effective, how can we justify standing still? And with police, local government and the health and social care fields calling for a move from evidence to action, surely it’s time for every region to be clear and purposeful in getting on with it.

Claire Brown, editor

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Scots signal drug policy shift

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Aileen Campbell: Discussed policy shift for those most at risk

Leading members of the Scottish Government have discussed a potential shift in policy ahead of the country’s new drug strategy, which is due to be published in the summer. The government aimed to ‘change the provision of treatment and support for those who are most at risk’, said public health minister Aileen Campbell, which meant ‘taking forward evidence-led measures even if they prove controversial’.

Nicola Sturgeon: ‘We should be prepared to do things that may be unpopular.’

Earlier this month Scotland’s first minister, Nicola Sturgeon, also called for cross-party collaboration to implement ‘bold and new’ initiatives to tackle drug-related deaths. ‘We should try and come together and be prepared to sometimes do things that may be controversial and may, in some areas, be unpopular,’ she stated. ‘But where there is an evidence base for them we should have the courage to do them.’ Scotland’s drug-related death rate is now double that of a decade ago and the highest in the EU (DDN, September 2017, page 4).

Aileen Campbell’s comments were part of a presentation to the Dundee Partnership Forum, which has launched a commission to address the rising number of drug-related deaths in the city. ‘The Scottish Government is reviewing our current drugs strategy, recognising that patterns of drug taking and their challenges have changed since we published it in 2008,’ she said. According to the Times, Campbell stated that a ‘public health response’ to problem drug use would require ‘safer injection rooms or heroin-assisted treatment’.

While plans to launch the UK’s first consumption room in Glasgow were approved by city officials almost 18 months ago (DDN, November 2016, page 4) the facility has yet to open, and fears remain that users or staff could be vulnerable to prosecution.

Drugs trade driving huge increase in modern slavery cases

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The exploitation of young people by drug dealers is contributing to a significant increase in the number of ‘modern slavery’ cases, according to a report from the National Crime Agency (NCA).

The number of potential victims of human trafficking and modern slavery reported to the authorities rose by a third between 2016 and 2017, says the agency, from 3,804 to 5,145. A two-thirds increase in the number of minors referred also means that British citizens for the first time make up the largest nationality recorded, due in part to a rise in ‘county lines’ gang exploitation referrals where minors had been ‘exploited by criminals involved in drug supply’.

‘County lines’ activity sees drug gangs from urban centres expand their distribution chain to regional and coastal areas using young people to transport and sell the product – a trend that by late last year had been reported by nearly 90 per cent of police forces in England and Wales (DDN, December/January, page 5).

The new figures are taken from the National Referral Mechanism framework, which sees potential victims referred by ‘first responders’ such as the police, and ‘almost certainly represent an underestimate of the true scale of slavery and trafficking in the UK’, according to the NCA.

‘What this report reinforces is that we are now dealing with an evolving threat,’ said NCA director Will Kerr. ‘Particularly concerning to us is the rise in young people being exploited for sexual purposes or drug trafficking.’

‘Modern slavery and trafficking are despicable crimes which see some of the most vulnerable people in society targeted by ruthless predators,’ said crime and safeguarding minister Victoria Atkins. ‘These figures show that more potential victims are being identified and protected thanks to a greater awareness and improved understanding of modern slavery.

‘We are also beginning to see the operational results of the renewed focus on modern slavery, with over 600 live police operations underway, and the first conviction of county lines gang members under the Modern Slavery Act. But we know there is more to do, and we are working to improve the system for identifying victims and supporting them to leave situations of exploitation and begin to recover and rebuild their lives.’

National referral mechanism statistics available at www.nationalcrimeagency.gov.uk

Letters to the editor – March issue

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DDN welcomes your letters.

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

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

The power of e-cigs

I am writing in support of Dr Neil McKeganey and his view on the prescribing of e-cigarettes (DDN, February, page 18). As a proponent of harm minimisation in all its forms and bearing in mind the alarming percentage of service users in their forties and fifties with a diagnosis of COPD, anything that can reduce the numbers smoking tobacco is to be welcomed.

In 2008 at Build on Belief we did an impact evaluation and asked our service users how many of them smoked toba­cco. The answer was 73 per cent – more than three times the national average. In 2014 we repeated the evaluation and asked the same question. The answer didn’t change by a single percentage point and remained at 73 per cent. Then, in 2016 we did another, smaller survey in one borough and were astonished to discover the percentage of tobacco smokers had dropped to 50 per cent.

The following year, we thought to ask how many of them used e-cigarettes. The answer was 23 per cent, the exact percentage of the recorded drop in tobacco smokers. Interestingly, the great majority of those who had switched to vaping were in treatment and identified as being in recovery.

It seems self-evident that there is a useful piece of work to be done with those service users who smoke, while they are in treatment, to encourage them to make the switch to vaping as a part of moving toward a healthier lifestyle if they are unwilling or unable to give up tobacco. The health benefits would be enormous, and our research suggests that a significant number would, with a little support, do so.

Tim Sampey, chief executive, Build on Belief

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Road to recovery

I sincerely found the experience of the DDN conference really amazing as a new peer mentor for Turning Point Leicester. I had no help from the armed forces and left after 30 years both as an engineering apprentice and soldier, followed by be­com­ing an officer with the rank of captain.

I was simply told ‘as an officer, sort yourself out!’ I had a well-won nervous breakdown and PTSD that will be with me for life. I take professional counselling once a month and have been abstinent from alcohol for nearly four years now. I left the armed forces 20 years ago and never once as a family man thought a road to hell was ahead. I now enjoy life with my lovely wife of some 47 years – without her support I know I would not be here.

Trevor Mills, by email

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Get the picture

Natalie Davies’ outstanding analysis of the Cycle of Change (DDN, February, page 20) was let down by your illustration. Natalie’s discussion demonstrates that the stages of change model is a really good description of what happens when people make a significant shift in habits and behaviour.

When it was first introduced in the early 1980s some in the UK fell on it a little too enthusiastically. Whole services were reconfigured to reflect the stages as though they were discreet, evidence-based stepping stones in a process. In truth, there was probably little harm done. A good description is better than what we had before. It certainly chimed with the emergence of broader, more nuanced under­stand­ings of alcohol and other drug use that were overtaking simplistic, diseased models.

The stages of change model has become a staple of addictions training presentations ever since. It is accessible. Many of us will have lost of count of the number of times we’ve been presented with it, often by people who apparently haven’t read any of the articles and books the originators produced.

How many of these trainers and presenters have noted that since 1992 the term ‘relapse’ no longer featured. The diagram describing the model changed from a circle to a spiral. In 1994 the new diagram featured in a book (for the benefit of those of us who don’t have easy access to academic journals).

Your illustration includes the ‘r’ word. Most addictions trainers continue to use the older diagrams and spout on unthink­ing­ly about Relapse (sic) despite the fact that it is over 25 years since the original authors eschewed the ‘r’ word in their model. Obviously there are reasons for this. These probably include:
• It’s a challenge to keep up to date
• People don’t read journals, or books
• It is hard to draw a spiral
• We don’t like change apparently (espec­ially to our favourite model of change)
• The diseased models are alive and sick and worryingly continue to infect the field and the language we use to train new entrants and the wider community.

New ideas take time to catch on. Prochaska & DiClemente’s model was an exception. Their Cycle of Change is here to stay. It has been more than a quarter of a century since they (with Norcross) stopped talking about relapse. Anyone claiming to cite them to add legitimacy to their views on alcohol and other drugs should stop using the ‘r’ word right now.

As a field, we have a duty to advocate for the people who need our services. We do them no favours by education and com­m­unications that wilfully misrepre­sents the work of key academics. We can’t really expect journalists and politicians to get reporting and policy right if we’re 25 years out of date (and counting) ourselves.

References:
Prochaska, J,O., DiClemente C.C., Norcross J.C. (1992) In search of how people change. Applications to addictive behaviors. Am Psychol 47(9):1102-14
Prochaska, J.O., Norcross, J.C. & DiClemente, C.C. (1994). Changing for Good. New York: Morrow.

Trevor McCarthy, independent consultant

Natalie Davies, assistant editor, Drug & Alcohol Findings responds:
We would like to thank Trevor McCarthy for his comments on our article about Prochaska and DiClemente’s ‘stages of change’ model – especially for clarifying that the diagram featured is no longer an accurate depiction. There are many dia­grams of the stages of change in circula­tion, but just looking at a sample of publications from the originators, it is apparent that they went on to embrace a way of describing the stages where a lapse or relapse did not necessarily mean that people regressed all the way back to where they started.

They recognised that people can learn from their mistakes or what didn’t work, and try something different the next time. For example, this was illustrated in 1992 with a ‘spiral’ diagram (each loop in the spiral taking people closer to lasting recovery), and in 2003 with an adapted ‘cycle’ diagram placing the first stage (pre-contemplation) outside the circle to illustrate that people re-‘cycling’ through the stages would likely not return to where they started. We have made changes to the hot topic on the Effectiveness Bank website to reflect this, and would encourage readers to visit: http://findings.org.uk/PHP/dl.php?file=cycle_change.hot

Step up testing to meet hep C target, say MPs

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‘Significantly greater’ numbers of people need to be tested, diagnosed and treated in order to eliminate hepatitis C, according to a report from the All Party Parliamentary Group (APPG) on Liver Health. England needs to agree on a national elimination strategy if it is to make the most of a ‘once in a generation’ opportunity to eradicate the virus, the group stresses.

The report is the result of an inquiry by cross-party MPs and peers, in which expert contributors ‘overwhelmingly agreed’ that England is currently not on track to achieve either the NHS target of eliminating the virus by 2025 or the World Health Organization target of elimination by 2030. ‘The upcoming deal between NHS England and the pharmaceutical industry must include innovative new measures to find those still living with hepatitis C and engage them into treatment,’ says the APPG.

The report urges the government to ‘express its explicit support’ for the elimination agenda, and make sure that the agreement between the NHS and industry includes ambitious national and regional targets, as well as mechanisms to make sure funds are distributed ‘equitably’.

Funding pressures on local authorities are having a negative impact on testing and prevention initiatives, says the report, while levels of awareness among the public and even primary care professionals remain low. Many of the 40-50 per cent of the estimated 160,000 people living with the virus who are still undiagnosed are ‘part of vulnerable populations with chaotic lives’, it adds, while ‘overly complex’ care pathways are still creating barriers to accessing treatment.

The report calls for treatment to be ‘universally accessible’ and available in community settings, as well as the introduction of ‘opt-out’ testing in drug treatment services, with ‘commissioning contracts stipulating clear mechanisms to hold services to account’ for failing to meet targets.

Last month’s Get Connected conference heard how CGL’s hep C strategy was focusing on ‘the huge cohort of people who could benefit from testing and treatment’ in drug treatment services to make the maximum impact (DDN, March, page 6).

Charles Gore: We all need to up our game

‘Much as there has been great progress, as this report makes clear, we all need to up our game,’ said Hepatitis C Trust chief executive Charles Gore. ‘No one should be walking round with a virus that could give them liver cancer. No one should have to wait for treatment. No one should die from this disease when we have these miraculous drugs. We can eliminate this virus so let’s get on with it.’

‘With the exceptional context of a deadly virus now being fully curable with easily deliverable, highly cost-effective medicines, finding those still undiagnosed and living with hepatitis C should be a national ambition,’ added APPG co-chair Sir David Amess. ‘Eliminating a public health issue that disproportionately affects some of the poorest and most marginalised groups in our society is an extraordinary and eminently achievable opportunity which should be seized with both hands.’

Eliminating hepatitis C in England at www.appghep.org.uk

 

Trump calls for death penalty for drug dealers

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DDN
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US president Donald Trump has said that his Department of Justice intends to seek the death penalty against drug traffickers ‘where appropriate under current law’. The announcement was one of a range of measures set out as part of his latest initiative to attempt to tackle the country’s ever-worsening opioid crisis.

The initiative would address the factors fuelling the crisis, he said, including ‘insufficient access to evidence-based treatment’ as well as both the supply of illicit drugs and over-prescription by medical professionals. The number of opioid overdoses in the US has quadrupled since 1999, as has the level of opioid prescribing (DDN, September 2017, page 5). Trump pledged to launch a ‘nationwide evidence-based campaign’ to raise public awareness of the dangers of prescription and illicit opioid use, and to implement a ‘safer prescribing plan’ to cut opioid prescriptions by a third within three years.

He would also ‘crack down on international and domestic drug supply chains devastating American communities’, he said. Alongside the possible death penalty for drug dealers this would include further securing ports and land borders, shutting down illicit online opioid sales and strengthening penalties for selling fentanyl and other substances that are ‘lethal in trace amounts’. The initiative would also work to ensure that ‘first responders are supplied with naloxone’, however, and increase access to evidence-based treatment ‘as an alternative to, or in conjunction with, incarceration’ for people in the criminal justice system.

‘We will work to strengthen vulnerable families and communities, and we will help to build and grow a stronger, healthier, and drug-free society,’ he said.

