About Public Health England

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1 Adult substance misuse statistics from the National Drug Treatment Monitoring System (NDTMS) 1 April 2014 to 31 March 2015

2 About Public Health England Public Health England exists to protect and improve the nation s health and wellbeing, and reduce health inequalities. It does this through world-class science, knowledge and intelligence, advocacy, partnerships and the delivery of specialist public health services. PHE is an operationally autonomous executive agency of the Department of Health. Public Health England Wellington House Waterloo Road London SE1 8UG Tel: Facebook: Prepared by: Jonathan Knight For queries relating to this document, contact: Crown copyright 2015 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence v3.0. To view this licence, visit OGL or Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. You can download this publication from Published December 2015 PHE publications gateway number:

3 Contents About Public Health England 2 Contents 3 Executive summary 5 1. Background and policy context 8 2. Change in method of reporting alcohol and drug statistics Assessment of quality and robustness of NDTMS community data Characteristics of clients Substance use profile Age of clients Gender of clients Ethnicity of clients Source of referral into treatment (new presentations) Age and presenting substance (new presentations) Injecting behaviour (new presentations) Housing situation (new presentations) Access to services Waiting times for first and subsequent treatment interventions Treatment interventions Engagement Treatment and recovery outcomes Treatment exits and successful completions Six-month outcomes Trends over time Trends in numbers in treatment Trends in age group and presenting substances Trends in club drug and new psychoactive substance (NPS) use Trends in treatment exit reasons Trends in waiting times for first intervention A ten-year treatment population analysis History Relevant web links and contact details Comparability of data to previous reports Drug treatment collection and reporting timeline Other sources of statistics about drugs Prevalence of drug use Young people 54 3

4 9.4.3 Criminal justice statistics International comparisons Drug-related deaths Abbreviations and definitions Abbreviations Definitions 56 Appendix A 60 Diagram to show flow through treatment 60 Appendix B 61 Trends in new presentations 61 Appendix C 64 Ten-year treatment population 64 4

5 Executive summary For the first time, this report brings together information on people receiving specialist interventions for drugs and alcohol. Because many people experience problems with both substances and receive interventions for both, drugs and alcohol services are increasingly commissioned together. However, while the people who seek treatment for drugs and alcohol share many similarities they also have clear differences, so this report divides people in treatment into the four substance groups described below. 152,964 Numbers in treatment by main substance group Alcohol only 30% Numbers in treatment by main substance group ,107 25,025 28,128 Opiate Non-opiate Non-opiate and alcohol Alcohol only Non-opiate and alcohol 10% Non-opiate 8% Opiate 52% In all, 295,224 individuals were in contact with drug and alcohol services in Of these, 141,646 started treatment during the year 97% started within three weeks. The age profile of people in treatment is rising. For example, 44% of the 152,964 people in treatment for opiates are now 40 and over. Since , the number of opiate users aged 40 and over starting treatment has risen by 21% (12,761 to 15,487). This ageing cohort is often in poor health, with a range of vulnerabilities associated with long-term drug use. These people require a wide range of support, including social care. When considering all ages, presentations to treatment for opiates have been falling over the last six years (55,494 to 44,356), reflecting the downward trend in prevalence of heroin use. The number of people presenting for alcohol problems in was 150,640. Of these, 89,107 were treated for problematic drinking alone, and 61,533 for alcohol alongside other substances. Alcohol only clients had an older age profile than opiate users (68% aged 40 and over). While the overall numbers accessing treatment for alcohol have increased by 3% since (86,385 to 88,904), the number aged 40 and over accessing services has risen by 21% and the number aged 50 and over by 44% (42,128 to 50,786, 21%, 16,627 to 24,017, 44%). Many of these people will have been drinking at high-risk levels for some time and are likely to be experiencing health harm such as liver disease and hypertension. 5

