Is harm reduction the primary goal, or acceptable only in the service of eliminating drug use? Mike Ashton examines two very different sets of beliefs

Drugs are an evil, and with evil you can’t give way or compromise.’ For Pope Francis, harm reduction in the form of prescribing substitute drugs is just such a compromise: ‘drugs are not defeated with drugs!… Substitutive drugs… are not a sufficient therapy but a veiled way of surrendering to the phenomenon.’ His words derive from a view of drug use as either inherently wrong, or so inevitably and extremely damaging that ‘no use’ is the only justifiable aim.

More temperate variants see harm reduction aims and services as permissible, but only as steps towards stopping drug use altogether. Others elevate harm reduction to an overriding objective which should never be sacrificed to an anti-drugs agenda. Between these poles UK policy has shifted, driven by the threat of HIV from its default anti-drugs base towards the harm-reduction pole.

When in the 1980s harm reduction emerged in Britain, what it was for was clear: to stop the spread of HIV among injectors, and even more so from injectors to the rest of the population. Sometimes reluctantly, its proponents accepted that prioritising this objective meant de-prioritising others, including treatment of addiction and achieving abstinence. The turning point came in 1986 in the report of a committee set up by Scotland’s chief medical officer. Using the new test for HIV, in 1985 an Edinburgh GP discovered that half his injecting patients were infected. Facing this frightening challenge was a committee drawn largely from outside the drugs field, led by Brian McClelland from Edinburgh’s blood transfusion service.

Looking through the eyes of infection control specialists, they relegated to side issues reservations deriving from treatment philosophies focused on abstinence. For them, saving lives was the name of the game. Since ‘Infection with HIV poses a much greater threat to… life… than the misuse of drugs,’ they straightforwardly concluded: ‘On balance, the prevention of spread should take priority over any perceived risk of increased drug misuse.’

What that meant was that injectors who won’t stop must be given clean injecting equipment, and that maintenance prescribing was a way to reduce injecting and maintain contact with injectors, not primarily a step towards detoxification and abstinence. Even enforcement was to be subjugated to the anti-HIV imperative: ‘Police policies in relation to individual drug misusers should be reviewed to ensure so far as possible that they do not prejudice the infection control measures recommended.’

The following year McClelland’s report was cited when the UK’s Conservative government announced pilot needle exchanges to test if they could combat the deadly infection. Also in 1987, harm reduction emerged as a coherent philosophy, not just an emergency response to HIV. It was ‘high time for harm reduction’, argued Russell Newcombe in Druglink magazine. Rather than a ‘deviation’ to be rectified, ‘In many cases, even “dependent” drug use can be reconstrued as just another example of the basic human desire to repeat pleasurable activities.’ Across drug policy, ‘controlled use (rational choice, care and moderation)’ would displace the focus on abstinence.

In 1988 government’s official drug policy advisers echoed McClelland, asserting that ‘The spread of HIV is a greater danger to individual public health than drug misuse.’ Though abstinence remained the ‘ultimate goal’, for the Advisory Council on the Misuse of Drugs, ‘services which aim to minimise HIV risk behaviour by all available means should take precedence in development plans’. They urged that ‘The different goals for drug misusers must not be seen as in competition’, but in fact they were. HIV could only be curbed by accepting drug use rather than primarily trying to stop it.

Hedged about as it was, at first this reversal of priorities from tackling illegal drug use to tackling HIV was not fully embraced by government. But by 1989, on the streets of England a government campaign poster forefronted the risks of sharing needles. Only the small print sought to reduce injecting, miles away from the ‘Heroin screws you up’ campaign of a few years before.

By 2012 policy had definitively reversed back. The UK government’s ‘roadmap’ to recovery-oriented treatment subjugated ‘all our work on combating blood-borne viruses’ to the ‘strategic recovery objective’, arguing that ‘It is self-evident that the best protection against blood borne viruses is full recovery’. For the UK Harm Reduction Alliance and co-signatories, including the UK Recovery Federation, this was not at all self-evident. Their response transformed the government’s Putting full recovery first title into Putting public health first, challenging what they characterised as an ‘ideologically-driven hierarchy’ which places ‘full recovery’ at the top, with ‘any other achievement marked as inferior’.

Attacking the roadmap, the Australian Injecting and Illicit Drug Users League insisted that ‘harm reduction is the goal – not a step along the “road to recovery”,’ a formulation derived from their core belief that ‘all other approaches (eg demand reduction, supply reduction) can have validity only where there is strong evidence that they are appropriate, practical and equitable means of reducing drug-related harm.’

These polarities are endemic in debates about methadone maintenance, seen both as a treatment for dependence and a harm-reducing way to maintain dependence. In 2012 an expert group drawn largely from the UK drugs field attempted to reconcile these objectives. Complaining that ‘the protective benefits [ie harm reduction] have too often become an end in themselves rather than providing a safe platform from which users might progress towards further recovery,’ they were prepared to see recovery pursued even if this ‘potentially more hazardous path’ risked relapse. At the same time, ‘preservation of benefit’ was seen as a reason for continuing treatment. Again the attempt was made to mount horses galloping in different directions – possible at a clinical level, but at a policy level, choices have to be made.

For some, the harm reduction benefits of remaining on methadone are a clinching argument in its favour, and a warning that an evangelistic recovery agenda will cost lives. Others think the risks worth it, arguing that ‘Leaving the protection of methadone maintenance treatment may increase the risk of death. But it might also be the way to a brand new life beyond your wildest dreams, where you find jobs, homes and friends.’ Leaving methadone is a dangerous business, but a proportion of former patients will swim rather than sink, and for some on the banks, the sight of those ‘recovered’ swimmers leaving methadone and addiction behind seems worth the loss of others.

Peacemakers try to gloss over the divides with, ‘We are all in the same game in the end, aren’t we?’, posing harm reduction and abstinence-based recovery as ends of an unbroken continuum of helping the patient, to which all can sign up. But in reality these are different games, their rules and aims deriving from differences in what we value most and how we see drug use: as always bad, or only bad if it causes harm.

This article is based on the Drug and Alcohol Findings Effectiveness Bank hot topic, Harm reduction: what’s it for? Full text with links to documentation at here.

Mike Ashton is editor of Drug and Alcohol Findings, findings.org.uk.

Encouraging clients to talk about their childhood can help to release them from the long-suppressed trauma of abuse, as psychotherapist Elaine Rose explains

Enduring adversity in childhood presents both challenges and opportunities in later life. But it is known that experiencing significant trauma in childhood considerably increases the risk of misusing drugs and/or alcohol. Research tells us that our early life experience programmes the brain and the body for the environment that it encounters. So a calm, nurturing childhood is likely to orientate a child to thrive in most conditions, while a highly stressful, bleak, abusive one will predispose it to conditions of anxiety, insecurity and chaos. What is interesting is why some individuals do not suffer from addictive behaviours and mental health problems, while others do.

Abuse and trauma in childhood take many forms and are categorised under physical, emotional and sexual harm. Much under reported but very common, is the impact upon children of a low level but pervasive parental vacuum, where there is a significant absence of real parental engagement. This can be because the parent is preoccupied with their own problems, such as depression or mental illness; or it can be because they are dangerously immature, and therefore more concerned with having their needs met than nurturing their child and overseeing their teenager. Even more damaging to a child can be the chronic recurrent humiliation of emotional abuse – being told that you are useless or not good enough.