Maria McFarland Sánchez-Moreno: Trump’s administration should stop its obsession with killing

The US-based Drug Policy Alliance said that while measures such as improving treatment provision and rolling out naloxone would be helpful if there was a focus on putting the latter ‘in the hands of individuals and community groups’, the president had ‘done little to offer a public health response’ to the situation. ‘Rather than helping people at risk of overdose and their families, Trump is cynically using the overdose crisis to appeal to the worst instincts of his base, and pushing for measures that will only make the crisis worse,’ said executive director Maria McFarland Sánchez-Moreno. ‘If this administration wants to save lives, it needs to drop its obsession with killing and locking people up, and instead focus resources on what works: harm reduction strategies and access to evidence-based treatment and prevention.’

Meanwhile, visits to US emergency departments for suspected opioid overdoses increased by 30 per cent in the year to September 2017, according to the Centers for Disease Control and Prevention (CDC). The Midwest saw the largest increases, with Wisconsin recording a 109 per cent rise. ‘Long before we receive data from death certificates, emergency department data can point to alarming increases in opioid overdoses,’ said CDC acting director Anne Schuchat. ‘This fast-moving epidemic affects both men and women, and people of every age. It does not respect state or county lines and is still increasing in every region in the United States.’

Opioid initiative briefing at www.whitehouse.gov

Vital signs: opioid overdoses treated in emergency departments at www.cdc.gov

 

 

 

 

 

 

PHE updates on hepatitis B vaccine shortage

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Since mid-2017 the UK has experienced a shortage of hepatitis B vaccine due to global manufacturing issues. In response to the shortage, Public Health England (PHE) developed temporary recommendations on use of hepatitis B vaccine.

Vaccine supplies are now improving and more vaccine is becoming available during 2018. Supplies will remain constrained, however, due to backlog demand from 2017 and low UK allocations from some manufacturers. Supply management and some monthly ordering restrictions will therefore need to continue to prevent stockpiling.

Hepatitis B vaccine remains available for those at highest immediate risk of exposure, ie PHE priority groups 1-3 (see PHE temporary recommendations, August 2017).  These include people who inject drugs.

PHE has recently published a recovery plan to support re-introduction of vaccine for lower priority group 4 in 2018 in a phased approach to maintain continuity of supply.

Commissioners and providers of drug services are advised to read the plan, share with relevant staff in their organisation – especially those who purchase and offer vaccine – noting that they can now order larger volumes of vaccine from manufacturers, and increasingly without the need for an override request.

 

DDN March 2018

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‘Where there’s a will, things can happen’

How do we get connected? With healthcare, with peers, colleagues, commissioners, policymakers, politicians? It’s a question that goes far beyond the DDN conference – but the spirit of this event confirmed that where there’s a will, things can happen.

On the following pages you will find not just the record of the day’s events, but a host of possibilities, questions and ideas. How can we make sure the relationship between those providing and seeking healthcare is as good as it can be? How do we ensure these all-important interactions are not one dimensional, but create pathways to other vital support services and branches of healthcare? What do we do if we’re not getting the treatment we need?

The crucial component in a day like this is those who come along to say ‘I did it like this and it worked for me’ – call it expertise by experience, service user involvement, or whatever you will. But whether it’s hepatitis C treatment, supported housing, education and training, or taking part in local decision-making, the people who look back after they have tried the route are the ones who leave doors open for the rest of us.

Equally important was the emphasis on ‘having your say’ – PHE, commissioners and researchers all wanted service user involvement in feedback, planning and ‘lived experience’. This surely must give impetus to including peer-led groups and enterprises as a standard component in every local tender.

Claire Brown, editor

Click here to view the virtual magazine or the PDF version

Brief encounter: what happened to alcohol brief interventions?

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Alcohol brief interventions promised a way of improving the nation’s public health – so what happened to this ambitious initiative? Mike Ashton looks back at a 27-year journey.

The advent of brief interventions represented a radical realignment away from aiming for abstinence among relatively few ‘alcoholics’ to reducing risk among risky drinkers of all levels. Instead of narrow and intensive, the strategy was to spread thin and wide, deploying easily learnt interventions that could be delivered in a few minutes by non-specialist staff.

Drinkers whose consumption generated no impetus to seek advice were nevertheless to be offered it, after being identified by screening questions or clinical signs while coming into contact with services for other reasons. Some might not benefit and others only modestly, but – unlike treatment – the population was the target.

Screening and brief intervention was primarily a public health strategy to reduce alcohol-related harm at the level of a whole population, to a degree otherwise unattainable without imposing politically unpalatable restrictions on the availability of alcohol.

This is the story of the partial retreat from those ambitions, traced through three British studies in which the same researcher was involved – Professor Nick Heather, the first to evaluate an alcohol brief intervention in primary care, a venue chosen for its near-universal reach. The most influential thinker and researcher on brief interventions in Britain, his work forms the spine of the research-driven realisation that hopes and potential were one thing, realising them another.

Conducted in Dundee in 1985, the results of his first trial can in retrospect be seen as a harbinger of what was to come. Whether screening had been followed by no advice on drinking at all, a very brief warning from the doctor, or the more elaborate ‘DRAMS’ brief intervention, drinking reductions did not significantly differ. The researchers commented: ‘The results… provide little support for the hypothesis that the DRAMS scheme is superior to simple advice and to no intervention.’

Fifteen years later recruitment started for another study co-authored by Professor Heather, seen as the UK trial closest to routine practice, an essential step in showing ‘potential’ could be turned into public health gains. After suffering from low recruitment to the trial and low rates of screening and intervention, it found no statistically significant evidence that a five- to ten-minute brief intervention by primary care nurses in England was more effective than usual unstructured advice, despite costing nearly £29 more per patient.

Though appreciating the difficulties, in 2006, the year these results were published, Professor Heather still optimistically identified the ‘steadily gathering momentum’ of an ‘international movement dedicated to reducing alcohol-related harm by achieving the widespread, routine and enduring implementation of screening and brief intervention’.

That same year, the UK Department of Health had funded a more definitive study, a real-world test with a sample large enough to detect small effects, overcoming a limitation of the previous two trials. Professor Heather was one of the investigators. For alcohol screening and brief intervention in Britain, the ‘SIPS’ study was critical, intended to help government decide whether to invest in incentivising these activities in GPs’ surgeries – there were also parallel studies in probation and emergency departments.

In March 2012, a conference and factsheets revealed the unexpected results, later confirmed in formal publications: brief interventions as normally understood were generally not found to be any more effective than an unsophisticated 30-second warning to patients about their drinking plus an alcohol advice leaflet:

Thank you for taking part in this project. Your screening
test result shows that you’re drinking alcohol above safe
levels, which may be harmful to you. This leaflet
describes the recommended levels for sensible drinking
and the consequences for excessive drinking. Take
time to read the leaflet. There are contact details
on the back should you need further help or advice.

This terse warning was to be a relatively inactive ‘control’ condition against which the brief interventions could shine. Instead, it captured the limelight. ‘Do just the minimum,’ is the message austerity-hit commissioners might have received, encouraged by the ‘less is more’ take on the findings from the Department of Health’s director of health and wellbeing. In fact, whether any of the advice options were better than doing nothing could not be determined by the trial.

Another important finding was that implementation often required specialist support and patient throughput was low. Though incentivised with per-patient payments, the average primary care practice identified just two risky drinkers a month.

The year these results were revealed, 27 years after embarking on the first trial in Dundee, Professor Heather addressed the key question posed by the title of his article: ‘Can screening and brief intervention lead to population-level reductions in alcohol-related harm?’ The optimism expressed just six years before had evaporated, though not entirely dried up: ‘Widespread dissemination of [screening and brief intervention] without the implementation of alcohol control measures… would be unlikely on its own to result in public health benefits.’

Screening and brief intervention might persuade individuals to cut their drinking, but as a public health tool, it had become relegated to a (still potentially important) adjunct to the primary elements – the availability restrictions to which brief interventions had been seen as a more acceptable alternative.

Of the four requirements for public health benefits, Professor Heather judged only one had been satisfied – evidence that brief intervention ‘reduces consumption to low-risk levels in some of those who receive it’ – and depending on how many the ‘some’ are, even that has arguably not been demonstrated in real-world circumstances. Meeting the remaining three requirements was, he wrote, ‘currently unlikely, either because they are difficult to achieve or because there is no evidence to support them’.

A major gap was that ‘public health potential… is unlikely to be realised without the widespread deployment of universal screening’, something no national health care system had been able to achieve. The ideal scenario of drinking being asked about at every contact with a health professional, followed if indicated by help or advice, ‘might not be tolerated by the general public, not to mention the health professionals asked to deliver it, and might therefore be an electoral liability to any political party supporting it’.

By 2017 his caution was being cited and reinforced by UK and US brief intervention researchers. Their downbeat verdict was that ‘After more than three decades of study in primary care, it now seems unlikely that brief interventions alone confer any population level benefit, and their ultimate public health impact will derive from working in concert with other effective alcohol policy measures.’

What prompted this conclusion was lack of evidence that in real-world circumstances, brief interventions reduce alcohol-related ill-health, coupled with the difficulty of persuading GPs to focus on not-very-heavy drinking when patients often have multiple lifestyle risk factors – and when they and their doctors may be more concerned with here-and-now problems rather than the risk drinking will cause future harm.

It is in the nature of the methodologies used to evaluate screening and brief intervention programmes that the door cannot be closed on the possibility that they can appreciably improve public health – if, for example, interventions are refined and incentives to implement them and checks on quality strengthened. And although wider public health benefits are doubtful, these procedures can benefit individual heavy drinkers.

Nevertheless, the rather intractable worlds of doctors and patients trying to cram their priorities into a ten-minute consultation in which alcohol has no natural place has helped drain the optimism of past decades. Even in relatively ideal circumstances, screening and brief interventions are not likely to affect the numbers needed to substantially relieve the UK of its burden of alcohol-related harm.

Mike Ashton is editor of Drug and Alcohol Findings

The author is grateful for comments from Professor Heather. For the full story and more on brief alcohol interventions click here

Get Connected: DDN Conference issue, films and photos here!

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Supported by:

     

Watch conference highlights:

         

  

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 View speaker presentations:

Sunny Dhadley – SUIT
James Graham – Phoenix Futures

 

 

 

 

 

Dot Turton – Recovery Conections
Stacey Smith – CGL

 

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A huge THANK YOU to all of you who came to the DDN conference and made it a special day. Our speakers were amazing, our exhibitors were out of this world, and it goes without saying that our delegates were the best! We are indebted to our sponsors who made it possible and to every organisation, large and small, who sent representatives and took part in the exhibition.

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One size fits nobody

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With much anecdotal evidence that people are losing their OST of choice, a meeting was held at the DDN conference to ask, ‘are you getting what you want?’ The comments suggest new action points for services.

Drug-related death statistics are well documented and at their highest level since records began. Evidence also tells us that opioid substitution treatment (OST) is protective against opioid deaths, when given at the right dose and for the right duration.

At the DDN conference we took the opportunity to run an interactive session with people in treatment, those who were thinking about it, and others who had experienced it for better or worse. In an informal group, Dr Chris Ford and Stuart Haste invited people to comment on their situation. Could this help to shed light on a lost connection between services and those whose lives – and quality of life – depended on them?

It was clear from the outset that the dwindling state of funding was affecting each group of participants, with many people being told that choice of OST was no longer an option because of cuts: ‘I really wanted to try buprenorphine, as I’d tried methadone twice before. But the worker said I couldn’t have it because it wasn’t right for me and too expensive,’ said one member of the group.

Others were having their dose of OST reduced without their consent, leading to them becoming unstable. In John’s case an abstinence agenda was being used as ‘law’ to reduce his medication: ‘My prescription keeps me alive, and I’ve been on it for a good 12 years,’ he said. ‘But they keep saying I need to reduce – that it’s the law. I know it isn’t, but I have to fight at each appointment. The new staff don’t understand, or believe in, harm reduction – but I’ve seen too many friends die when they stop treatment and I’ve got to live to bring up my kid.’

For those trying to access OST, either for the first time or after a break in treatment, new barriers had appeared.

‘I had to jump through so many hoops to get into treatment,’ said one participant, while another commented: ‘I wanted to try being drug free, but felt very odd and soon relapsed. I asked to come back into treatment quickly so I wouldn’t lose everything but they said it’s not possible to do that because there are rules. I would have been dead when I overdosed if my friend hadn’t been there.’

Climate of Mistrust
This lack of flexibility was cultivating a climate of mistrust. ‘They asked me about my motivation and didn’t like it when I said, “I’m here, isn’t that enough”,’ said one person, while others had become used to feeling that services were not listening to them. ‘If you have your own answers, don’t ask me for mine,’ was Linda’s response to this; while Deb commented that her reaction had been, ‘If you don’t want to listen, tell me what you want to hear.’

In practical terms, services’ unwillingness to be flexible could put an insurmount­able hurdle in front of treatment: ‘I missed the first day of my three-day pick-up because my child was ill and I had to go back for re-titration,’ said one mother.

Some felt that they could not risk being honest about their needs or challenge treatment provision for fear of the consequences: ‘I feel that I can never say what’s going on with me or ask for something like an increased dose, because it means they will probably reduce me or put me back on daily dispensing, which is impossible as I need to live,’ said Angela.