6 The majority of younger people (18-24) presenting to treatment in cited problems with either cannabis or cocaine (7,369, 52%, and 3,272, 23%). Most presentations for new psychoactive substances (NPS) are also in the younger age groups, though the total number accessing treatment for NPS remains relatively low (1,370, 0.5%). Overall, the number of under-25s accessing treatment has fallen by 33% since , with the largest decrease in opiates (mainly heroin) where the numbers presenting to treatment have fallen by 60%. This reflects a shift in the type of drug use among young adults. Men made up 70% of the entire treatment population in The gender split varied depending on the presenting substances 73% of people using drugs were male compared to 62% presenting with alcohol only. Individuals recorded as white British made up the largest ethnic group in treatment, (85%, 245,380) with a further 4% from other white groups. Since 2013 the overall rate of people exiting treatment successfully has slowed. This is mainly because the rate of opiate clients successfully completing treatment has fallen, which is likely to be a result of those now in treatment having more entrenched drug use and long-standing and complex problems. In all, 130,609 people exited the drug and alcohol treatment system in , with 52% (67,788) having successfully completed their treatment free of dependence. Non-opiate-only clients had the highest rates of successful exits with almost two thirds (64%) completing treatment, followed by 61% of alcohol clients. Opiate clients had a completion rate of 30%. The recovery rates for non-opiates and alcohol have remained higher and stable largely because users of these substances are more likely to have access to the personal and social resources that can aid recovery, such as employment and stable housing. The number of people who died while in contact with services in was 2,360. Most of these (61%, 1,428) were opiate clients who tended to be over 40 (median age 43) and were likely to have been using heroin for a long time. While not all deaths in treatment will be attributable to an individual s substance use, the use of drugs is a significant cause of premature mortality in the UK. 1 Drug misuse deaths registered in England and Wales between 2012 and 2014 increased by 42%, with the number now 2,120 per year, the highest since records began in The number of deaths involving heroin in 2014 increased by 64% from Murray, CJ, Richards, MA, Newton, JN, Fenton, KA, Anderson, HR, Atkinson, C,... & Davis, A (2013). UK health performance: findings of the Global Burden of Disease Study The Lancet, 381(9871),

7 Among those accessing treatment for alcohol only problems, there were 792 deaths. Again the majority were aged 40 and over, (median age 49). Users of other substances made up the remaining deaths, with the lowest number of deaths seen among users of non-opiates (39 deaths), the lowest median age (35 years) was also seen in this population. The drug-related death rate among people in treatment is significantly lower than among those who are not in treatment. 3 3 White, M, Burton, R, Darke, S, Eastwood, B, Knight, J, Millar, T, Musto, V & Marsden, J (2015). Fatal opioid poisoning: a counterfactual model to estimate the preventive effect of treatment for opioid use disorder in England. Addiction, 110,

8 1. Background and policy context The statistics in this report on treatment for alcohol and drug dependence are collected through the National Drug Treatment Monitoring System (NDTMS). This publication is the first time information on individuals receiving specialist interventions for drugs and alcohol are brought together in one report. In doing so it recognises that people may experience problems with the use of many substances, including alcohol and may well require treatment to address issues of dependence together. It also reflects a growing trend for local authorities to commission drugs and alcohol services together. Specialist treatment services are vital component parts of local authority treatment and recovery systems. Treatment services have a key part to play in helping local authorities address the harms associated with alcohol and drug use, including to health, families and communities, along with the associated crime. The government s drug and alcohol strategies stress the importance of treatment services in reducing both the harm and public expense caused by problematic use (www.gov.uk/government/publications/drug-strategy , Specialist treatment is one of a range of interventions that need to be in place to address alcohol and drug problems effectively to reduce harm and to help people recover. Others include alcohol identification and brief advice (IBA); information and advice on reducing harm; needle and syringe exchange programmes; outreach work and support along with broader but related support such as access to housing and employment opportunities. Such interventions are provided in a range of settings including specialist services, general practice, pharmacies, hospitals and prisons, and by a range of providers the NHS and the voluntary sector. Local authorities, who are responsible for commissioning treatment services, are well placed to bring the component parts of an effective system together, along with the NHS, to ensure all elements work together for the good of their populations. Alcohol and drug treatment services are now well established in communities across the country and over the past decade the number of people accessing help has increased considerably, as has the proportion recovering from their dependence. Evidence-based and effective interventions can improve the lives of individuals and the life chances of their children and the stability of their communities. They also have a significant impact in reducing the spread of blood-borne viruses, in reducing crime and in saving lives. The harmful effects of alcohol and drugs are greater in poorer communities and effective treatment services can play an important role in addressing these inequalities. These statistics are used by national and local government to monitor the availability and effectiveness of alcohol and drug treatment in England. The information is collected from approximately 1,500 treatment services on a monthly basis. This data is regularly fed back to local service commissioners and service providers in the form of benchmarked reports, toolkits and data packs to inform local joint strategic needs assessments. 8