The term ‘child’ refers to pre-birth from the time of conception, through to the age of 18. Some parents consider that their role as vigilant and nurturing carers ends when their child reaches ten or 12 years. But young people require love, care and actual parenting until they are adults themselves – and beyond. Many young people find themselves becoming increasingly involved in drug and alcohol misuse, but this can be overlooked, minimised or rationalised by a parent until it is too late.

In my 35 years of practice in this field, the most common factor I have come across when talking to those suffering from substance misuse and mental health problems, is that there has been some very significant trauma in their lives that they have not fully revealed before, and certainly not recovered from.

Research bears out that those who misuse drugs or alcohol have so often been victims of sexual abuse. Such victims suffer post-traumatic stress disorder leading to poor coping skills, anti-social behaviour, depression, anxiety, low self-esteem and problems in forming trusting relationships. Substances can be used to cope with or escape the trauma and memories of sexual abuse, and as a way to reduce a sense of isolation and loneliness. They become a form of self-medication, to boost confidence and improve self-esteem, or a form of self-destructive behaviour and self-harm. Either way, an individual has raised the red flag asking for help, and as practitioners we need to respond quickly.

A significant percentage of those who have a substance misuse problem also have a recurring mental disorder such as depression, anxiety and/or post-traumatic stress disorder. Process addiction, such as gambling, disordered eating and internet addiction, has been found widely in those who report childhood sexual abuse. Of course one of the difficulties of this kind of abuse is the difficulty for survivors in acknowledging and reporting it, and it is also difficult for caregivers to identify.

Research confirms that the more adverse childhood experiences encountered, and the higher the types of stress, the greater the odds are of an individual suffering with later life addiction. The adverse childhood experiences (ACE) study included 17,000 participants and found multiple relationships between severe childhood stress and all types of addictions, including under and over-eating. These adverse experiences included emotional, physical and sexual abuse, neglect, and living in a house where domestic violence had taken place. Compared to a child with no adverse childhood experiences, one with six adverse or more experiences is nearly three times more likely to become a smoker as a child; a child with four or more is five times more likely to become an alcoholic and 60 per cent more likely to become obese. A boy with four or more ACEs is 46 times more likely to become an IV drug user in later life than one who had no severe childhood experiences.

An adult survivor of child sexual abuse cannot be categorised easily. There are complex dynamics at play and deep trauma at work. Generally speaking, adults will normally have one or two outlooks on life after such abuse. They will either collapse or they will attempt to rise above the abuse. The collapsed outcome is an adult who has easily recognisable symptoms and problems that stop them from being functional in more than one area of their life. They have depressive, addictive or victim status personas, and require ongoing medical and other assistance to cope.

The second outcome often includes those who dissociate from the abuse by ‘soldiering on’ and maintain, for some time, an intact functional life in work and social settings. But they often withdraw or have serious impairment issues in intimate relationships.

Behaviours and coping mechanisms common to both groups can include impulses to abuse another person in some way; promiscuity, frigidity, suicidal thinking, self-mutilation or absence from relationships. There is also a body of evidence that psychosomatic medical disorders often accompany sexually abused children later in life. Survivors can experience unexplained pelvic pain, irritable bowel syndrome, cervical cancers and rashes. The issues are complex.

The good news is that the same key factors which cause some people to misuse drugs and alcohol also provoke resilience, i.e coping with chronic stress and coming through it, developing inner controls and self regulation when provoked. The same factors spur recovery from addiction, finding and maintaining social support, developing a confiding relationship with someone, becoming a loving partner or parent, and being involved in groups or religious organisations. Safe, familiar people in whom an individual can confide buffer against stress since our stress systems are designed to be calmed down with a nurturing word or touch from someone we trust.

It takes courage to talk about an adverse childhood experience, especially when it may have become muddled or confused, and particularly if it was a sexual experience. Encouraging individuals who are suffering as substance misusers to speak about their early life experiences is often the start of helping them to become released from the burden – and the real beginning of the healing process.

Elaine Rose is a child and family psychotherapist with a background as a social worker. She is in private practice in Kent, specialising in work with all in the adoption triangle.

Breach of trust

With the help of One in Four’s Survivors’ Voices Project, Gerard shares his devastating experiences – a process that has helped him to engage with therapy and start to rebuild his life.

I was sexually abused by my mother. Every part of me felt ruined by this, all the way through me, right to my soul. I thought I was the only one. It was something I was certain I would never and could never speak about. I didn’t even see it as sexual abuse when I was a child as I only heard of uncles abusing or perverts in parks, not a female, let alone a mother, so I saw myself as having the most vile, terrifying and disgusting things happen to me.

But it must have been my fault because it never happened to anyone else in the world ever, and that’s why I thought I was the most disgusting thing on the planet. Even though I tried to stop it in any way I could think of, I was also dependent on this person for my life, food and shelter.

My first memories of it were as a five-year-old and I still can’t get the contaminated feelings and taste out of my mouth from what she made me do.

I feel I didn’t have a childhood. I have felt so horribly isolated and alone in a world that was unsafe, especially at home in any room, at any time. I tried to speak out when I was five, but nothing was done and it just made it worse, as I was told by my mother that no one wanted to know and no one would believe me.

As a young child I felt completely different to everyone else. I knew I only had myself to depend on. I cannot remember any moment in my childhood being truly happy.

Self-annihilation, utter isolation, shame, self-disgust, extreme trauma, anxiety, depression and anger are all things I have lived with throughout my life; with the resulting self-harm in many forms through having no value to my life, and addictive tendencies to keep away from my inner reality and beliefs.

Waking up screaming in the middle of the night or not sleeping at all for very long periods, or indeed being overwhelmed with flashbacks, visual and non-visual, day and night, as if in my worst nightmare, and resulting suicide attempts. These were all my symptoms of complex post-traumatic stress disorder.

The horror of the years of abuse, which was emotional and physical also, at times torturous on all levels, still haunts me. The horrid, contaminating, vile, and most disgusting thing that could happen and the betrayal by the person who brought me into the world – breaking what I believe should be a sacred bond.

One in Four provides support and resources for those who have experience of sexual abuse, www.oneinfour.org.uk

References:

Cohen L.R., Tross, Pavlicova, Hu, Campbell, Newns, Substance Use Childhood Sexual Abuse and Sexual Risk Behaviour among Women in Methadone Treatment.  A.M. J. Drug Alcohol Abuse 2009, 35, 305-310.

Freeman, Collier, Pirrill, Early Life Sex Abuse is a Risk Factor for Crack Cocaine Use in the Sample of Community Recruited Women at High Risk for Illicit Drug Use, 2002, 28, 109-131.

Edwards Lee & Lyvers, Childhood Sexual Abuse and Substance Abuse in Relation to Depression and Coping, General Substance Misuse 2008, 13, 349-360.

Manigilio, The Role of Child Sexual Abuse in the Aetiology of Substance Related Disorders, J. Addict Dis. 2011, 30, 216-228.

Dillon L., Chivite-Matthews N., Grewal I., Brown R., Webster S., Weddell E., Brown G. and Smith N., Risk, protective factors and resilience to drug use: identifying resilient young people and learning from their experiences, (OLR 04/07)

How can we develop our work­force against a backdrop of cuts and challenges? DDN reports from the FDAP conference.