Alisha was confronted with stipulations when trying to access hepatitis C treatment: ‘They told me I needed to reduce my dose before I could start hepatitis C treatment, but I knew they were wrong from going to a HCV support group,’ she said. ‘So I agreed to the reduction but bought some methadone to keep my dose the same. It’s madness that I can’t be honest.’

For many, the stigma of being identified as a ‘drug user’ permeated services and blocked the chances of a trusting and beneficial relationship with staff. Linda had frequently experienced the attitude of ‘there’s a queue over there for people like you’, while Billy’s experience was that ‘one worker said to me on first presentation – we know you people lie, so I will decide what you get’.

‘Top-down’ culture
They also speculated that the ‘top down’ culture of many organisations was affecting staff’s capacity to connect, particularly if they were not allowed to disclose to clients that they had themselves been in treatment.

‘My friend disclosed about her history of treatment and was quickly shown the door,’ said one participant. ‘The service manager’s reason for dismissal was that it was colluding with clients, which must not happen.’

Karl backed up this scenario from personal experience: ‘I was doing really well as a drugs worker and was offered promotion to team leader by my manager. I explained that I needed to share something to show I was honest and committed, so disclosed that I was on methadone. Suddenly I went from star worker to being before a disciplinary for using drugs.’

A trusting relationship with a drugs worker was seen as paramount to success in treatment, right from the entry stage. ‘I really need help but I’m scared of what they might ask me to do before I get a script,’ said Jake, while another participant demonstrated the importance of continuity: ‘I have had six key workers in the last six months – how can that be effective care? It’s a shame as well, because number three really listened, and it was then difficult to go back to the usual situation of not [being listened to].’

‘I never feel heard,’ said Dan, a theme echoed by many participants, including Linda, who described the all-too familiar experience of completing an assessment to enter a service: ‘They ask you how much drugs you are using and when you give your answer you risk being told that you can absolutely not be using that amount of drugs… Whenever I came across a person like that, I just used to say that they should fill out the form for me and I will sign it as they obviously seem to think that they know better than me,’ she said. ‘I feel like walking out as I am being called a liar.’

If she gets through this process, there can be a further wait before being scripted, she explained, and then a ‘carrot and stick’ approach to treatment – ‘but without the carrot on the end of the stick. For example, if you are late for your appointment you may not even be given your script and could be asked to come back another time. But if your worker is making you wait for ages, that’s just tough.

‘Sometimes you come to pick up your script and they’ve changed the amount that you will be taking,’ she added. ‘They have not discussed this with you first, but instead inform you when you come to pick up your script and by then it’s too late to do anything about it. Your script has been written up and it becomes a “take it or leave it” scenario.’

Understanding
For some who could benefit greatly from treatment and advice, the opportunity is negated by the fear that they would be misunderstood and coerced into treatment they did not want or were not ready for.

Tom had considered going into treatment to tackle his long-standing use of pharmaceutical opioids – primarily oral morphine capsules, supplemented with a mixture of codeine linctus and promethazine (known as a ‘dirty sprite’).

‘I have described my use patterns to drug services and asked if I would qualify for substitute prescribing,’ he said. ‘The service workers have said yes in principle, but what put me off going through the process was that I would be unlikely to be prescribed what I’m getting hold of now.

‘The other primary issue for me is supervision… I’d have to use something every day [breaking his usual pattern of spending ‘three days per week fairly euphoric and the other days clear headed’] and how long would I be subject to supervision for? I am hearing of people in different local authorities being stuck on daily supervised pick-up for years with no apparent end point… and that would be a problem – a deal-breaking one – for me.’

Clearly these are important issues that need talking about at the start of a trust-based relationship with a drug worker. The question that seemed to come from the session at conference was: how can we make sure that treat­ment moves beyond ‘take it or leave it’, to be tailored to the individual?

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

Vital Links

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DDN
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The group of NHS providers, NHSSMPA, is looking at new ways to make sure service users stay connected with essential skilled healthcare.

‘Nostalgia isn’t what it is used to be’ goes the quote, but are drug and alcohol services what they used to be? Well no. Historically, before the formation of the National Treatment Agency (NTA), some areas saw two year plus waiting lists for opiate substitution therapy (OST), and investment in alcohol services was severely lacking.

While there had since been improvements in these areas, the combination of commissioning by local authorities, the global financial crash and ongoing austerity has conspired to result in devastating disinvestment in our services.

Disinvestment and retendering cycles have resulted in changes in the skill mix of services, with fewer nurses, doctors and psychologists (those registered with professional bodies) in teams, and an over-reliance on staff without professional registration or specialist training, and volunteers. There has been a significant loss of knowledge, practice and skills along the way, as provider organisations design services that try to manage the reduction in budgets while still meeting need.

The need for high calibre clinical skills and expertise were recently highlighted by two eminent leaders in the field – professors Colin Drummond and Sir John Strang in the Mental Health Times and BMJ respectively. Professor Drummond stated:

‘Without proper care there are serious risks including epileptic fits and hallucinations, brain damage, suicide and risk of overdose. Yet many services do not have doctors or nurses with sufficient specialist training and competence to provide safe care.’

This highlights that registered staff and doctors have been in steady decline, but also that many of those recruited lack the relevant training, supervision and support to ensure high quality provision for complex service users. These experts do exist, but more and more they are in a lead role rather than ‘on the ground’, which can affect their contribution locally. There are only so many hours in a week.

A reduction in budgets means cash-strapped services are able only to work the purest interpretation of the service specification, compounding the effect of smaller budgets with a loss of social capital from providers.

As a sector we have been eager to seek solutions, usually through collaborative partnerships across health and social care. The significant decline in registered staff, including nurses, social workers, clinical psychologists and doctors means it is harder to achieve improvements even when the willingness has been there.

Being able to speak the language of those that you wish to collaborate with has its advantages and enables effective partnership to prosper far more easily. The loss of these posts (and the assurance of the NHS badge) has negatively affected partnerships, most notably with health colleagues.

The continued reduction in professionally registered staff in treatment services is diluting the skills and professionalism required to address the needs of our service users. A recent CQC publication reports on serious concerns uncovered in many of the independent detoxification clinics across the country.

Furthermore, the reduction in registered staff and the number of NHS providers jeopardises the overall standard of care and the ability to forge meaningful ventures to enhance care pathways. In short, the loss of these providers, practice and skills means some drug and alcohol services are relying on limited clinical expertise, to the detriment of care.

Public Health England (PHE) recently commissioned three publications highlighting the importance of the roles of nurses, addiction specialist doctors and psychologists within the drug and alcohol sector (available at www.gov.uk). They are a call to commissioners and providers that these skills and professional contributions are core and essential, and that their loss is having an impact on the overall provision of care as well as putting service users at risk.

As a group of NHS providers, NHSSMPA hopes to contribute to changing this. The following examples show innovations by NHS services where good practice has been implemented to improve the wellbeing of our service users. They also illustrate why retaining an appropriately balanced and skilled workforce is essential.

STREET SEX WORKER INITIATIVE

A low threshold initiative was developed for street sex workers who elected to engage with it, and who were provided with 30mg oral methadone. They could pick up on any or all days, seven days a week, giving them the option of working and a safety net. Two pharmacies were part of the team and would work in partnership, closely monitoring risk. The expectation of the sex worker was that they would attend a three-monthly clinic. Its format was devised by service users and access was available for:

• rape crisis intervention
• genito-urinary medicine services for smear tests and sexually shared infections, high vaginal swabs and any necessary treatments
• family planning for depot contraception injections
• midwives for pregnant service users
• needle and syringe exchange
• condom provision
• vaccination for hepatitis A and B

Direct referral to colposcopy and appointments was provided at the time of attendance, as well as the ability to dress wounds, listen to breathing to identify respiratory disorders, examine injecting sites, monitor drug use and move into mainstream treatment if that was what the person wanted. Apart from the obvious direct benefits for service users it also improved relationships between services and the sex workers’ access to these.

 

Engaging complex clients
Nursing staff learned compression bandaging to work with some difficult-to-engage service users with venous leg ulcers. We worked with people who were not turning up to the dressings clinic, not having doppler studies, continually having breakdown of their ulcers, and suffering widespread infection, cellulitis and venous eczema.

We engaged with their GP practice and developed a shared care type approach. We increased outreach to service users and managed their dressings as per the care plan. We would make sure they attended doppler appointments where the GP and nursing staff would manage the dressings. This allowed a relationship to develop between the service user and the nursing team and allowed us to pull back when the service user was fully engaged.

Derby’s HIT
Derby Healthcare Foundation NHS Trust looked at their care delivery in an effort to address the effect of diminishing resources. They devised a ‘red flag system’ to identify service users most at risk of accidental overdose, through reviewing six years of local mortality data.

The common themes that correlated this risk of accidental overdose were largely expected – continued intravenous use of illicit drugs, erratic engagement, poor physical and/or mental health. But less considered was hepatitis C status and the link with those living in isolation. Other risk factors were a hospital admission in the last 12 months and having a physical health condition such as chronic obstructive pulmonary disease or a deep vein thrombosis. Being prescribed additional medication with a sedating effect by their GP was also a marker.

Collecting and analysing this data identifying who was at risk led to the creation of a health improvement team (HIT) in Derbyshire. This approach was incorporated into a tender for Derbyshire treatment services at the beginning of 2017, and the new service went live in April 2017. The HIT do not carry a caseload, but instead support key workers with their higher risk service users, and the sole focus is on improving their physical and mental health and preventing drug-related deaths.

Those with chronic and deteriorating physical health will have greater priority placed on managing these conditions integrated with their substance misuse treatment. Physical health assessments and advice will be provided by the HIT nurses, including more routine care such as blood-borne virus testing and vaccinations alongside ECG.

The role of nurses was central to the success of the Derby approach, and is fundamental to the other examples provided. Over the past decade or so, nursing and other clinical expertise has been lost – meaning that within drug and alcohol treatment, as many of our service users age and require broader health and social care, clinical expertise is less accessible. The multi-disciplinary team, which includes those with clinical expertise working with other disciplines and those with lived experience, has never been more important.

NHSSMPA is also part of a national working group led by the Royal College of Psychiatrists and PHE, with third sector colleagues, that is trying to reverse the reduction in addiction psychiatrists – an example of the sector responding to an important workforce issue. It is at our peril that we do not ensure that drug and alcohol services incorporate the correct blend of skills and disciplines, including highly skilled clinicians.

Authors are Jon Shorrock, Avon and Wiltshire Mental Health Partnership NHS Trust; Linda Johnstone, Cheshire and Wirral Partnership NHS Foundation Trust; Martin Smith, Derbyshire Healthcare NHS Foundation Trust; Mike Flanagan, Surrey and Borders Partnership NHS Foundation Trust. All are members of the NHS Substance Misuse Provider Alliance (NHSSMPA).

CQC consultation: Have your say!

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DDN
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Don’t miss the chance to change CQC inspections, says David Finney.

The Care Quality Commission (CQC) has recently issued a consultation on changes to the inspection of independent healthcare services, and this includes substance misuse services. The consultation has a deadline of 23 March 2018 for responses and is available here. In my view it is urgent that substance misuse services participate in this consultation, otherwise a key window of opportunity will be lost to influence the practice of the regulator.

The consultation document and previously issued Key lines of enquiry for healthcare services (July 2017) contain very little mention of substance misuse services at all, suggesting that they are being overlooked within regulation.

While CQC still publishes some ‘brief guides’, these mostly relate to detoxification services rather than other residential or community services. In practice there are regional leads for substance misuse services, but below that level the experience of inspectors is variable, so there is a danger of inconsistency in inspections. Specialist professional advisors have been used alongside inspectors, but the overwhelming majority have been nurses or doctors with experience of NHS settings rather than independent residential or community services. Once again, it seems that residential rehabs, in particular, are being marginalised within regulation.

The new approach has positive and negative aspects for the substance misuse sector – however, a key problem at present is lack of engagement with the sector by CQC corporately. A report highlighting the failings of detoxification services has been published (30 November 2017), but no other recognition of the residential rehabilitation services has been forthcoming. When substance misuse services were regulated within the adult social care directorate of CQC, many providers felt that they were not understood by the regulator.

To avoid substance misuse services becoming marginalised within regulation once again, providers need to make an active response to this consultation. The sector should come together and lobby CQC to help it to become the informed and proportionate regulator it aims to be.