9 These resources are integral in assisting local areas to respond to need and improve outcomes. They can help local authorities ensure that the services they commission are effective and good value for money within the context of competing local priorities. Information on the total number of people in alcohol and drug treatment in each local authority in England, the numbers accessing it each year, and the numbers leaving treatment can be found at While these statistics provide information on the numbers of people accessing treatment for alcohol dependence, they do not give an indication of prevalence of alcohol dependence in England. PHE will be releasing prevalence estimates of dependent drinkers in each local authority in early For information on the wider harms associated with alcohol use, the Local Alcohol Profiles for England (LAPE) fingertips.phe.org.uk/profile/local-alcohol-profiles present a comprehensive picture of different health harms for alcohol related conditions, as well as information on mortality where alcohol is considered to have been a contributory factor. Similarly for drugs, estimates of the number of individuals using opiates, crack and injecting drugs in England, reported nationally and by local authority, can be found at The Crime Survey for England and Wales reports the prevalence of the use of all drugs nationally and can be found at Information on the history of the data collection of specialist drug treatment can be found in chapter nine of this report and chapter ten provides an explanation of the abbreviations that have been used throughout the report. More detail on the methodologies used to compile these statistics and the processes that are in place to ensure data quality can be found at /www.ndtms.net/resources/secure/quality-and- Methodology-NDTMS pdf. If an error is identified in any of the information that has been included in this report then the processes described in the PHE revisions and correction policy will be adhered to. The policy can be found at 9

10 2. Change in method of reporting alcohol and drug statistics In the National Treatment Agency (NTA) consulted on changes to reporting practices and there was strong consensus among respondents that drug and alcohol treatment journeys should be combined. Previously, an individual recorded with a primary alcohol treatment episode concurrent with, or followed by, a primary drug one was reported twice, once as an alcohol client and once as a drug client. Some 6,000 individuals nationally had been double counted in this way. Following this feedback, the newly formed PHE consulted further to align the way treatment journeys were reported across alcohol and drug treatment, and the way individuals were categorised by their problem substances. The agreed methodological changes are illustrated in the diagram below. CLIENT ENTERS TREATMENT Has client presented to treatment citing opiates as a problem substance? NO Has client presented to treatment citing nonopiates as a problem substance? NO YES YES Has client presented to treatment citing alcohol as a problem substance? YES NO OPIATE CLIENT NON-OPIATE ONLY CLIENT NON-OPIATE AND ALCOHOL CLIENT ALCOHOL ONLY CLIENT CLIENT CLASSIFICATION 10

11 A client presenting to treatment citing problematic substance misuse is now categorised by the following hierarchal criteria: any mention of opiate use in any episode would result in the client being categorised as an OPIATE client (irrespective of what other substances are cited) clients who present with non-opiate substances (and not opiates or alcohol) will be classified as NON-OPIATE ONLY clients who present with a non-opiate substance and alcohol (but not opiates) recorded in any drug in any episode in their treatment journeys will be classified as NON-OPIATE AND ALCOHOL clients who present with alcohol and no other substances will be categorised as ALCOHOL ONLY Due to these changes it is not possible to compare the statistics in this report to previous adult drug and alcohol NDTMS statistical publications for more detail see section 9.2. Additional changes were also consulted on at the same time and subsequently agreed and implemented. The age limit for clients has been extended to 100 to reflect the increasing age of the general treatment population, in particular those citing alcohol only as a problematic substance. Individuals not citing any problematic substance (known as misuse free) are excluded from these statistics as the codes "drug-free" and "alcohol-free" were initially introduced to report on abstinent clients who were in structured treatment to prevent relapse. These were since removed from the valid drug codes a number of years ago with guidance being that the drug the individual was in relapse prevention for should be recorded. Prescribed opiates are also now included in the opiate category where previously they would have been classified as non-opiate only or non-opiate and alcohol. These changes have also been applied to all trend data in this report. The consultation summary can be found here: More information on the consultation can be found here: 11