‘Services are now expected to do more with less while caring for individuals with increasingly complex needs,’ said Carole Sharma, chief executive of the Federation of Drug and Alcohol Professionals, opening FDAP’s annual conference for workers in the sector.

So how could we drive workforce development to make sure that it was relevant and effective? First up was a well-known figure, Paul Hayes – formerly head of the National Treatment Agency (NTA) and now leading Collective Voice, representing treatment providers.

‘If we’re despondent about the state of the sector, odds are we’re going to be under-serving people,’ he said. ‘People say to me, can’t we have the NTA back – people who wanted to hang them from the nearest lamppost… but we have to get much smarter at tapping into a new narrative.’

Commissioners needed to be driving innovation and we had to make sure people had the skills to deliver. ‘We need to focus relentlessly on delivering outcomes,’ he said. ‘The most significant challenge for all of us is deaths – they’re going up very rapidly. We have to be ready to change our practice.’ Hayes acknowledged the climate of uncertainty, with no sign yet of when the drug strategy would come out. ‘Is all this easy and comfortable? No. But it is possible and necessary,’ he said, adding ‘If you think we’re all going to hell in a handcart, get out of this game.’

‘Nothing was ever positively done from despondency,’ said Pete Burkinshaw of Public Health England (PHE), who was keen to emphasise the sector’s ‘rich evidence base’. Another reason to be cheerful was localism, he said, as it ‘makes all of you much more important’.  But with a growing cohort of people with complex needs, we had to develop specific competencies to manage the risks faced by service users.

‘Your doors need to be wide open to engage with need,’ he said. ‘Services can’t be a reflection of what we do, what we’re comfortable with and have always done. What you need is workers who have techniques and have belief in those techniques.’  As well as a set of universal core skills, workers needed meta competencies – and to ‘know when and where to do and not do things’ – an important element of adaptive and purposeful treatment.

FDAP had asked two of the larger treatment agencies how they prepared an effective workforce, so the conference heard from David Bamford from Change, Grow, Live (CGL, formerly CRI) and Guy Pink from Addaction. Pink believed it was ‘a really good time to be in the sector’ and described Addaction’s guiding principles as being ‘collaborative, ethical, inspiring, resilient and self challenging’ – ‘a team-based approach. We want people to be driven by integrity,’ he said, ‘so we recruit and manage against these guiding principles.’

The organisation was constantly reviewing challenges and solutions, looking at different patterns of working and ways of increasing productivity.  ‘We’re doing more for less, but we have a good pool of workers,’ he said, emphasising that they did not want to be among the two thirds of the workforce who were disengaged. ‘We all know that people don’t leave organisations, they leave managers,’ he added, ‘so we’ve put a lot into improving managers.’

‘What’s difficult for staff to feel they manage is multiple requests from a lot of people wanting loads of different things,’ said Bamford. ‘We need to develop a growth mindset for our staff, as that’s what we want for people they work with.’  CGL believed that ‘top down doesn’t work’, he said. ‘We know that most people are interested in what’s going on around them or their first line manager. It’s pointless pitching things top down.’ So a flat hierarchy needed to go hand in hand with things that increased reliability – awareness of risk, expertise and the ability to adapt to the unexpected.

Staff were encouraged to reflect, plan, act, observe and evaluate, and were introduced to the ‘dreaded drama triangle’ during training – an illustration of how a worker can become a ‘rescuer, victim or persecutor’ in the workplace and recognise what triggers the situation. ‘Profound simplicity, such as five ways to wellbeing’ was also an aim, he said, ‘because simplicity of focus is effective.’

‘There was a positive side to being asked to do more with less, said Bamford, in that they were ‘also doing more with more – linking with people we’ve never linked with before.’ He also had a question for FDAP: ‘How do we extend the ladder downwards to the peer mentoring community, so people can work their way up?’

Sunny Dhadley, manager of Wolverhampton’s Service User Involvement Team (SUIT) was speaking next, and well placed to offer answers. He set up SUIT ten years ago, while still in active addiction and began attending meetings ‘where people were saying the same old rhetoric’. He realised that by sharing knowledge between his peer-led organisation and the workforce, they could develop competence and make treatment more compassionate. ‘We have a fantastic treatment system in this country and should be very proud of it – but we need to look at ways of doing more,’ he said.

‘Initiatives don’t need to cost the earth – we draw upon resources in society,’ he explained. With an annual budget ‘that costs less than sending an adult to our local cat B prison’, SUIT has worked with 522 different agencies and supported 146 people back into work in the past five years, as well as offering ‘a huge range of activities’. Top ten interventions have related to welfare, employment, education, emergency food, volunteering, housing, IT, healthcare, criminal justice and treatment.

‘We see a huge amount of inequality and low levels of literacy and numeracy,’ he said, mentioning that 24 per cent of prisoners had been in care as a child, with many having the English and maths skills of a primary child, so there were ‘high levels of vulnerability’. We needed to ask, ‘what are we doing to support people’s dream happening?’ he suggested.

Sam Thomas from Making Every Adult Matter (MEAM) added to the picture of working with people with multiple needs, talking about the ‘sheer complexity of the world that clients are trying to make sense of and that practitioners are trying to make work’. Around half of people with substance misuse issues also had another problem such as offending or homelessness, but we were ending up with services that dealt with one problem at a time.

‘We have a system that deals with numbers, but behind every number is a human being,’ he said. The MEAM project, Voices from the frontline, was trying to build a better dialogue between people making decisions and those affected.‘This often requires people to work in a way they may not have thought about or feel comfortable with,’ he said.

‘The family workforce could be an important part of this, said Oliver Standing from Adfam, who challenged the perception of families being ‘a bit of an add-on’.

‘The family workforce can be hard to pin down – they could be a service, a standalone community group, a carers’ centre, volunteers, drug and alcohol workers or a generic service – there’s no standard qualification but lots of dedicated people in it,’ he said. Whatever their background, they needed to be competent, trained, supported and connected to local services, including police, bereavement and mental health services.

‘Like others, we’re being asked to do more for less,’ he said, and ‘very high regional variation’ meant there was even greater need for drug and alcohol services to be trained to work with families. Adfam worked with decision-makers, practitioners and families and helped the three strands of activity to feed into each other. ‘There’s no gigantic evidence base on family support,’ he said. ‘But there’s something so affirming when families can meet someone in a similar situation who may be able to help.’

At the heart of effective outcomes were commissioners, and Fiona Hackland, strategic commissioner from the London Borough of Newham, shared her thoughts. ‘Commissioning is not just buying services, it’s a much more complex task,’ she said. ‘It’s about identifying what’s needed locally across services and making sure provision is in place to meet those needs.’ There was no qualification for commissioners, other than relevant components of DANOS. Local authority people were not used to commissioning health-based responsibilities and didn’t necessarily understand the process. ‘We can get bogged down in numbers and targets, but we need to focus on the differences we want to see,’ she said.

Funding was ‘clearly an issue’, with having to find savings from the public health grant, and the changing profile of substance misuse was an ongoing challenge. Reprocurement cycles were going to get worse, with short contracts causing ‘huge problems among service users’. Not viewing the commissioner-provider relationship as a partnership was also ‘not helpful’.