Key features of the consultation

CQC say that the aim of their new approach is to be ‘targeted, responsive and collaborative’. They propose that some key developments will be:

a. Unannounced or short-notice inspections:
an initiative to be launched in April 2018. This will be a change from the current practice of giving long notice for announced inspections and mean that providers will not have the opportunity to organise the day so that they can present their service to the inspection team. Neither will they will be able to arrange for service users to be available to speak to the inspector, apart from by taking them out of their existing programme commitments at short notice.

b. A new model for collecting data, called CQC Insight. This seems to match the type of data collection used by the NHS, but may prove difficult for smaller residential services that do not have the data systems available to larger corporate bodies.

c. Rating of services. The characteristics for rating services defined in the assessment framework (KLOE) are very general, and do not reflect what a ‘good’ or ‘outstanding’ substance misuse service looks like. There is the possibility that services may be rated according to the subjective view of the inspector, rather than a recognised benchmark.

d. Changed frequency of inspections: so that outstanding services are inspected every five years, good services every three and a half years, services requiring improvement every two years and inadequate services every year. There is also a provision for ‘special measures’, which will lead to more intensive monitoring. I have two major concerns for services awarded a lower rating: if there is a long time before another inspection, this may adversely affect the availability of the service to local authority funded placements and the business overall; and secondly, it is likely that services will not be able to admit new service users, which will very quickly undermine the business financially and not allow it to recover.

e. Effective use of accreditation schemes. In contrast, this is an opportunity for the sector, because CQC say that these schemes could shorten inspections or even replace them altogether. Although previous accreditation schemes for this sector have fallen by the wayside, this is a new chance to focus on the distinctiveness of substance misuse services.

f. Relationship management. This is about the development of strategic planning and the encouragement of improvement within the sector. Some larger providers already have a relationship manager within CQC, but this function has been inconsistent across the country. So the challenge is to regularise the arrangement so that all providers have the advantage of access to this service.

g. Emphasis on well-led domains. Good leadership and governance is clearly important; however, aspects which tend to feature highly in the consultation are document-based factors such as quality assurance systems and methods for implementing lessons learned. These are relevant, particularly in corporate bodies, but it is equally important to recognise the impact of management, which is in regular informal contact with service users and their progress through recovery.

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

Can we challenge inexperienced CQC inspector?

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DDN
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Nicole Ridgwell answers your legal questions.

Our inspector had insufficient expertise – can we challenge?

Following a recent inspection we were unhappy with our CQC report. We felt that the person conducting the inspection did not have adequate experience of the substance misuse treatment sector and that the specialised nature of our service was not taken into account. Can we challenge our inspection on these grounds or ask for a second opinion from someone with more understanding of residential drug and alcohol services?

This is a scenario we at Ridouts recognise all too well from our regular interactions with substance misuse providers. It is not unique to the sector but is certainly a greater problem here than in some others.

This is because, due in part to the relative youth of the sector in terms of distinct CQC regulation, inspection teams often include no specialist advisors (SAs) with expertise in the field; instead, teams may include SAs with NHS-only experience, contrary to CQC’s published guidance emphasising the important role of SAs in inspections.

CQC’s SA recruitment advert stated that the ‘job purpose’ of an SA was ‘to provide specialist advice and input into the CQC’s regulatory inspection and investigation activity. This advice ensures that CQC’s judgements are informed by up to date and credible clinical and professional knowledge and experience’.

CQC consistently insists that inspection teams attend inspections equipped with individuals skilled and experienced in that specific environment. In the case of substance misuse sector providers, therefore, the appropriate SAs would without exception have substance misuse expertise relevant to that provider. As readers know, the NHS environment is wholly distinct from the independent sector and should rarely be compared. In the absence of appropriate SAs, inspection teams necessarily lack the judgement required for the job; inevitably, mistakes, misinterpretations and simply factual inaccuracies will occur.

Providers should not be afraid to challenge either the conduct or experience-level of the inspection team where this has clearly had an unfair impact on the draft report or seems otherwise inappropriate. This is best done through the factual accuracy process.

Providers should also consider making a formal complaint on conclusion of the inspection, rather than on receipt of the draft report. This stops CQC from alleging that complaints are only raised when providers are unhappy with inspection results.

As said before in this column, challenging factually inaccurate reports and submitting detailed, evidenced complaints are necessary steps all providers must take to safeguard their reputations. All reports should reflect the reality of the service, rather than the prejudice and/or inexperience of the inspection team. Providers must remember that prospective service users and their families will use the finalised report, as will commissioners, to inform decisions about admission.

I also echo David Finney’s article and encourage all providers to actively engage with the new CQC consultation. Providers can help CQC to appreciate the importance of expertise, and indeed the financial, resource and time costs of the legal appeals required to remedy the absence of such expertise. Providers can be the change they want to see, but if they stay silent they will only perpetuate the status quo.

Nicole Ridgwell is solicitor at Ridouts Solicitors

Mark Reid reviews Long Day’s Journey into Night

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DDN
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This is a family story of addiction with all its fragmentations and energy-draining disputes.

O’Neill’s own upbringing is the basis of the play. It was so close to home and raw that he requested it not be performed until 25 years after his death. His widow, Carlotta, chose to honour his brilliance as a dramatist rather than his dying wish. Three years on, in 1956, it was on the stage. It secured his reputation as America’s foremost playwright and earned O’Neill a posthumous, third Pulitzer Prize.

It is around Mary Tyrone’s morphine addiction that the myriad anxieties and tensions swirl. Her husband and two sons all drink way too much whisky. O’Neill’s own mother developed the same dependency from being given morphine to ease the pain of his difficult delivery into the world. As a teenager, he found out about her habit and her neurosis over childbirth. She was ‘cured’ only by menopause which took away childbearing and its fears.

In ways perhaps only a family can be, the protagonists are by turns brutally honest, even plain vicious, and then over-sentimental and imploring each other for understanding and forgiveness. The past and what might have been (if it weren’t for you) are recurring and unresolved themes. Mary had known intense happiness with her husband James and waxes lyrically and endlessly about her perfect wedding dress.

It’s a happiness long gone, after following him everywhere to cheap hotel rooms instead of setting up home. This itinerary echoes O’Neill’s own father’s on-the-road acting career which saw him play the Count of Monte Christo 6,000 times. So in the play, Jeremy Irons plays an actor who could have been a great Shakespearean lead, had he not settled for less.

The men of the family alternate between exchanging strong words in vino veritas and declaring their indelible bonds, according to how much whisky they have had. Yet they seem to think their drinking is just fine; it is Mary’s morphine intake that is the real issue.

Mary is extremely affected by her predicament and especially the suspicions around her. She concludes that ‘the only way (to deal with it all) is to make yourself not care’ and ‘the only past, when you are happy is real’. Mary had originally wanted to be either a nun or a pianist. Her hands are now too arthritic to play, she says, and that’s also why she needs the morphine. She concedes the nun ambition is probably done with.

Review by Mark Reid

The resentments and frustrations constantly exchanged sum up the draining emotions and confusions of active addiction. At times I felt like marching them all off to the nearest Al-Anon meeting.

These are only actors of course – albeit brilliant ones – but if you might feel triggered by watching people drink and dash off upstairs to take drugs, then this might not be for you, although I thought the real cigar and pipe smoke really enhanced the play’s atmosphere.

This is a true tragedy because these are not random characters; people who find each other just because they are drunks and addicts. It is paramount that they are family.

Buffeted by three dysphoric drinkers, Lesley Manville as Mary gives a spot-on portrayal of the capricious addict. You feel for all of them as the natural love which they are too entangled to express is ever more lost to their demons.

Long Day’s Journey Into Night by Eugene O’Neill is at the Wyndham’s Theatre, London until 7 April

 

Media Savvy

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

 

Medical students need to learn, in a compassionate way, about the particular challenges of treating patients with drug addiction. And they need to learn from doctors who are tolerant and compassionate towards patients… phrases like ‘person that uses IV drugs’, in theory, should remind us that we are indeed dealing with a person and not a diagnosis – in the same way that my patient is a ‘person with schizophrenia’ or ‘a person with alcohol misuse’, rather than a schizophrenic or an alcoholic, defined by their diagnosis.
Elizabeth Romer, BMJ, 12 February

You can tell the state of a society, said Alexis de Tocqueville, by its prisons. Today you tell it by its attitude to drugs. Ten years ago the Labour government recklessly upgraded cannabis from class C to class B, ‘because of concerns of its impact on mental health’. Then they were minimal. After reclassification, police evidence is that 95 per cent of cannabis used is now skunk.
Simon Jenkins, Guardian, 1 March

Our prohibition of cannabis jeopardises children’s safety, encourages gang violence and leaves millions in the dark about what they’re taking. This approach has failed and the public know it. More Britons support a legal, regulated cannabis market than oppose it.
Daniel Pryor, Times, 1 March

More than a dozen times I have pointed out here that almost all rampage killers, all over the world, have one thing in common – the use of mind-altering drugs. I am not trying to exonerate them. On the contrary. But I am trying to prevent these things happening in future by being much tougher on illegal drugs, and much more cautious with legal prescriptions. Sometimes it is cannabis. Sometimes it is steroids. Sometimes it is prescription ‘antidepressants’ – themselves a scandal waiting to be exposed and understood. But it’s always there… The USA has always had legal guns, but these massacres are new. What else is new? Mass use of mind-altering drugs, legal and illegal, that’s what’s new.
Peter Hitchens, Mail on Sunday, 4 February

Cuts by councils to funding alcohol and drug treatment services are deeply concerning. Particularly when they come against a backdrop of increasing referrals in some areas. Given the proven links of addiction to mental health and other problems surely the pressing case for investment is self-evident.
Sunday Express editorial, 11 February

Increase focus on older people, royal college urges

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DDN
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Services should increase their focus on older people because of the sheer number of ‘baby boomers’ needing help for substance misuse issues, says a report from the Royal College of Psychiatrists.

Improved training is needed at all levels, including the training of more addictions psychiatrists, says Our invisible addicts, an updated version of a 2011 report from the college. With most substance problems in older people ‘going undetected’ there is an urgent need to improve diagnosis, treatment, education, training, service development and policy, it stresses.

Older people with substance issues face a ‘complex constellation of risks’, the report says, which can result in presentation to a wide range of services including drug and alcohol treatment, primary care, acute hospitals, older people’s mental health, social care, housing, criminal justice and the voluntary sector – in many cases ‘the staff in these settings have little specialist knowledge of how to deal with such complexity’, it adds.

The document calls for a multi-sector approach, improved peer support and development of a clinical workforce with the ‘appropriate knowledge, skills and attitudes’ to provide identification, assessment, referral and treatment – ‘in particular, we see a need to reverse the loss of multi-professional specialist training in addictions that has taken place in recent years’.

While older people respond well to brief advice and motivational therapy – and in some cases can have better outcomes than younger people – there is a ‘paucity of UK-based research and evidence for treatment interventions and services’ around the management of substance use disorders in older people, and the population has also traditionally been under-represented in research studies. It is also vital that people not be excluded from treatment because of their age, stresses the report, which was produced by a working group of professionals across a range of clinical specialities as well as service users.

‘In the 21st century, substance misuse is no longer confined to younger people,’ said working group chairs Professor Ilana Crome and consultant psychiatrist Dr Tony Rao. ‘The public is poorly informed about the relationship between substance misuse and health risks in older people. We need a clear and coordinated approach to address a problem that is likely to increase further over coming decades. By improving our approach to substance misuse in older people from detection to continuity of care, we can also improve both quality of life and reduce mortality in a vulnerable group that deserves better.’

Our invisible addicts 2018 at www.rcpsych.ac.uk

Sustained recovery hugely beneficial for drinkers’ families

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DDN
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The recovery journey of dependent drinkers can ‘markedly improve’ the lives of their family members – as long as the recovery is sustained, says a report from Sheffield Hallam University and Adfam. The research – the first of its kind on this scale and led by Prof David Best – surveyed more than 1,500 family members, around half of whom were parents and a quarter spouses or ex-spouses. Almost 90 per cent of respondents were women.

There are almost 600,000 dependent drinkers in England, and an estimated 222,000 children living with one, while in 2016-17 just over 108,000 dependent drinkers accessed treatment. For those who do enter treatment outcomes tend to be positive, the report notes, with more than 60 per cent completing successfully.

Recovery journeys can be an emotional challenge, says the report.

‘Family members are both a resource to support recovery, and people whose own lives can be transformed through recovery,’ the report says. Those surveyed reported improvements in a range of areas when a dependent drinker was in recovery, including emotional and mental health, debt, problems at work, involvement in the criminal justice system and violence. Around a third of respondents were victims of family violence during their family member’s active dependency, which fell to 10 per cent during recovery, and while more than 70 per cent reported receiving treatment for mental health issues during the drinker’s dependency, this fell to just over a third.

‘Recovery journeys’ can also be an emotional challenge, however, the report points out, with relapses leading to poorer physical and mental health and quality of life. ‘While families as a whole experience significant benefits through the recovery journey of loved ones, not all of the emotional damage is reversed, and relapse undermines at least some of the positive gains,’ it says. Family members need support in their own right, the document stresses, with many respondents struggling to find appropriate help.

‘This report is an invaluable addition to a growing body of knowledge about the impact of substance misuse on families,’ said Adfam chief executive Vivienne Evans. ‘It supports and adds weight to Adfam’s 30 year mission to provide help and support for these families, who are such a key element of recovery and yet need to have a journey of recovery for themselves.’

‘The pressures of caring for a family member who is dependent on alcohol can be overwhelming,’ said Dr Richard Piper, chief executive of Alcohol Research UK, which funded the study. ‘It’s clear that families are a key resource in supporting recovery, and that they benefit significantly where recovery is successful. This research highlights the need for a better focus on families and their role in the recovery journey. In particular, families need better access to support services.’