So how could commissioners ensure effectiveness?

‘Be clear about needs, prioritise needs and find the best way to meet those needs,’ she said. Specifying the service and outcomes we wanted was important – ‘without over-specifying, as that kills innovation’ – as well as taking service users’ views into account. For those worried about the added pressures of CQC inspection since April, Patti Boden, CQC inspection manager, had words of encouragement.

‘I don’t go out looking for inadequate services – we go out looking for good,’ she said. ‘How open are they with commissioners? We’re trying to make sure services are well led, with clear vision and values and performance targets, KPIs and visible leadership. ‘We’re also looking to see that the recovery agenda is at the top of their list,’ she said, adding ‘this is not a tick list, but around evidence from service users.’ Among the elements for improvement were risk, care/recovery plans that were too generic, and the quality of commissioning and clinical interventions. ‘We tell you where you’re going wrong, but we don’t tell you how to fix it – that’s up to you,’ she said.

Taking stock of the day’s contributions, Carole Sharma asked ‘do we need to rethink the skills and knowledge of the effective practitioner?’
‘We’re facing an aging client population, multiple and complex needs, reduced generic services and a simplified view of what alcohol and drug problems are and how to fix them,’ she said.

It was more complicated than ‘just say no’ and a spell in rehab, with ‘entrenched problems’. Reduced budgets for training and development, reduced learning environments for some licensed practitioners such as doctors, large caseloads and the demands of the regulator were constant challenges – although the demands of the regulator were a step in the right direction ‘as they stop a lot of arguments about what is good’. But there were a lack of national drivers for workforce development and still no national qualification framework.

‘What are the questions we need to consider?’ she asked. ‘What’s the best use of trained specialists’ time and competence? Do we broaden our skills and knowledge to meet the emerging needs of clients and patients? Do we use our specialists to support the generic health and care workforce in relation to alcohol and other drugs? Has DANOS had its day?’

Appealing to the audience – and the profession as a whole – she added, ‘Is there a need for FDAP to change? If you do feel you need a professional organisation, a safe space to develop the workforce, you need to get people to join.’

New paradigms

We need to go beyond training to tackle workforce development, says Professor Ann Roche
The workforce is without doubt the most important element in addressing alcohol and other drug (AOD) related problems.

Without an appropriately skilled, competent and confident workforce able to execute evidence-based interventions and policies the AOD sector will always be hampered in its efforts to prevent and ameliorate the ever changing array of issues. Ensuring that our services, programmes and policies offer best available options requires our workforce to be able to function to maximum effectiveness in increasingly challenging environments.

Traditional thinking has relied heavily on training as a mechanism by which to achieve optimal service delivery, but while training is a necessary component in this complex picture, it is insufficient in itself. Research increasingly indicates major flaws in the ‘train and hope’ approach to knowledge transfer and innovation dissemination. That is, training often fails to deliver the ultimate expectation and goal – ie behaviour change. This is through no fault of the individual worker, as a multitude of factors are at play when attempting to change workers’ behaviours.

In recent times an important paradigm shift has occurred, as training has been reconceptualised with the broader, more diverse and more comprehensive concept of ‘workforce development’. This is a multi-faceted approach, which addresses the range of factors impacting on the ability of the workforce to function with maximum effectiveness in responding to alcohol and other drug-related problems. Workforce development should have a systems focus; unlike traditional approaches, this is broad and comprehensive, targeting individual, organisational, and structural factors, rather than just addressing education and training of individual mainstream workers.

Without tackling the broad array of systems factors that determine and shape what workers and services can do we will be forever limited to ineffective, costly and inappropriate responses. A workforce development approach that incorporates a systems perspective allows issues related to social equity and work conditions, government policies and organisational structures to be seen as central. It then allows other factors such as worker wellbeing, recruitment and retention, career pathways, supervision and support to be addressed as pivotal concerns in regard to knowledge and skill transfer.Without taking this broader approach, transient training pro­gram­mes will continue to soak up limited funds and produce relatively modest, if any, change in services and programs.

Although it may seem counter-intuitive that training alone cannot deliver pressingly needed changes and supports to our crucial AOD services, the evidence is abundantly clear. Training is, and will always be, only a small part of the solution. A broad and comprehensive workforce development approach that focuses on systems issues is what is required.

For further details and resources visit NCETA’s website: www.nceta.flinders.edu.au
Professor Ann M Roche is director, National Centre for Education and Training on Addiction (NCETA), Flinders University, South Australia

It’s time to ditch the ‘one size fits all’ approach and be ready to respond to clients’ needs – whatever stage they’re at says Dr Julia Lewis

‘I absolutely swear by it’ – a phrase normally prefacing someone’s sure fire solution to weight loss, eradicating the ‘soggy bottom’ from your home-baked pies or some other conundrum of modern life. Some can be surprisingly evangelical about their guaranteed cure and cannot entertain the possibility that there might be an alternative, even backing up claims with a degree of pseudoscience. The history of addictions treatment has been peppered with similar stories and as practitioners you can feel that you need to pick a side, which changes as often as the seasons. ‘Are we still recovery orientated?’ ‘Is it the chronic disease model now?’ ‘What happened to harm minimisation?’

Very often our particular allegiance is linked to the direct experience of our service users, yet what we practise is often determined by our commissioners. Gabrielle Glaser, author of Her Best-Kept Secret: Why Women Drink – And How They Can Regain Control recently criticised the way in which 12-step approaches are virtually mandated within the American healthcare system. And the situation within the UK is no different, with absurdities such as the commissioning of time-limited treatment programmes (because obviously everyone achieves recovery within the same time frame). The reality is, however, that we cannot have a ‘one size fits all’ approach as every service user is different and they all need a personalised response.

So, what’s the answer? Well, firstly, addictions treatment has to move out of the realms of pseudoscience and into the bold world of evidence-based practice – we cannot pour scarce resources into interventions that have no proven effectiveness. Secondly we have to embrace person-centred treatment fully and be prepared to put aside our own hobby horses – we are not here to mould service users into specific treatments because they just happen to be the ones we have on offer. We are here to ask the question, ‘what would a good life look like to you?’ and then support them to make those changes.

A ‘one size fits all’ approach is ineffective. We need to use the whole array of skills to provide the best service to each individual – and that means ensuring those working in the addictions field are sufficiently supported, challenged and empowered through evidence-based training and effective regular supervision.

Pulse Addictions provides tailored training, consultancy and clinical management in the field of substance misuse and associated areas to organisations across the UK. With a proven track record of developing services, whether community based, NHS, third sector, private sector, residential or secure, they have the expertise to meet the most demanding of briefs with a personal touch.

Dr Julia Lewis is medical director at Pulse, www.pulseaddictions.com

For details of their services visit www.pulseaddictions.com

Wales is gearing up to offer medically supervised injecting centres – an initiative that can’t happen soon enough, says Ifor Glyn 

There is a growing acceptance and evidence that providing safe and supervised injecting centres is a recognised harm reduction initiative that can lead to saving lives, encourage engagement with treatment services, and help reduce HIV and hepatitis C infections. They also address public concerns about discarded needles and public injecting, and do not attract drug users en masse from other areas.

According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), the first supervised drug consumption room was opened in Berne, Switzerland in June 1986, with further facilities following in Germany, the Netherlands, Spain, Norway, Luxembourg, Denmark and Greece. There are now 74 official drug consumption facilities operating in six EMCDDA reporting countries (following the closure of the only facility in Greece in 2014) and 12 facilities now operating in Switzerland.

The EMCDDA breaks this down further, to point out that as of February 2016 there are 31 facilities in 25 cities in the Netherlands; 24 in 15 cities in Germany; 12 in three cities in Spain; one in Norway; and one in Luxembourg (Norway and Luxembourg are both preparing to open a second facility in 2016); five in three cities in Denmark; and 12 in eight cities in Switzerland.

In January, French law approved a six-year trial of drug consumption rooms, expected to open by the end of this year. Outside Europe there are two facilities in Sydney, Australia and one medically supervised injecting centre in Vancouver, Canada.

There are plans to open the first centre in Dublin in later this year, and Scotland is also exploring the introduction of Medically Supervised Injecting Centre (MSIC). Even though there have been robust attempts to establish similar centres in the UK, there still no provision, despite the UK Home Affairs Select Committee recommendation ‘that an evaluated pilot programme of safe injecting houses for heroin users is established without delay and that if this is successful, the programme is extended across the country.’ The home secretary rejected this recommendation.

Wales is a country with a strong and unequivocal commitment to reducing the harm associated with substance misuse. The devolved Welsh government has harm reduction firmly embedded in its substance misuse strategy (Working together to reduce harm, 2008), which has led to a countrywide take-home naloxone scheme. It has also supported the set-up of Wedinos, a service to test substances to give individuals rapid and accurate information to reduce harms, and introduced and supported numerous harm reduction initiatives and projects. It is hoped that the Welsh government’s delivery plan (2016-2018) will reference the need to develop a case for MSIC.

Drugaid Cymru, Wales’s largest and leading third sector harm reduction agency, has started the work of developing the case for establishing MSIC provision in Wales. Not for a minute does anybody think this will be an easy task, and despite the evidence to support MSICs, winning the hearts and minds of politicians, law enforcement, businesses and neighbours is going to be a challenge. A multi-agency steering group has been established to progress this agenda in Wales, led by Drugaid Cymru, and includes leading figures from health, academia, PCC representatives, public health, Release and the Welsh Government.

Earlier this year, Drugaid Cymru’s chief executive Caroline Phipps visited Sydney’s Kings Cross centre and a deputation from Drugaid visited the Ana Liffey Drugs Project in Dublin who are close to opening Ireland’s first MSIC. While there might be a need for different models for different communities, there are a lot of commonalities and much that can be learned from those who are established or moving toward being operational. Wales is forming partnerships with others to develop the business case and propose the right model.

During the next six months the steering group will be engaging and consulting expert individuals and organisations in the UK and in other countries that have been involved in the research and development of MSIC provision. The work is at a very early stage in Wales and it is recognised that there are significant hurdles, but there is a commitment to develop a strong case for establishing MSIC as part of an overall comprehensive harm reduction approach – and to win over the hearts and minds of those with doubts.

Ifor Glyn will facilitate a workshop on MSICs at the upcoming conference SMTPC 2016: ‘The Post-War Dream’. To book your free place visit www.smtpc.org

Encouraged by results of a new form of community opiate detoxification, a team from substance misuse services in Bristol and the South West offer their ‘recipe for recovery’ .

The landscape for addiction treatment is changing. Since 2001, there have been three phases in the modernisation of treatment for substance misuse problems – access, retention, completion – that brought us to where we are now. We are now in an evolving fourth phase which is about producing real world recovery outcomes.

As a result of the Health and Social Care Act 2012, the public health function was transferred from the health service to the 152 local authorities. It is difficult to see where the investment in drug treatment is going with any precision but the direction is very clear; it is going down. Duncan Selbie, chief executive of Public Health England, addressed substance misuse commissioners and providers at a recent conference in Bristol entitled Sustainable recovery solutions. He highlighted the need to think and work smarter in these times of austerity: ‘The music has changed – you need to learn a new dance!’

Ironically, tightening budgets might be good news for abstinence-based community recovery. At the same conference, we noted that the current and evolving focus on real world social outcomes (such as jobs, homes, family and friends) offers great opportunities for the development of abstinence-based recovery and this reinforces a focus on innovation, improved outcomes and increased value.

As previous and current providers of substance misuse services in Bristol and the South West, we feel that our ‘detox in a box’ model demonstrates those very objectives – innovation, improved outcomes and increased value. However, not being the best of dancers, we prefer to liken it to cooking – our ‘recipe for recovery’.

Innovation

Back in 2010, South Gloucestershire Drug and Alcohol community services introduced a novel two-week community opiate detox protocol, which was created to address the problem of a long backlog of service users awaiting a structured opiate detox against a climate of limited bed availability for a medically supervised detox.

At this time, the practice was mainly focused on substitute prescribing and risk minimisation. The ‘detox in a box’ protocol brought a shift in mindset towards recovery and abstinence as well as higher aspirations for service user success, bringing hope back into the hearts of both clients and staff.

Improved outcomes

‘Detox in a box’ was rapidly embraced by both key workers and service users and proved highly successful over the subsequent four years, leading to a dramatic improvement in the number of service users exiting drug-free from our services. In the first year after its introduction, the number of patients achieving abstinence quadrupled. This dramatic improvement cleared the backlog of highly motivated clients waiting for a detox. Subsequent years showed a similar steady increase in the numbers of those achieving abstinence.

Unlike opiate detox methods involving gradual dose reduction, which may feel like an endless ‘Russian doll’ game (often ending up as long-term sub therapeutic OST prescribing), ‘detox in a box’ gave our service users a clear goal: the prospect of attaining abstinence in only 14 days. It also switched the client’s focus from the detox process, to the real and more deserving challenge of maintaining abstinence and recovery.

Increased value

Aside from the clear benefits of our clients having an improved chance of actually completing their detox, we found that running this model alongside the existing alcohol detox service made better use of resources – both in terms of facilities and staff. Having a programme that was time limited, with a clear beginning, middle and end, also enabled us to plan aftercare services more effectively. We also found that working alongside mutual aid groups such as SMART Recovery and NA was an essential ingredient in the success of the model. Using our existing relationships with our colleagues in community pharmacies helped to add another layer of support.

Who is it for?

As with cooking, a dish only suits some people but not others. ‘Detox in a box’ best suits patients stabilised on methadone or buprenorphine, highly motivated to detox in the community within a short period of time and with no major psychiatric or physical health co-morbidities. It is unlikely to be successful for those still using heroin exclusively or on top of methadone.

Challenges

Before implementing this approach, we were disheartened by the number of service users who had been held on non-therapeutic doses of methadone and buprenorphine for long periods of time, because of fear or anxiety about the opiate withdrawal process. Their fears were further reinforced by a lack of confidence in staff around the medications that could be prescribed or the psychosocial advice that could be provided to help reduce the severity of the symptoms of opiate withdrawal. In addition, we were faced with new challenges which included an increased focus on treatment exits, compliance with our payment by results targets, a staff culture that focused singly on maintenance treatment, a service user expectation that engagement in psychosocial interventions was not required, and a general fear of change.