Family life in recovery available at alcoholresearchuk.org

 

 

The Heart of the Matter

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DDN
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Can we meet six basic challenges to repair a fragmented treatment system, asks Paul Hayes.

Brexit continues to dominate mainstream debate. But far more important to most people, particularly the poor, the marginalised, and the ‘left behind’ is the cumulative impact of years of austerity and the continuing failure of the economy to grow.

The prime minister’s promise to overcome the ‘burning injustices’ which blight so many lives, seems distant. The reality of sluggish growth, falling wages, and slow but steady degradation of the services on which the poor and vulnerable rely, provide the context in which drug and alcohol treatment providers work and our service users live.

Below are six of the key challenges facing the drug and alcohol treatment system during 2018. As the government recognised in last year’s drug strategy, truly effective interventions depend on their cumulative impact. People need adequate access to physical and mental health treatment, a realistic prospect of a job, a safe place to live, and enough income for food and clothing.

Since the financial crash of 2008, the cumulative impact of squeezed budgets and changes in policy have placed strains on service users’ capacity to survive and recover, which treatment providers cannot address in isolation – no matter how brilliantly they implement the drug strategy or how assiduously they abide by the clinical guidelines.

******* ALCOHOL *******

Only one person in six who needs alcohol treatment is able to access it. Alcohol harm is concentrated in our poorest communities, with 30 per cent of all alcohol consumed by 4 per cent of the population. The health damage, the societal consequences and the costs to the NHS are well understood. Despite this, the government has thus far resisted publishing an alcohol strategy identifying how it will reduce the overall harm of alcohol use and in particular how it will close the gap between the growing need for treatment and shrinking capacity. There is growing political pressure for the government to be more active in social policy, and an alcohol strategy would be the ideal place to begin.

******* DRUG-RELATED DEATHS *******

The Local Government Association, PHE, and the ACMD have all identified treatment for England’s heroin-using population as the key to reducing drug-related deaths. Being ‘in treatment’ is a protective factor: deaths are significantly lower within the 60 per cent in contact with services than the 40 per cent who are not. Every local authority commissioner and provider should be striving to understand why people do not access services and find the most effective way to reach them. However, with providers extended to the limit to meet the needs of the 60 per cent, resourcing will be fundamental to success.

******* DISINVESTMENT *******

In 2012/13, total spend on drug and alcohol treatment in the community and prison was more than £1bn. It is now around £750m. Local authorities are increasingly focusing their commissioning on ‘must haves’; protecting rapid access to prescribing services by limiting the availability of the wider services that are crucial to success – those relating to homelessness, mental health, employment, offending, and services specific to gender, culture and communities. As services become hollowed out, the spectre looms of a government committed to recovery presiding over a system which is forced by financial constraints to focus almost exclusively on maintenance prescribing.

******* FRAGMENTATION *******

The 2013 reforms brought drug and alcohol treatment together as the responsibility of local authorities – but elsewhere we have seen fragmentation of provision rather than its integration. Most significantly, as the cohort of heroin users from the late 20th century epidemic age, their need for mainstream health services has grown dramatically. Decades of heroin use, accompanied by smoking, poor diet, insecure accommodation, fragile mental health, and alcohol misuse, has created a population with severely compromised heart, lung and liver function, whose health needs are more akin to those of the elderly than the middle aged. A hard-pressed NHS struggles to respond to those it experiences as ‘challenging’, and service users are easily discouraged by the bewildering range of NHS signposts and pathways.

Health and wellbeing boards, created to knit local authority and NHS services together, are preoccupied with the massive challenge of integrating health and social care and pay scant attention to lower priority issues such as alcohol and drug treatment. The impact of this is that a vulnerable population is excluded from healthcare, resulting in unnecessarily early deaths – in far greater numbers than the overdose deaths reported in the drug-related death figures.

A similar chasm has been allowed to develop between prison and community services. Since 2013 prison drug and alcohol treatment has been commissioned by NHS England and usually delivered within large multi-site contracts with generic healthcare providers. Startlingly this means that neither the Ministry of Justice nor NHS England know how much is spent on drug and alcohol treatment in custody – however the MOJ’s best estimate suggests that prison treatment has also experienced a 25 per cent reduction since they assumed responsibility. Before this, prison and community treatment was commissioned as one system to facilitate effective transfer between the two settings. The failure of the current system is illustrated by the fact that only 30 per cent of those assessed as having a continuing need for treatment on release actually establish contact with a community service.

******* COMPLEXITY *******

The narrowing of local authorities’ ambitions for their specialist treatment systems is accompanied by continuing decline in the generic services that are fundamental to recovery. Despite the government’s laudable commitment to parity of esteem for mental health within the NHS, the secretary of state has acknowledged that the need to recruit and train enough doctors and nurses will delay the achievement of this aspiration for many years.

The abject failure of the government’s Transforming Rehabilitation reforms of the probation service dramatically curtailed the support available to offenders serving community sentences, and on licence following imprisonment. In addition, the probation service is now largely absent from local strategic planning processes in which they used to play a prominent role. While these failings are largely hidden, what is visible in cities across the country is the dramatic increase in street homelessness, which has doubled since 2010 and increased 16 per cent over the past year. This is only one facet of unmet housing need for people with drug and alcohol problems, but it is currently the most visible manifestation of the failure of society to meet the needs of its most vulnerable citizens.

******* CRIME *******

The government’s modern crime prevention strategy, launched by then home secretary Theresa May in 2016, identifies drug treatment as one of society’s most effective tools to reduce crime. Home Office analysis attributes half the rise in acquisitive crime at the end of the 20th century to the impact of the heroin epidemic, and a third of the reduction this century to the improving availability of treatment from 2001 onwards.

The clear connection between heroin/crack dependence and crime made the police strong advocates of improved treatment access, and they were extremely influential players in drug treatment policy between 2001 and 2010. Over the past decade police interest in drug-related offending and their advocacy of treatment diminished as acquisitive crime continued to fall and priorities shifted to sexual offences, violence against women and girls, cybercrime, and terrorism.

Very recently there has been some reawakening of police interest in drug treatment. Traditional crime is beginning to increase; burglary is up by 8 per cent; theft from vehicles is up by 15 per cent; drug-related gang activity is becoming more of a concern and appears to be linked to increasing use of firearms. Use of firearms declined significantly alongside other drug-related offences from 2005 onwards but the most recent crime figures show an increase, including a 20 per cent increase in the use of handguns. None of these increases can be exclusively linked to the drug market, but if ready access to a well-funded drug treatment system helped crime fall between 2000 and 2010 we should not be surprised to see a reversal of the trend.

 

Despite the scale of these overlapping challenges there are reasons to be optimistic that we can find effective ways to respond. The drug strategy is a huge step forward in endorsing evidence-based practice and explicitly recognising the breadth of the responses needed to succeed. The routine denial of issues such as disinvestment and fragmentation that characterised official responses before the publication of the strategy has been replaced with greater willingness to own the scale of the challenge and seek pragmatic solutions. The increase in traditional crime creates a rationale for police to renew their advocacy of treatment, which has significant potential to shape local investment decisions.

Most importantly, the home secretary now chairs a cross-government board to drive this agenda forward. Her leadership, supported by the objective grassroots view of a newly appointed recovery champion, and underpinned by the willingness to hold local authorities to account (via PHE) for their delivery of key metrics, provides the best opportunity in a decade to address the complexity and scope of the problems facing service users and their communities.

Paul Hayes is head of Collective Voice

Commissioning for change

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DDN
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An independent expert faculty has been set up to consider a vital new approach to commissioning. Mark Gilman, Paul Musgrave, Niamh Cullen, Terry Pearson and Chris Lee explain the context and the plan of action.

[slideshow_deploy id=’21561′]

 

Important progress in developing services for managing problematic opioid use has transformed the outcomes for people with serious drug problems. This has been achieved through a balance of innovation and careful allocation of resources.

Coming together as a group of commissioners with extensive experience, we needed to look at the pathway leading to these successes, to enable us to review the challenges facing us today. Our aim was to define questions that are central to the ongoing development of care.

This pathway to developing opioid dependence treatment may be divided into a series of stages, with defining characteristics:

Initial problems related to heroin
The 1950s saw increasing non-therapeutic opiate use, a trend which continued to grow throughout the 1960s. Early strategies to address dependence focused on prescribing opioid agonist medicines, with methadone a common and effective choice for many. Residential rehabilitation centres were set up following relatively unsuccessful results with outpatient treatment.

Exponential growth of the problem
Treatment approaches emerged in the 1970s. Prescribed methadone doses were often challenged and inpatient treatment duration limited in response to increased demand and financial pressures. Subsequent explosive growth of problem drug use in the 1980s and 1990s led to a resurgence in ‘maintenance prescribing’ and introduction of on-site dispensing facilities with supervised consumption. Treatment availability and coverage were lower than they are today, locally governed, commonly led by NHS specialists and funded to provide services in a relatively limited capacity.

Expansion in treatment
The National Treatment Agency was established in the 2000s with the aim of addressing the increasing problem of heroin use by improving treatment availability and reducing waiting times. More resources and organisational change gave rise to a competitive provider market, while new models of care were designed with an emphasis on performance management. Innovative thinking led to a step change in successful outcomes for people with problematic opioid use.

Evolution: a shift in focus
Recently the incidence of new heroin use has reduced. The existing cohort of approximately 150,000 people remains engaged with treatment services, with potentially greater needs related to comorbidity. The treatment system and method has evolved: policy has promoted focus on recovery-oriented and abstinence-based approaches, and concurrent mental health disorders have received greater attention. In parallel a step-down in resources has occurred in many locations, placing stronger focus on the need to achieve efficiency and cost-effectiveness in providing services.

Challenges today
While funding for treating opioid-related disorders is decreasing in many areas, there has not been an equivalent change in working practices to compensate. At the same time, drug-related deaths have been increasing in all four nations, linked to the ageing population and also unexplained factors. In many cases, services are essentially delivering less of the same, which is keeping the system ‘ticking over’. Looking to the future, it is relevant to consider if services are achieving the impact the population needs and deserves. And in parallel, how can we focus on innovation to maintain continuing improvement in outcomes?

There are a number of areas of innovation: use of digital technologies to provide psychological interventions, different forms of opioid agonist medications, and options to better address comorbidities such as hepatitis C virus (HCV) infection. It is important for commissioners to consider how innovation can play a role in continuing to improve care, while balancing budgets. There is already evidence of a new group of injectable opioid agonist therapies from various pharmaceutical companies which, if approved for prescription in UK, may allow treatment to be delivered with injections weekly or monthly.

Current spending with community pharmacies on medications, supervised consumption and dispensing is substantial. There may be opportunity to restructure services to allow direct supply of medications or on-site storage at clinics, allowing resources to be redirected. Understanding the balance between innovation and organisational change is key in this instance.

Evolving treatment options pose questions about the different ways in which therapy is tailored to the needs of the individual. In some cases, medications for opioid dependency are used chaotically as part of a wider cocktail of drugs; for others it is part of a long-term fluctuating but largely stable lifestyle, while for some it is a tool to help achieve recovery or abstinence. Do the services we commission build treatment systems with the ability to tailor interventions to the individual?

Questions may focus on whether all parts of treatment are employed to best effect – particularly psycho-social interventions. Do the treatment services we commission make the best use of the right kind of quality psychological and social therapies?

Considering future optimisation, commissioners should consider the readiness of the workforce providing care. Is the workforce appropriately skilled, and could a smaller number of competent staff be more efficient and effective? Is comprehensive training, supervision and support provided?

Collaboration is also key to future success. Do care pathways remain largely isolated from parts of the public sector that serve the same target audiences? Greater integration with mental health and housing services could help to reduce duplication.

Equally important is the approach to measuring performance. Do the outputs we measure as a part of the commissioning process tell us enough to improve health and wellbeing, while reducing offending and safeguarding fears?

Addressing questions such as these is key if continuous improvements in treatment and social outcomes are to be delivered while managing the balance of resources – an essential equation for commissioners in achieving continuing improvements in outcomes for all.

Key questions for commissioning

1. Planning based on individual needs
How can commissioning approaches assist providers in planning high quality support, by skilled staff, for groups with different aims, goals and characteristics? How can we improve outcomes while focusing resources effectively? We need to consider introducing case management functions and systematic commissioning for mutual aid.

2. New thinking and innovation
Consider how commissioning can build in new thinking to services which may reduce the need for resources directed to managing misuse and diversion risk, and ensure efficiency in medicines delivery – for example, by using innovative product formulations of opioid agonist therapy, which may not require resource intensive use of dispensing services or supervised consumption.

3. Integration and collaboration
Can commissioning ensure that specialist services better align with partner services (mental health, housing, social services, probation, police, justice, etc), to avoid duplication, create efficiency and improve continuity of care? Can we align competencies systematically so that the right skills are used most efficiently?

4. Using the right measures
How can commissioners ensure a complete holistic assessment of impact, including real world measures of health, wellbeing, crime, safeguarding and resource utilisation? Commissioners need to make decisions based on insights from a broad set of outcome measures.