Our greatest challenge during the implementation stage wasour ability to embed this approach as ‘treatment as usual’, alongside the slower reduction or ‘Russian doll’ approach that was more commonly used. Changing culture is often the hardest thing we do in healthcare services and staff engagement in the process was the key to ensuring the approach was owned by the service and offered to service users. To our surprise we achieved this very quickly. Peer mentors were involved from the start and their views adopted into the model; all staff members were trained, and awareness sessions delivered to partnership agencies. Leaflets were placed with all blank care plans, ready for discussion at the service users’ next review appointment.

For us, it offered a fresh new treatment choice to add to the menu of options for our service users who were looking to make significant behaviour change and improve their lives.

About the authors:

R Iosub and I Seeger are senior registrars, South Gloucestershire and Bristol Specialised Drug and Alcohol Services, Avon and Wiltshire Mental Health Partnership NHS Trust. F D Law is consultant in substance misuse psychiatry at Turning Point. M Gilman is managing director of Discovering Health. N S Wallbank is team manager at Stokes Croft, Bristol Specialised Drug and Alcohol Services, Avon and Wiltshire Mental Health Partnership NHS Trust. J K Melichar is medical director, DHI; medical director, DMT Ltd and consultant in substance misuse psychiatry at Turning Point.

Steve Hodgkins is the founder and CEO of Jobs, Friends and Houses (JFH) – a multi award-winning social enterprise offering employment, peer support and accommodation to people in recovery from addiction.

A serving police officer of 27 years, he founded the enterprise in 2014 after seeing that more could and should be done to rehabilitate offenders afflicted by addiction.

Now 18 months into the venture, he reflects on how he came to establish the community interest company and its successes so far – including creating jobs for 28 people in recovery, renovating nine properties to create 15 homes, and changing the lives and fortunes of dozens in Blackpool, Lancashire

I’ve always believed in redemption – especially as a police officer. I have been an officer for 27 years working in London and Lancashire, but I never went in for just catching and convicting people. I wanted to reduce crime and the numbers of victims by helping people.

Sometimes, though, it was hard to help them. I remember picking up an offender on his release from prison. He’d managed to detox from drugs and was feeling hopeful about finally turning his life around. I had to drop him off at his new home – there was no running water and the walls were covered in mould. Perhaps unsurprisingly, he relapsed within just a few days. I realised that many people had limited chances to succeed in life, and that this led them to addiction and criminality.

In Blackpool one of my roles was custody sergeant at Bonny Street Police Station. I’d be sitting on my side of the desk, knowing I was in a purposeful job with loving family and friends around me and a nice home to go back to, while these people being brought in rarely had all that. I’d wonder how their life came to be so different to mine that we’d ended up on opposite sides of the desk. I realised that so often their criminality was linked to limited life chances – family breakdown, transiency, poor education, no work skills and negative social networks.

Later as a community safety sergeant, I worked with organisations across the town on early intervention work, bringing people together to make something new – greater than the sum of their parts.

That’s what I’ve been able to do at JFH. It’s a property development and management enterprise, and two thirds of our team are in recovery. We will take on a property and renovate it, training team members through adult apprenticeships in plumbing, plastering, painting and decorating, electrical engineering, joinery and tiling. Then once they’ve completed the house they are able to move into it. Along the way we offer wraparound and peer support.

We then have a lettings team, which manages the rental of these units as well as hundreds of others across Blackpool. Here adults also in recovery are undertaking office-based apprenticeships.

JFH is a community for people in abstinent recovery to join, inspire others and show them there can be life after addiction. There were a number of ‘lightbulb moments’ that got me to here. A turning point was seeing the rehabilitation work being undertaken by the substance misuse service at HMP Kirkham, a category D prison near Blackpool, where prisoners were being supported to stop using drugs and achieve abstinence. But as with the lad who ended up in the grotty flat, I knew there was limited support for offenders upon release. I knew they needed to be engaged in purposeful activity and have a good, stable home too.

We work to Maslow’s Hierarchy Of Needs. If you haven’t got your basic needs for safety and shelter met, it’s difficult for you to progress in other areas of your life, whether work, education, relationships or general wellbeing.

Thus, JFH was formed in my head. I had to jump through a lot of hoops to get the initial funding, but I worked on property in my own time and knew you could make money out of renovating it. I pitched and pitched until NHS Gateways gave me the money to get started. Then things started to pick up pace and we received money from the Transformation Challenge Award network, the police and crime commissioner’s office and the local authority, and had the backing of the police.

I am now on full-time secondment from Lancashire Constabulary to lead the enterprise. We have police officers and ex-offenders working side by side, united by the common purpose of creating meaningful employment and good accommodation.

The adults we work with are ex-offenders and people who have been in addiction, many of whom have been homeless or suffered from family breakdown or mental illness. But I see these people as amazing, with innate abilities – no matter their previous lives. As we help them to reconnect with their families, improve their skills, build new homes and strive for a better future, I see their passion, not their past.

A powerful thing we are able to do at JFH is to change a person’s identity – from being a heroin addict, a burglar, or a drinker, to being Mr X the plumber or Mrs Y the health and social care professional. They need to learn how to communicate with others, how to do the weekly shop or just what to wear for the appropriate occasion. When a grown man asks, ‘How do you make a friend?’ it gives you some idea of the personal challenges confronting the adults we work with – and just how difficult it can be for someone who is reintegrating into society.

There has been so much learned in our first 18 months. From day one we have been the subject of an independent academic evaluation, led by Professor David Best, a leading criminologist from Sheffield Hallam University, with a team from ACT recovery. Professor Best, who has evaluated dozens of recovery-related projects worldwide, said JFH is ‘the most exciting’ he’s seen.

While ours is a common sense approach, it is not common. We hope that our evaluation, on top of our anecdotes and inspirational stories, will mean we can help more people in this way. Early intervention work to prevent the root causes of why people use substances, or experience mental health problems or family breakdown, is proving to be an effective way of reducing crime and reoffending, and austerity measures within the police meant they were open and receptive to new and innovative ideas.

We don’t get rid of people the first time they fail – we would sooner put our arms around them tighter and love them that bit more. JFH is all about building and promoting a person’s self worth, so we do a lot of supporting and handholding; budgeting for the weekly shop, sorting out bank accounts, arranging doctors’ appointments. But we do operate a ‘tough love’ programme, and set high expectations alongside that support. Our job is to inspire them to aspire to a positive future, and we support them to do this by paying into a workplace pension, even for apprentices, and paying well above the minimum wage. We’re really starting to show the benefits of investing in people in this way.

We now have people who were long-term homeless, sleeping rough for years, eating from bins and stealing to survive, living in a quality flat that they’ve built themselves. We have had parents telling us that they can be proud of their sons again; partners thanking us for giving them their loved one back. It’s very humbling, very special.

Phoenix Futures has launched the Griffiths Edwards Fund to champion his belief that ‘no one size fits all’ 

Access to drug treatment saves lives, gives people a second chance, and reunites families. This was the message from Phoenix Futures, at the House of Lords to launch the Griffiths Edwards Fund – to help people to access residential treatment, when they were unable to find funding through other routes.

Former clients, several of whom now work for the organisation, stepped forward to talk about what the treatment had done for them. ‘When I entered treatment I felt helpless, but when I walked through the doors at Phoenix I felt there was hope,’ said Leanne. Ian told the story of how he had moved from a life of crime to running a successful business, putting back into the system through paying taxes and creating employment.

Another Ian and Stuart, both employed by Phoenix, talked of the satisfaction they got from working for the organisation and the opportunity it gave them to give something back, while former Addaction chief executive Peter Martin spoke of how his incredible journey had started at Phoenix.

Phoenix Futures supports many people with complex needs around mental health, housing, poor general health, unemployment and debt. Speakers talked about how they often benefited the most from residential care, through respite from day-to-day challenges and removal from an often chaotic environment, allowing them to focus fully on treatment. It also gave providers the opportunity to build a support package around them.

Last year Phoenix gave away more than half a million pounds worth of residential rehabilitation and had risen to the challenge of providing these services despite limited resources, said chief executive Karen Biggs. Much of this work was with ‘people whose lives are not straight lines’, she said. But that fact that 23 per cent of service users gained their first ever qualification while at Phoenix demonstrated how they were helping people move on with their lives.

The new fund will provide access to residential treatment within the Phoenix group, for those who are unable to access funding through other routes. As well as providing support during treatment, the fund will enable people to engage with housing, education and training opportunities to help them build a new life.

‘The fund isn’t named after Griffith Edwards purely because he was the founder of Phoenix Futures,’ said Biggs. ‘It is because he was a humble self-effacing man who believed that no one size fits all.’

To find out more or to donate, visit www.phoenixfutures.org.uk/griffith-edwards-fund

David Finney gives the latest essential chapter on preparing for Care Quality Commission inspection

Do you know what’s happening with CQC inspections? You may have had a CQC inspection already, or you may be waiting for the next email or visit. Well, from now on all inspections will be announced approximately 20 weeks in advance, giving you an opportunity to send all the information to CQC in a ‘Provider Information Return’ in advance of the visit.

You are probably aware that inspections have switched within CQC to the Hospitals Directorate. This means that the focus of inspection is now firmly on the quality of the treatment on offer rather than the social care matters, which predominated previously. You will probably also find that, alongside the allocated inspector, there may be a ‘specialist professional advisor’ with a clinical background.

Some services have had a positive experience of inspection while others have found it negative. To my knowledge, four rehabs have already closed following their inspection, realising that they were not going to meet the standards required. Others have had to work hard to achieve compliance.

So how can you prepare for your inspection?

1. Detox services:

The emphasis during inspection will be on the clinical and prescribing aspects of the service and CQC’s expectations are that there will be:

• Medical oversight by:
  • A consultant psychiatrist with specific addiction treatment knowledge or
  • A GP with at least RCGP part 1 in the treatment of alcohol and drug misuse.
• Nursing staff with the right training.
• Adherence to NICE guidelines on alcohol and drug misuse.
• Clinical assessment tools.
• Thorough physical health assessments on all people joining the service.
• A multi-disciplinary team (MDT) which coordinates treatment.
• A clinical governance framework which includes audits, a track record on safety and quality assurance.

2. Mental Capacity Act and the Deprivation of Liberties Safeguards (DOLS)

CQC have a statutory duty to monitor the implementation of this Act. Obvious examples of where this Act applies are when a person is intoxicated and so has no capacity to make a sensible decision, or when they have alcohol-related brain injury which limits their cognitive functioning. So:

• Staff need to be trained and be able to explain the principles behind the legislation.
• Staff need to be able to explain that any restrictions in the treatment programme are not infringements of people’s liberty, but agreements which people make to ensure effective treatment.

3. Enforcement

It is important to highlight the fact that CQC have become much more robust in their enforcement procedures. This means that where services are found to be non-compliant:

• CQC may initially seek the voluntary agreement of the provider to cease admitting people to the service until certain measures are in place.
• In some cases CQC may quickly issue statutory warning notices if they believe that concerns about practice are serious.

4. Other crucial areas

• Risk assessments and risk management plans need to be clearly outlined. Recently CQC have specifically been asking about risks associated with early discharge, suicide or self-harm and destabilisation following detoxification.
• Documentation must be thorough. There must be an audit trail of decision making and care planning. Also CQC may ask for a whole range of policies and procedures be sent to them.

5. What do you need to do?

Ensure all staff are inducted into the meaning of the CQC regulations and the five key questions.

Undertake a thorough audit of the operation of your services before your inspection. If you are not sure what to do, then seek advice from an external advisor/trainer who can explain exactly how to achieve compliance.

This course is no longer running. Please email ian@cjwellings.com if you have any enquiries.

Is the focus on recovery undermining a highly skilled workforce? As Neil McKeganey said in 2010 (in Controversies in Drugs Policy and Practice), if you need to visit a doctor you can rest assured the person you are seeing will have had a medical education. If you want to buy a house you know that the solicitor has been educated to degree level, and if you take your dog or cat to the vet you know that they will be one of the most highly trained professionals around. But if you see a drug worker you will probably be seen by someone who has not been to university, does not have a professional or postgraduate qualification, and who may have only just entered the field. At a conference on Workforce development: challenges, opportunities and the way forward, speakers from different specialisms painted a picture of a sector in danger of paying the price of undervaluing essential skills, and asked, are we compromising service users’ safety by ‘doing it on the cheap’?

The nurse: ‘We need to find our voice’

‘There are half a million nurses working in this country, but I’m not sure where our voice is’, said Dr Carmel Clancy, head of department of mental health, social work and integrative medicine at Middlesex University, who is also chair of the Association of Nurses in Substance Abuse (ANSA).

In the 1960s nurses were working in regional drug dependency units (DDUs) and the 1980s saw an increase of nurse specialists in community drug and alcohol teams. In the 1990s nurses were central to harm minimisation and there were nurse consultant roles – but the title of nurse was now becoming interchangeable with key worker and drug worker.

‘Non specialists are taking over nursing roles,’ she said. ‘Nurses are there, but are not as visible. How do we claim a stake at the table?’

The sector had ‘no idea’ of the number of nurses working in addiction, with many falling into it by default, through promotion or changing location. Despite nurses seeing addiction as a specialism, they did not receive any undergraduate training on it and felt they were starting again when they came into addiction, said Clancy.

Changes were afoot however, with ANSA’s proposed merger with the International Nurses Society on Addictions (IntNSA) in July, which would strengthen the nurses’ voice and raise their profile in the addiction workforce.

The law change on ‘non-medical prescribing’ in 2012 (extending the right of a professionally qualified person to prescribe) had resulted in a growing number of nurse prescribers, added Mike Flanagan, consultant nurse and clinical lead for substance misuse services at Surrey Borders Partnership NHS Foundation Trust and chair of the National Substance Misuse Non-Medical Prescribing Forum.

The changing landscape of the last ten years had seen drug and alcohol treatment more performance monitored than any area of health and social care, he said. When commissioning moved to local authorities in 2013, the sector had been subjected to repeated cycles of retendering with diminishing budgets, all of which had contributed to making specialist addiction treatment a less attractive career option.

So what had been the impact on nursing? Medical roles were increasingly provided by non-medical prescribers – which was fine if properly supervised, said Flanagan. But with nursing posts increasingly provided by drug workers, there was ‘a risk that commissioners and managers may fail to fully appreciate the impact on quality.’ 

The psychologist: ‘Everyone does psychosocial interventions’

Many of the barriers and facilitators to change were psychological, but ‘absolutely everyone’ did psychosocial interventions now, including staff and service users, said Dr Christopher Whiteley, consultant clinical psychologist at South London and Maudsley NHS Foundation Trust.