 

This article represents the authors’ personal views.

The right focus

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DDN
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An effective review of commissioning will need input and inspir­a­tion from everyone involved – practitioners, commissioners, and especially those using services. DDN reports.

There have been many calls for a review of commissioning practice as budget cuts have sliced through services and severely curtailed treatment capacity. So the newly formed Expert Faculty on Commissioning’s consultation (page 10) is certainly timely. ‘The financial squeeze on drug and alcohol services will seriously undermine the quality and effectiveness of services,’ says Annette Dale-Perera, chair of the ACMD Recovery Committee, which at the end of last year announced that the commissioning structure needed an overhaul (DDN, November, page 7).

Annette Dale-Perera: Financial squeeze is undermining quality

The faculty’s review offers key questions for commissioning, asking how we can ensure skilled staff are providing high quality support, incorporate innovative thinking, make sure that services are well integrated with partner support services, and consider whether we are using the right outcome measures.

The question of staff skills and training is being addressed by the Federation of Drug Alcohol Practitioners (FDAP), which is now administrated by SMMGP. Interim executive director Kate Halliday explains that FDAP has been developing an apprenticeship for the sector to drive up standards. A ‘trailblazer group’, including major employers in the field, is putting forward a proposal to the Institute of Apprenticeships for a Drug and Alcohol Practitioner Apprenticeship level four qualification.

Kate Halliday: FDAP’s apprenticeships will bring exciting prospects for workforce development

The standardisation of training for drug and alcohol practitioners represents an exciting time for workforce development in the sector, says Halliday: ‘We can hope to see an improvement in the provision of services, the retention of staff and the encouragement of new talent to the field.’ FDAP hopes that the first apprenticeship courses will be ready for roll-out in 2019.

The question of adopting more innovative commissioning practice depends on ‘a fluid dialogue between commissioners and those at the front delivering the services,’ believes Yasmin Batliwala, chair of WDP – whose organisation, alongside Blenheim and Addaction, supports the Drugs, Alcohol and Justice Cross-Parliamentary Group. The group’s recent Charter for Change called for the creation of a national commissioning ombudsman to address failures in commissioning practice.

Yasmin Batliwala: More innovative commissioning depends on a fluid dialogue

‘By establishing firmly this culture of transparency, the often-byzantine process of allocating funding is made that little bit simpler,’ she says. On the one hand commissioners are put at ease, safe in the knowledge that the money is going to dedicated experts and professionals, and on the other, it instils confidence in the providers on the front line, ensuring that they remain valued and supported.

Blenheim’s interim chief executive, Deborah Jenkins, acknowledges that innovation is difficult when commissioners are under such huge pressure to do the best they can, with continuing levels of disinvestment against a rising number of service users. She sums up the ‘lose-lose situation for commissioners, providers and most importantly service users’, as ‘tenders are issued where it is just not possible for even the leanest organisation to deliver’.

‘Commissioners are facing extremely difficult choices about where to cut back,’ she points out. ‘Do they cut back on needle exchanges, which are perhaps an easy choice but which would lead to wider public health risk of an increase in blood-borne viruses such as HIV and hepatitis C? Do they try to commission innovative digital services which, while largely unproven, are cheaper than face-to-face services and don’t require the overheads of premises? Do they decommission the wrap-around employment, training and education programmes that are designed to help people integrate back into society, sealing that final step on the recovery journey, and without which relapse is highly likely? Or do they cut back on children and young people’s services, where the interventions have the greatest possible lifelong impact for service users and their families?’

Deborah Jenkins: Commissioners need to think laterally, focusing on the return on investment

There is no easy answer, she acknowledges, as all these services are crucial in providing highly effective drug and alcohol support services. But her suggestion is that commissioners think laterally, focusing on the return on investment to the wider economy. And yes, she believes there is scope for a more innovative approach.

We need to ask ourselves whether there are better ways of commissioning drug and alcohol services, she says, such as ‘commissioning jointly with CCGs who are responsible for mental health, with police for prevention of drug and alcohol-related crime, and with housing departments.

‘The same vulnerable and high-risk cohort of people appear in the pathways across all these organisations, so let’s take a people-centric approach and a joined-up view of how to address the problem and complexity surrounding substance misuse.’

‘Successful peer-led initiatives take time
and commitment to design, implement
and grow, and like roses are difficult to
revive if allowed to wither and die.’

The question of integrating services has to take service user involvement as its starting point, believes Tim Sampey, founder and chief executive of the peer-run service user charity Build on Belief.

A lot has changed in service user involvement in the past decade, with peer-led initiatives springing up all over the country – ‘Build on Belief and the FIRM in London, Red Rose Recovery and the Recovery Republic in the north of England, SUIT in the Midlands, to name but a very few,’ he says.

‘In the past couple of months, the importance of these service user initiatives has been the focus of both the APPG Complex Needs and Dual Diagnosis People powered recovery report and the EMCDDA paper, User-led interventions – an expanding resource? But where do they sit in the commissioning framework?’

Tim Sampey: Service user involvement needs to be built into tenders

In too many instances, peer-led initiatives are not written into the tender specification at all, he says – or if there are, they are levered into service provision as ‘added value’. In such cases, the specification is often ‘so fuzzy it risks becoming meaningless’, with the vast potential to add valuable layers of peer support and aftercare completely missed.

The practice of ‘whole system commissioning’ excludes many peer-led organisations with strong track records, who are formally constituted as CICs or charities, from taking part in the tendering process unless they can subcontract their services to a major provider, he points out. He acknowledges that some of the big treatment providers have been highly supportive of such organisations over the past few years, but adds ‘the buy-in is not universal, and there are those who think it both cheaper and less risky to keep everything in house.’ And while some projects are directly commissioned by local authorities, ensuring their independence, ‘this practice is not as widespread as it should be,’ he says.

Sampey does, however, have news about a different approach that he hopes will become more widespread. ‘In the past year, two small contracts were put out in Southwark and Medway separately from the main service provision tender, with the specific intention of attracting smaller, bespoke organisations,’ he says. ‘It’s too early to say if this is the beginning of a trend, or an exception to the rule, but such initiatives are far-sighted and welcomed.

‘I’ve also heard stories, mostly from the Midlands and the north of England, of commissioners protecting small peer-led initiatives by making it clear that they must be supported by whichever main provider wins the contract,’ he adds.

He sees this as good practice. ‘Successful peer-led initiatives take time and commitment to design, implement and grow, and like roses are difficult to revive if allowed to wither and die. Clearer provision for them in overall tender specifications, smaller bespoke commissioning, and protection for existing services in whole system commissioning would go a long way to ensuring that a lot of the effort, innovation and creativity put into the wider service user involvement agenda over the past decade is not lost.’

As Sampey points out, working with service user networks is invaluable in informing consultation documents and strategy papers around complex needs. An important factor in getting this right is to connect effectively with the many other support services, rather than commissioning for substance misuse as a separate entity.

‘The drug strategy acknowledges that the drug strategy in isolation can’t deliver the changes that most people need in their lives – the need to incorporate changes around employment, accessing mental health and physical health services, offending, domestic violence, and caring for your children,’ says Paul Hayes, head of Collective Voice and former head of the National Treatment Agency (NTA). ‘Drug treatment makes a vital contribution to all of those things, but in isolation won’t address any of them.’

Paul Hayes: Drug treatment cannot be delivered in isolation

Commissioning will need to be informed by broader measures than relying solely on the Treatment Outcomes Profile (TOP), he points out. ‘Just as a whole range of services need to be available to people with drug and alcohol problems, so outcome measures need to reflect what’s happening to people’s lives with broader communities, within all of these domains,’ he says.

‘TOP is an excellent way of identifying the progress an individual is making towards addressing a number of those issues, but in isolation can’t tell the whole picture about the impact of drug misuse, or its cumulative impact, along with other services, for whole communities.’

The DDN conference on 22 February will give the opportunity to get involved in the commissioning consultation.

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

 

Most UK cannabis now ‘high potency’ 

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DDN
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Almost 95 per cent of cannabis seized by police in 2016 was of a high potency variety, according to a report from King’s College, London and GW Pharmaceuticals. Researchers analysed almost a thousand police seizures across the country and found that 94 per cent were of strong ‘skunk’ sinsemilla, compared to 85 per cent in 2008 and just over half in 2005.

Increase in potency is significent risk to mental health, says report’s author Marta Di Forti

The study, published in the Drug Testing and Analysis journal, found that the stronger varieties’ market dominance was the result of lack of availability of weaker cannabis resin, which could account for as little as 1 per cent of the product in the London area. While cannabis resin is usually rich in cannabidiol (CBD) – thought to help moderate some of the effects of the psychoactive component THC – this is often absent from sinsemilla. Stronger cannabis strains are thought to be a contributory factor to increasing first-time admissions for drug treatment, says the study.

‘In previous research we have shown that regular users of high-potency cannabis carry the highest risk for psychotic disorders, compared to those who have never used cannabis,’ said senior author Dr Marta Di Forti. ‘The increase of high-potency cannabis on the streets poses a significant threat to users’ mental health, and reduces their ability to choose more benign types.

‘More attention, effort and funding should be given to public education on the different types of street cannabis and their potential hazards,’ she continued. ‘Public education is the most powerful tool to succeed in primary prevention, as the work done on tobacco has proven.’

Study at http://onlinelibrary.wiley.com/doi/10.1002/dta.2368/abstract

Scotland confirms alcohol minimum unit price at 50p

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DDN
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The Scottish Government has confirmed that it will recommend the country’s minimum price per unit of alcohol be set at 50p, following the results of a public consultation. Minimum pricing is set to come into force on 1 May, after a five-year legal battle with the drinks industry (DDN, December/January, page 4), and the 50p recommended price will now be laid before parliament.

The consultation received 130 responses, almost equally split between organisations and individuals. Nearly three quarters of those who commented on the 50p price were supportive while 17 per cent felt it should be higher and 5 per cent thought it should be lower.

Shona Robison: This move will save thousands of lives.

‘I am grateful to everyone who took the time to respond to the consultation on our proposed minimum price per unit of alcohol and I am happy to confirm that we will be moving forward with our recommendation of 50 pence,’ said health secretary Shona Robison. ‘With alcohol on sale today in some places at just 16 pence per unit, we have to tackle the scourge of cheap, high-strength drink that causes so much damage to so many families. This move will save thousands of lives.’

Scottish Liberal Democrats leader Willie Rennie, however, has called for the price to be set at 60p to reflect factors such as the impact of inflation.

‘In excess, alcohol wrecks lives, families and communities,’ he said. ‘Low prices for decades have increased that harm caused in Scotland. Inflation has eroded the value of the original minimum price during the years that this policy has been caught up in the courts. That is one of the reasons why Scottish Liberal Democrats pressed the Scottish Government to introduce a higher rate but ministers have bottled it. With hospitalisations on the rise, we need to see the Scottish Government do far more to tackle the scourge of alcohol abuse.’

Meanwhile, a new report from the University of Sheffield’s alcohol research group, commissioned by the Welsh Government, has found that three quarters of all alcohol drunk in Wales is consumed by less than a quarter of the population, with just 3 per cent of harmful drinkers consuming 27 per cent.

Nearly 40 per cent of all alcohol bought in Wales is sold for less than 50p per unit, it adds. Last year’s Public Health (Minimum Price for Alcohol) (Wales) Bill (DDN, November 2017, page 4), is set to introduce minimum pricing if passed by the National Assembly for Wales.

‘People who drink alcohol at hazardous and harmful levels drink 75 per cent of the alcohol consumed in Wales,’ said health secretary Vaughan Gething. ‘The report shows the greatest impact of a minimum unit price would be on the most deprived harmful drinkers, while moderate drinkers would experience only small impacts on their alcohol consumption and spending.’

A level playing field

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DDN
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Effective treatment starts with a meaningful partnership, says Dr Steve Brinksman.

We recently had a new doctor join our practice who had worked elsewhere for a number of years. I was chatting to her about how she was settling in and interested to hear that she felt the biggest difference was that we were a genuine partnership working together, whereas where she worked previously she’d felt that she’d been a partner in name only.

This led me to ponder on the many occasions we are in situations with clients that are essentially unequal in terms of who holds the power, and how this can cause dysfunctional relationships. Sometimes this is due to pushing back against perceived authority, and sometimes from complete passivity – neither of which is likely to produce the best outcomes.

Gary had been in and out of treatment for years; he knew more about substance use and misuse than most doctors and he knew it. However he also frequently used on top, was in and out of prison, and was hep C positive. He had dropped out of treatment with the community treatment agency about six months before registering with us.

The first time we met I let him talk, and the second and probably the third and fourth as well, then gradually we started to explore what had happened in his life and what he really wanted. By now he was on 60mls methadone and still using heroin and crack a couple of times a week. I was keen that he increased his medication dose to see if we could stop the on-top use; he wasn’t.

Despite his bravado and subject knowledge about street drugs it became apparent that he had very low self-esteem and that this was tied in with his poor literacy. We have an excellent adult education college in Birmingham and with a little encouragement he eventually contacted them and started a course to improve this.

The change in Gary was profound. He started to develop real confidence, rather than just a front. He met people who had struggled like him, and who like him were looking to make a positive change. He stopped his own ‘use on top’ without ever agreeing to an increase in medication dose.

I thought I knew what was needed for Gary from a medical perspective, and yet what was really needed was for us both to form a real partnership where he had the confidence to talk openly about what mattered to him and I listened and helped him achieve his goals.

Whatever our professional role may be, the balance of power seems heavily stacked in our favour by those we see. We need to realise this and make an extra effort to develop meaningful partnerships that facilitate change rather than impose it.

Steve Brinksman is a GP in Birmingham, clinical lead of SMMGP, and RCGP regional lead in substance misuse for the West Midlands. He will be speaking at the DDN Conference on 22 February.

SWEAT – a new project for steroid users

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DDN
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A new project is helping steroid users to recalibrate their lives while providing evidence for better treatment, says Jody Leach.

At Open Road we launched a project – Steroids, Weights, Education And Therapy (SWEAT) – in 2017 in direct response to the growing number of steroid users accessing our needle exchange programmes across Essex. SWEAT is funded by The Big Lottery and tackles the increasingly complex needs of those using image and performance enhancing drugs (IPEDs). The service is based in needle exchanges, where steroid users are first identified, and offers support to those who are using, thinking about using, or have previously used IPEDs.

We work alongside local gyms and pharmacies to promote our SWEAT contact points, but the project goes way beyond generic needle exchange provision. We ensure access to specialised psychosocial interventions, harm minimisation programmes and educational resources to dispel myths and promote understanding of the potential side effects and long-term harm of IPED use.

Our project guides clients through post-cycle therapy (PCT), good diet and nutrition, training regimes and sleep, to support them in making informed decisions about steroid use. A combination of one-to-one sessions with specialist workers and formal in-house counselling allows them to explore their motivators for using and the impact this lifestyle could be having on their mental health and relationships.

SWEAT is a three-year project and will be formally evaluated in collaboration with the University of Essex, with the intention of informing IPED-specific service provision at both local and national level. In April we will be running a conference, ‘A Shot in the Dark’, to bring together experts, practitioners and support services to learn, inform and share their expertise in IPEDs and to hear about the impact of our project in its first year of operation. Among the speakers will be Prof Jim McVeigh, director of the Public Health Institute at Liverpool John Moores University.

‘The use of anabolic steroids and other IPEDs amongst the general population is now a recognised public health issue,’ he says. ‘However, there are few services providing and evaluating interventions for this population. While some of those beacons of good practice remain, others have fallen victim to the current funding crisis. The SWEAT Project is an exception and an important development, not just for the population it serves, but in generating evidence of effectiveness.’

There are many health implications associated with IPED use, with physical risks ranging from superficial harms such as acne and balding, through to sexual dysfunction, cardiovascular disease and impaired liver function. Injecting-related harms are a potential feature of steroid use, with site swelling, abscesses and exposure to blood-borne virus infection being possible. Users’ mental health can be impacted in varying degrees, with changes in mood, levels of aggression and an impact on general psychological wellbeing relating to existing body image and/or self esteem conditions.

IPED users rarely view their behaviour as being similar to users of other substances. This mindset results in many users being reluctant to access any formal treatment services outside of generic needle exchange programmes. Consequently, IPED users are less likely to recognise and acknowledge, let alone address, the potential risks and behavioural issues associated with this group of substances.
Jody Leach is SWEAT project manager and quality coordinator at Open Road

‘It helped me help myself’

Most other services just give you your needles, but SWEAT actually listened, says Justin

Justin was a long term steroid user. During 20 years of use, he recognised that steroids were having serious negative effects on his life but he was afraid of letting go of the habit and he didn’t know how to stop. In particular he feared damaging his relationship with his wife and young family, if his image changed.

Justin constantly feared losing respect from his children – they were proud of his hulk like figure, often asking him to ‘show off his muscles’ to their friends – and he was afraid of how they would feel about him if he stopped using steroids became just an ‘ordinary dad’.

He also felt that his steroid abuse was affecting his libido but did not know how to tell his wife for fear that she would feel it was her fault. He had been using steroids for so long he feared that, even if he stopped now, it was too late for his testosterone levels to return to normal and he worried about any withdrawal effects on his mental health. Justin knew he got the short term boost from steroids he needed, but he also realised it was time to stop.

Justin discussed his options with the SWEAT worker and we looked into ways to boost testosterone naturally through diet, workout regimes and mind-set. We then looked at how to reduce his dependency and eventually cease his current cycle of behaviour. We discussed what his side effects or ‘come down’ may be, to prepare him.

As Justin’s testosterone levels started re-balancing, he was ready to cope with the low moments and he stuck with the programme. A new healthy diet and workout regime meant, to Justin’s surprise, that his testosterone levels began to return to normal after a few months – he even kept most of his ‘pumped-up’ physique.

He also conquered all the self-doubt and re-built his self confidence. His relationship with his wife is now more honest and fulfilled, his children are even prouder of their father, and he spends more time with them now because he is no longer obsessed with weight training. And he’s no longer feeding dodgy suppliers with cash that should be spent on his family.

‘SWEAT is the first service that actually listened to my needs and understood the difficulties behind my steroid misuse,’ he said. ‘Most other services just give you your needles and don’t ask how you are.

‘The team gave me hope and helped me help myself into a sensible diet and fitness routine, and I would probably still be using now with no way out, if I hadn’t found them.’

Open Road’s conference, ‘A Shot in the Dark: Steroids, IPEDS – the hidden harm’ is on 26 April in Colchester, Essex. Details and booking here

Anxious times

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Shocked by cases in his constituency, Bambos Charalambous MP is calling for government action on Xanax.

The powerful sedative Xanax is being used by young people across the country (DDN April, page 6). Some are taking it to self-medicate to cope with anxiety, while younger teenagers are being groomed and exploited by drug dealers taking advantage of the drug’s ‘zombie-like’ effects.

On 15 January, Xanax was mentioned for the first time in the House of Commons chamber. I held the debate to bring to light a disturbing case of a 14-year-old girl in my constituency who had become hooked on the drug. Her mother had contacted me shortly after I was elected to ask for my help and this was the first time I had heard of Xanax. I then became aware of how widespread its use is.

For the next six months, I pretty much asked every young person that I met if they had heard of Xanax. They almost laughed in my face at my ignorance and I’ve since been instructed to use the word ‘Xanny’. I’ve now listened to more rap music than I ever thought I would and was utterly shocked by the selfie Youtube video shot just six hours before the death of Lil Peep from a Xanax overdose.

Some young people in their early twenties told me that they easily buy Xanax online for as little as £1 a pill and use it to self-medicate for their anxiety. This is worrying enough, but the case of my 14-year-old constituent is far more sinister. Zoe (not her real name) was a bright and popular girl with lots of friends, but after she was approached by an older girl at her school and an ex-pupil, she started going to private raves and parties in houses across North London. She was swept up in a whirl of excitement by this new lifestyle and was introduced to Xanax, mixing it with alcohol and becoming sedated.

Zoe would go missing for whole weekends and would come home with marks and bruises on her arms and legs with no recollection of how she got them. The vulnerable state that Xanax puts users in leaves them extremely vulnerable to abuse, and who knows what happened to Zoe – she certainly can’t remember. On some occasions, Zoe became aggressive towards her mother and after a fraught evening she ended up spending the night in a police cell. Again, she had no recollection of any of this.

Despite help from the police and abduction warning notices that were served on six people, Zoe was now being heavily groomed. ‘Baggies’ were hidden in Zoe’s bedroom and things took a turn for the worse when Zoe and her best friend were found in a mess on the school premises after taking Xanax. Zoe wasn’t excluded and was allowed to stay on at school with some extra support services. Zoe’s mother, and the school tried their best but she was still able to get hold of dirt-cheap Xanax, peddled by a dealer from a booth in a McDonalds restaurant right next to a police station. All the information that had been pieced together was passed on to the police who arrested three people on drug-related charges in December. This was not before Zoe and her best friend were found to be drunk on the school premises and then permanently excluded from school.

Whether the glamourisation of Xanax use is a matter of art imitating life or life imitating art, the problem is certainly a real one in the UK. The truth is that there is a cultural and age divide and, for whatever reason, the fact remains that Xanax is the drug of choice for some young people. Maybe it’s because it helps numb the pain, maybe it’s because it is fashionable, maybe it’s because it is cheap and easy to get hold of – I can only speculate. I’ve called on the government to research the prevalence of Xanax use in the UK, to raise public awareness about the effects and potential harms and to provide specialist support for those who have developed a dependency.

Bambos Charalambous is MP for Enfield Southgate

West Midlands PCC proposes consumption rooms and prescribed heroin

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DDN
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A range of proposed harm reduction measures to cut drug-related crime and deaths, and reduce costs to public services, has been set out by West Midlands police and crime commissioner (PCC) David Jamieson. They include prescribing heroin in a medical setting for people who have not responded to other forms of treatment, establishing a formal scheme to divert people away from the courts and into treatment, and ‘considering the benefits’ of consumption rooms.

Other measures in the PCC’s report include joining up funding streams for police, public health and community safety to increase efficiency, introducing on-site drug testing in the night time economy, and equipping and training police in the use of naloxone. More money could also be seized from large-scale drug dealers to invest in treatment, it says.

Half of all burglary, theft, shoplifting and robbery in the region is thought to be committed by people with serious drug issues, at a cost of £1.4bn per year. Jamieson’s announcement follows similar proposals from other PCCs including those for Durham (DDN, March 2017, page 4) and North Wales (DDN, September 2017, page 5).

‘Despite the good work being done by many, collectively our approach to drugs is failing,’ said Jamieson. ‘It means people are forced to live with more crime, public services are put under strain and not enough is done to reduce the suffering of those who are addicted. If we are to cut crime and save lives there’s one thing we can all agree on; we need fresh ideas. These are bold but practical proposals that will reduce crime, the cost to the public purse and the terrible harm caused by drugs.’

Jamieson wanted to see many of the measures ‘in place and having an effect’ by the end of his term of office in 2020, he said. ‘I will be working with partner organisations intensively over the coming period to deliver on these practical and common-sense proposals.’

The announcement has been welcomed by organisations including Release, Transform, the Association of Police and Crime Commissioners and the Royal Society for Public Health (RSPH). The recommendations were an ‘important and welcome contribution to the growing momentum behind common sense drug policy reform in the UK’, said RSPH chief executive Shirley Cramer. ‘Health professionals, police, and the public are all agreed that a public health – rather than criminal justice – approach to drug policy is what is needed to tackle rising rates of drug harm in this country and beyond. It is heartening to hear more influential voices, with on the ground experience of these issues, give these measures their backing.’

The measures ‘would undoubtedly save lives if implemented’, added Release executive director Niamh Eastwood. ‘Yet again, the police are leading the way in the debate for drug policy reform while the government continues to pursue the failed approach of prohibition and criminalisation. The government must consider the insight of police officers, many of whom are on the frontline of the so-called war on drugs, witnessing the horrific impacts that prohibition has on communities every day.’

 

 

 

‘Get Connected’ – The DDN conference programme

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DDN
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Thank you to everyone who made the conference a success. Watch this space for photos, video and our special conference issue of DDN!

 

Here’s what happened on the day…

DDN conference, 22 February 2018
The New Bingley Hall, Birmingham

9.00-10.00am – Registration

10.00-11.15am – Opening session. Chair: Claire Brown, DDN editor
Welcome, setting the scene, making the most of your day. Introducing the ‘Get Connected’ theme and the DDN ‘Wider Health’ initiative.

Treating the whole person: Stacey Smith looks at addressing linked conditions and better healthcare through a journey of hepatitis C treatment.

Finding the right match: Sue McCutcheon considers screening, outreach and getting into treatment, whatever the health need.

It takes two – the unwritten contract of mutual respect: Nick Goldstein shares experience of communicating effectively with healthcare professionals to get the best from the therapeutic relationship.

What a team: Dr Steve Brinksman explores the best kind of patient-doctor alliance.

11.15-11.45am – Refreshments

11.45-1.00pm – Session two

More than bricks and mortar: James Graham shows how supported housing can open so many doors.

Current data on prevalence and harms, and your experience on the ground: Session led by Pete Burkinshaw and a team from PHE. This session will give an overview of some of the key data and engage you in an ongoing conversation about trends and causes, and whether the data reflects your experience.

We’re listening to you: an interactive session with the Faculty of Commissioners on planning addiction care services for the future. With Mark Gilman, Terry Pearson, Paul Musgrave and Kerrie Hudson.

 

1.00pm- 2.30pm – Lunch and networking.
Enjoy the amazing DDN Exhibition, with information, expertise, and peer-led support groups. Special features include dedicated zones for health, training and employment, support and advice, and wellbeing; naloxone training and kits; and taster therapy sessions.

2.30-4.00pm – Session three

Returning to learning: Dot Turton explains the dynamic initiative called collegiate recovery, helping students in higher education to thrive.

Thinking about drinking: Ben Parker and Chris Campbell explain their pathways for reaching clients with harmful alcohol use in their homes, so they can start their wellness journey whatever their health problems.