The ‘recovery juggernaut’ had involved everyone in ‘building recovery capital’ – human, physical, cultural and social – which had helped to address issues of confidence, joining in meaningful occupations, maintaining accommodation and staying in recovery.

But there were challenges: with many of the psychosocial interventions being undertaken by people who were not psychologists, outcomes were greatly affected by the quality of the working alliance.

Organisations were prone to heavy caseloads, high turnover of clients and a lack of resources for training. To be effective there needed to be synergy between leadership, a culture of innovation, training and supervision, he said, while more could be done with families, peers and community networks.

Addiction doctors: ‘We’re an endangered species’

Addiction specialist doctors were becoming an endangered species, according to Dr Kostas Agath, medical director at Addaction. Decreased availability of addiction psychiatry training posts brought with it disappearance of skills. ‘Once my generation has expired you cannot download us from the internet,’ he said.

Throughout the disruptive environment of retendering we needed to make sure training plans were robust, he said. The way forward in preserving the disappearing specialism relied on a national sphere of influence, but also local sustainable solutions.

‘Localism shapes the context – one size does not fit all,’ he said. Future-proofing psychiatrists’ roles involved effective integration with GPs, non-medical prescribers, pharmacists and psychologists.

Social workers: ‘We need specialist knowledge’

‘Of 90,000 social workers in the UK we have no idea how many specialise in alcohol and drug use’, said Dr Sarah Galvani, professor of adult social care at Manchester Metropolitan University’s department of social care and social work, who had ‘more than 30 years of identifying the lack of drug and alcohol knowledge in social workers’.

Alcohol or drug problems were identified as criminal justice or health problems, which explained the lack of engagement with social workers.

‘But the vast majority say alcohol or drug education is very or extremely important to their practice,’ she said. ‘Most social workers can talk – but they have a problem talking about substance misuse as they don’t know what to ask.’

Social workers could have three key roles – to engage with people about the topic of substance misuse; to motivate people to change and support them in doing this; and to offer follow-up support to maintain changes.

The challenges included political constraints and direct government intervention into social work education, with the devaluing of specialist practice on substance misuse. There was dissolution of specialist teams and roles, with whole services being cut and others going to the cheapest bidder.

But there were also clear opportunities, said Galvani, including the move of specialist services towards holistic and recovery-oriented approaches and embracing the wider health and wellbeing agenda, which was ‘social workers’ bread and butter’.

We were lucky to have a strong evidence base, new teaching partnerships and an increasing number of resources relating to social work and substance use, she said. ‘We need to take the opportunities.’

A long and winding road

With a clear set of challenges ahead, the Scottish Drugs Forum is learning lessons from the past in developing its work­force programme, said George Burton

‘Scotland has had a long-standing alcohol and other drug problem and has been disproportionately affected,’ said Burton. Drug-related deaths were stubbornly high and had increased again, with last year’s figure of 613 the highest ever recorded.

Looking back, policy responses in the 1980s had been rooted in harm reduction and methadone, until the newly elected SNP introduced a strategy of ‘drug- free recovery’ in 2008 (and a ‘new hostility to methadone’). Drug services began changing their names to take on recovery, with drug workers becoming recovery workers.

But the quality of services depended on the quality of professionals. How much was the ‘strategic objective’ to recruit people in recovery about money and levels of pay?, he asked.

A two-tier workforce had meant that agreements on outcomes between the health service and voluntary drug and alcohol services were ‘difficult to develop, when one half of the workforce [the NHS] was paid considerably more’ and there was ‘such disparity across providers’.

Alcohol and drug partnerships (ADPs) across Scotland were aligned to local authorities, and support teams included officers for different functions, such as development, policy and research, some of whom ‘had no knowledge of drugs and alcohol but were responsible for big commissioning decisions’.

The Scottish Drugs Forum (SDF) provided training, which covered an introduction to the field, motivational interviewing, stigma, recovery outcomes and new drugs, as well as offering strategic support to ADPs for quality development.

A survey of service users also suggested the workforce needed local knowledge, flexibility and non-judgmental practice, and some suggested they benefited from ‘lived experience’.

‘Workforce development is becoming understood as more than just training, but it’s taking time and it’s still early days,’ said Burton.

Among the SDF’s current priorities were the nation­al naloxone programme, work on quality development and service improvement, strong user involvement including a programme to train people in recovery to join the workforce, programmes on hepatitis and needle exchange, and work with the Scottish Prison Service, including dealing with NPS in prisons.

The absence of a clear pathway to the drug and alcohol field meant there was a rich mix of people with a range of experience, ‘but we need to pay properly – this race to the bottom is not acceptable,’ he said.

‘It’s important to recognise that most people can’t do this type of job,’ he said. ‘But being in recovery does not make you a recovery worker.’

George Burton is workforce development programme manager at the Scottish Drugs Forum

Have you noticed the world is getting more complicated? It’s not just technology that’s stretching our capabilities but, in the addictions field, it’s the increasing complexity of our clients challenging us on a daily basis. The traditional ‘street’ addiction service was never set up to work with clients with learning disabilities, chronic pain disorders, personality disorders, over 75s – and so many more issues. In fact, these comorbidities are often exclusion criteria for many treatment services but then their substance misuse excludes them from the health services able to deal with their comorbidity. They can get stuck in a loop of rejection with no one prepared to take on their treatment for fear that they lack the necessary skills.

Some have suggested that the answer is the development of highly specialised comorbidity services but these would be costly, numerous and likely to increase the level of exclusion and stigmatisation felt by their service users. The reality is, though, that in order to address their substance misuse needs you do not require an ‘expert’ level of experience in both issues. The expertise is in the ability to adapt substance misuse interventions to fit the needs of the individual in front of you. To do that you do need an understanding of how the comorbid condition influences use and treatment for substance misuse but you also need enough confidence in your own approach to be able to adapt it in a person-centred way.

Addiction services are beginning to recognise their need to improve their ability to manage more complex service users. Cwm Taf University Health Board’s substance misuse service (RISMS) saw an increase in referrals for individuals with a learning disability (LD) and neurodevelopmental disorders and wanted to enhance their knowledge and skills to engage with these service users more effectively. Although they linked with their local LD team, neither group of staff felt equipped to deal effectively with this group, so they approached Pulse Addictions for training.

Using our knowledgable trainers with their wealth of experience working within the complex needs addictions field, we were able to design and deliver tailored training, focussing directly on the needs of the service. From general considerations such as allowing service users to wait in quiet rooms away from the main waiting areas and avoiding the use of jargon and metaphor through to how to adapt specific psychosocial interventions for use in those with cognitive impairment, the course took the findings of the limited research in this area and turned it into tangible techniques appropriate for day to day use. The training provided staff at all levels with a balance of evidence-based knowledge and skills-based practice, empowering them to be able to work with service users with LD and neurodevelopmental disorders with confidence.

Pulse Addictions provides tailored training, consultancy and clinical management in the field of substance misuse and associated areas to organisations across the UK. With a proven track record of enhancing and developing services whether community based, NHS, third sector, private sector, residential or secure, they have the expertise to meet the most demanding of briefs with a personal touch.   For details of their services visit www.pulseaddictions.com