Get connected!: Sunny Dhadley shares inspiration on how you can make the most of potential to widen your horizons.

 

 

Book here

 

Partner up

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DDN
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Co-production and partnership working can help organisations thrive in troubled times. DDN hears from the MD of Equinox Care and Penrose Criminal Justice Services, Kelly Hallett.

‘As a sector we can still do more to work together to find better or more innovative ways of pooling resources and supporting people,’ says Kelly Hallett. ‘Certainly one of my priorities is to identify more opportunities for us to be building these relationships and combining expertise.’

Joined-up working is a subject she knows quite a bit about – late last year she was appointed MD of Equinox Care and Penrose Criminal Justice Services, both of which are part of the Social Interest Group (SIG), which was established as a charity in 2014. ‘At the time Equinox was looking for a merger partner and Penrose wanted to build a much stronger infrastructure, which it couldn’t afford on its own,’ says Hallett. ‘SIG was the answer.’

The group now includes five charities, and provides the framework to support them and help develop their strategies. This means organisations can remain true to their charitable aims and retain their own boards while benefitting from being part of a ‘much bigger picture’, she explains. ‘It’s about strengthening our charities by opening up opportunities to freely learn from each other and innovate, working closely together and remaining financially robust enough to enjoy the back-office services that they could not have achieved on their own.’

The new MD role offers the opportunity to ‘lead two charities as businesses that truly care about individuals’ recovery and rehabilitation’, she says. ‘I have great ambitions for Equinox, Penrose and our service users.’ She’d worked at Penrose for more than six years, rising to director of operations and director of criminal justice services, before taking on the current role. Before was Turning Point – first as regional manager for Kent and then assistant director for substance misuse – and before that a period in prison drug treatment. ‘I started as a volunteer, progressing to CARAT worker, CARAT manager and then eastern area manager, overseeing 11 drug treatment services in prisons across the East of England,’ she says.

So was the drugs sector something she’d always been interested in? ‘Not specifically. I always knew I’d work with vulnerable people and I always had an interest in prisons. Many years ago I worked with the elderly, then I had a temp job in a prison doing admin which gave me the opportunity to be introduced to the prison substance misuse team. I started volunteering with them in 2003, which led to a job within the team – this field has captivated me from day one, and I’m still very grateful to have been given that volunteer position.’

Drug treatment in prisons is obviously facing hugely challenging times, with the consequences of the dramatic increase in NPS use making regular headlines. What could be done to improve treatment provision in the current climate? ‘I think that whilst there are some excellent examples and outcomes out there, there are still many challenges to providing effective, choice-based treatment,’ she says. ‘The cuts to funding and staffing are well known, and the environment itself is restrictive – prisons are facing their own challenging times. Access to, and movement of, prisoners is not always easy, and prison regimes often mean that it’s hard for meaningful activity to take place – boredom and lack of daily structure can be very demotivating.’

Despite all the evidence showing that ‘safe environments improve outcomes’, access to specific resettlement, wellbeing or drug-free wings isn’t always an option, she points out. ‘And we need to think about where we locate offenders post-treatment within a prison setting.’ Healthcare-led models can also dilute the emphasis on treating substance problems, she adds. ‘The focus on overall wellbeing is welcome – we know that offenders will almost always have many needs – but it does mean that there are fewer opportunities for intensive treatment for offenders. I think every positive outcome achieved in a prison is a testament to the skill and dedication of the support provider.’

In terms of the specific challenge of NPS, their use has changed the prison landscape ‘significantly, if not completely’, she states. ‘There isn’t an easy answer. Availability is high, it’s difficult to detect, and it makes an already difficult environment even harder in terms of treatment and – from a prison perspective – control.’

Education around the risks and effects needs to be dramatically stepped up, she stresses, with the allocation of dedicated resources alongside more action to interrupt supply. ‘It should be a top priority – the introduction of NPS has created the perfect storm, and I don’t think we saw it coming in time to be anything other than reactive.’

A key concern that predates the NPS crisis is the crucial period immediately after release, when the risk of overdose can be high. What kind of support should organisations be putting in place? ‘We know from experience and data that the take up of treatment post-release is lower than anyone would like, and there are many ways it could be improved,’ she says. ‘We’re still in the position where a great many offenders across the country walk out of the gate on release alone, and that can be scary – no matter how many appointments have been made – and transition between support and/or treatment agencies can be particularly hard for some.’

Many prisoners will have multiple needs to address, and little support when it comes to safe and positive influences – just trying to navigate services can feel overwhelming. While peer support and ‘meet at the gate’ services can undoubtedly be effective they remain underfunded, and those that do exist struggle to meet the demand. ‘A true through-the-gate model that holistically supports offenders through that first few weeks would be welcomed by many agencies,’ she says. ‘Then there are the challenges of working effectively with someone who may only be in prison for a few weeks, or remand prisoners who come and go so quickly and yet can have the highest needs.’

Our current sentencing system also means we’re ‘still sending far too many offenders to prison for short periods’, she says, which mainly serves to ‘disrupt already unstable lives further’. Far more people would benefit from intensive drug and alcohol treatment, mental health treatment or both, she states. ‘I am determined for Penrose Criminal Justice Services to successfully develop and promote alternatives to prison for this cohort – and we haven’t even touched on the need for safe and secure accommodation.’

When it comes to populations whose needs have traditionally been under-served by the sector perhaps the most obvious is women, and part of her remit was to set up a residential complex needs service in Brighton, which opened last month. How important are specialised services like this in the sector? ‘There’s such a need for female-specific services,’ she says. ‘Demand for our service is high, and that’s just three weeks in. These services are essential, and there need to be more. We’ve been able to create a safe, female-only environment, and all of the evidence shows us that when women feel safe and are appropriately supported they achieve greater independence and higher self-esteem.’

The women in the service have ‘multiple and very complex needs,’ she continues. ‘Lots of emotion, lots of trauma – domestic violence and exploitation is a prevalent need – and all of our residents have chosen our service because it’s female only. That speaks volumes in itself. Women in our service are able to articulate themselves away from stigma, away from control, and reflect. They’re supported with all individual needs within the service, including those who have children, and what we can’t provide ourselves we bring in. Brighton has some amazing partnership working, some of the best that I’ve seen anywhere – there’s clear progression within the service towards independent living and this gives our women hope. I definitely plan to develop more female-only services in the near future.’

As someone whose experience covers substance use, offender services, mental health and more, how far has genuine joined-up working become a reality? ‘I think things have improved, but there’s still a long way to go,’ she says. ‘Again, there’s a mix of examples in the field, from excellence to non-existence. It’s always troubling when we meet service users who have failed in recovery or resettlement simply because they couldn’t navigate, or find cohesiveness between, community support services. Just a few months ago I was talking to a service user who had had eight assessments from different services in ten days. Is this really where we still are?’

The flipside of that is the excitement that comes with seeing great services or innovation, however. ‘I come away thinking “I want that!”’ she says. ‘It’s not always reflected in data – what I want to see is the tangible impact. I hope that one day health and social care can be used in the same sentence in a much more meaningful way. They’re all too often miles apart.’

The answer ultimately lies in ‘truly joining things up solely to the benefit of service users, co-producing services and improving access using their experience – they really do know best’, she states. ‘To see that across the board would be phenomenal. It’s actually one of the biggest strengths of the Social Interest Group – we have all of that expertise under one umbrella and we can work in a very cohesive way to offer more joined-up services, but it’s more than just us.’

So what sort of strategies should the voluntary sector be adopting generally in these challenging times? ‘Co-production and partnership working – there are so many great organisations out there, and many examples of organisations really strengthening their offerings to service users by joining forces.’ Funding keeps going down while demand keeps going up, and there’s ‘still a lot of duplication in what we do and how we do it’, she says. ‘We could be working together in a much more powerful way to influence and deliver real change in the sector – both locally and politically. We’re so good at what we do – our voices should be heard more.’

Training key to boosting alcohol brief interventions

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DDN
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Targeted training leads to a ‘significant increase’ in the delivery of alcohol brief interventions in primary care, according to new research. Specifically trained nurse mentors are able to play a key role in leading and delivering interventions and brief advice (IBA), says the study, which was funded by Alcohol Research UK and conducted by SMMGP.

Even provision of a ‘relatively low level of support’ to nurse mentors can lead to a significant increase in the delivery of IBA, it says. Supporting nurse mentors to lead on their implementation can help reduce alcohol-related harm ‘within existing resources’ in primary care settings, while awareness raising and training across the practice also help staff become better at both identifying harm and providing effective advice to those at risk.

NICE guidelines urge the prioritisation of IBA as an ‘invest to save’ measure, as around one in eight ‘higher or increasing risk drinkers’ receiving it go on to lower their consumption levels. However uptake in primary care has been patchy through a combination of issues such as perceived lack of staff support, confidentiality concerns, low levels of monitoring and a feeling among professionals that they lacked the necessary knowledge, skills and ‘role legitimacy’.

‘The primary care team has great strengths in identifying, assessing and preventing health harms,’ said the study’s lead author, Dr Steve Brinksman.

Dr Steve Brinksman: potential for reducing alcohol-related harm within existing resources of the surgery

‘By supporting nurse mentors in leading on the implementation of IBA there is potential for reducing alcohol-related harm within the existing resources of the surgery. This could support primary care in the practical implementation of an evidence based cost effective intervention which has experienced patchy uptake.’

‘Alcohol brief interventions are a key component in helping to identify people at risk of alcohol harm and in giving them the best advice to reduce that risk,’ added Alcohol Research UK’s director of research and policy development, Dr James Nicholls. ‘But, despite the benefits, such interventions are not always implemented effectively. This research shows that with improved leadership, knowledge and training, alcohol brief interventions can bring about important benefits in primary care settings to those drinkers who are experiencing alcohol-related harm.’

Supporting nurse mentors to reduce the barriers to implementing alcohol interventions and brief advice in primary care available at alcoholresearchuk.org

Record number of drug-related mental health admissions

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DDN
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There were 82,135 hospital admissions with a primary or secondary diagnosis of drug-related mental and behavioural disorders in 2016-17, according to figures from NHS Digital, up from 81,904 the previous year. The total is nearly double the 38,170 figure from a decade ago, although NHS Digital says this increase will be ‘partly due to improvements in recording of secondary diagnoses’.

The number of admissions with a primary diagnosis of drug-related mental and behavioural disorders, however, was down by 12 per cent in 2016-17, to 7,545, although that figure is still 12 per cent higher than a decade ago.

The figures are from the ‘hospital episode statistics dataset’ section of NHS Digital’s annual Statistics on drugs misuse report, which is a compendium of new and previously published data. Around a third of people admitted for drug-related mental and behavioural disorders were in the 25 to 34 age group, while just over a quarter were aged 35 to 44. Three quarters of those admitted were male, with the highest admission rates in Liverpool and Hull. The highest admission rates for a primary diagnosis of poisoning by illicit drugs were also found in the 25 to 34 age range, the report states.

Karen Tyrell: Harm reduction must be taken seriously

‘People with both mental health and substance misuse issues can find it extremely difficult to access mental health services,’ said Addaction spokesperson Karen Tyrell. ‘All too frequently mental health services refuse treatment because a person is not abstinent, or has not been abstinent for a sufficient length of time. This is despite government guidance and best practice. Getting people connected with community services at an earlier stage could prevent hospital admissions.

‘It’s positive that the numbers have come down over the past year, but we know that there is still a long way to go before they could be said to be acceptable. Harm reduction must be taken seriously and services such as needle exchanges must be adequately provided across the country.’

 

Statistics on drugs misuse, England 2018 at digital.nhs.uk

Sell e-cigarettes in hospitals, says PHE report

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

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

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

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

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

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

Alcohol strategy is ripe for refreshment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A moral imperative

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

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

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

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

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

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

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

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

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

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

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

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

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

Danny Hames is chair of the NHS Substance Misuse Providers Alliance

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

Facing the inevitable

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

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

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

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

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

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

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

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

Letters to the editor – Feb issue

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DDN
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Quadruple bypass

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

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

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

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

Paul Bennett, by email

 

Pedantic semantics

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

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

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

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

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

Molly Cochrane, by email

Free to breathe

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

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

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

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

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

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

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

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

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

How do we prove our service user involvement?

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DDN
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Nicole Ridgwell answers your legal questions

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

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

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

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

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

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

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

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

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

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

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

Nicole Ridgwell is solicitor at Ridouts Solicitors

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

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

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

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

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

The five stages of change

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

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

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

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

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

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

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

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

The crunch point

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

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

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

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

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

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

Natalie Davies is assistant editor at Drug and Alcohol Findings

Media Savvy

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

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

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

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

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

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

 

DDN February 2018

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DDN
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‘Service users must stay at the
heart of commissioning’

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

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

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

Claire Brown, editor

Click here to view the virtual magazine or the PDF version

NHS England sets out ambitious plans to eradicate hep C

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

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

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

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

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

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

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

Charles Gore: ‘wonderful news that will galvanise action’

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

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

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

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

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

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

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

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

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

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

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

Report at www.rsph.org.uk

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