12 3. Assessment of quality and robustness of NDTMS community data Data collection through NDTMS was suspended between November 2014 and February 2015 (a period of four months), to introduce security enhancements into the system. The system was fully restored in March Providers were given up until the end of July to submit and validate data entered locally during the downtime, as well as to catch up with any backlog of data that they may have not been able to record while the systems were suspended. PHE worked closely with all providers of drug and alcohol treatment through eight regional based teams to support this process. While the NDTMS closure was unscheduled, it was possible to ensure that the downtime was well managed and coordinated. Through the commitment and goodwill of the treatment providers, PHE were able to ensure that any risks to the provision of a complete dataset were minimised. The intelligence gathered by PHE NDTMS teams as part of their support of treatment providers suggests that data collected for is reflective of activity and that all appropriate measures were put in place locally to ensure full data recovery. There is no current evidence that the downtime had any adverse long term effects on quality or compliance. More detailed information can be found at 12

13 4. Characteristics of clients During NDTMS reported a total of 295,224 individuals aged 18 to 100 in contact with structured treatment. This total includes all individuals in treatment for either problematic drug use, alcohol use or both. Figure 4 below presents how the 295,224 individuals are segmented by the four substance groups used throughout this report. Just over half the clients in contact with treatment during the year (52%) had presented with problematic use of opiates, a further 18% had presented with problems with other drugs and just under a third (30%) had presented with alcohol as the only problematic substance. Figure 4 Numbers in treatment by main substance group ,964 Alcohol only 30% 89,107 25,025 28,128 Opiate Non-opiate Non-opiate and alcohol Alcohol only Nonopiate and alcohol 10% Nonopiate 8% Opiate 52% 4.1 Substance use profile Table and figure show the distribution of substances for all individuals in treatment in , by the four substance groups used within this report. Forty per cent of opiate clients also presented with crack cocaine, the next highest adjunctive substances were alcohol (22%), cannabis (19%) and benzodiazepines (12%). Cannabis was the substance that the majority of non-opiate only clients presented to treatment (62%) with, this was followed by 31% of clients presenting with cocaine and 17% with amphetamines. Cannabis was also the drug that the majority of non-opiate and alcohol clients presented with to treatment (60%), with 39% of clients presenting with cocaine and 11% with amphetamines. Overall, 51% of clients in treatment in presented with problematic alcohol use, 89,107 of these individuals presented with alcohol alone, with the other 61,533 individuals also reporting problematic use of other substances. 13

14 Crack cocaine (not opiate) Cannabis Cocaine Benzodiazepine Amphetamine (other than ecstasy) Other drug Ecstasy Alcohol Opiate (not crack cocaine) Both opiate and crack cocaine Cannabis Cocaine Benzodiazepine Amphetamine (other than ecstasy) Alcohol Opiate (not crack cocaine) Both opiate and crack cocaine Cannabis Cocaine Benzodiazepine Amphetamine (other than ecstasy) Alcohol Crack cocaine (not opiate) Cannabis Cocaine Benzodiazepine Amphetamine (other than ecstasy) Other drug Ecstasy Novel psychoactive substances Hallucinogen Adult substance misuse statistics from NDTMS Figure Substance breakdown of all clients in treatment % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Opiate 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Non-opiate 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Non-opiate and alcohol 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Total 14

15 Table Substance breakdown of all clients in treatment Substance Opiate Non-opiate Non-opiate and alcohol Alcohol only Total n % n % n % n % n % Opiate and/or crack cocaine use Opiate (not crack cocaine) 91,530 60% ,530 31% Both opiate and crack cocaine 61,434 40% ,434 21% Crack cocaine (not opiate) - - 2,178 9% 2,449 9% - - 4,627 2% Other drug use Cannabis 29,568 19% 15,425 62% 16,809 60% ,802 21% Cocaine 8,896 6% 7,822 31% 11,039 39% ,757 9% Benzodiazepine 19,017 12% 1,515 6% 1,314 5% ,846 7% Amphetamine (other than ecstasy) 7,666 5% 4,160 17% 3,110 11% ,936 5% Other drug 1,917 1% 1,370 5% 764 3% - - 4,051 1% Hallucinogen 403 0% 618 2% 347 1% - - 1,368 0% Other prescription drug 488 0% 121 0% 148 1% % Alcohol Anti-depressant 437 0% 37 0% 143 1% % Solvent 137 0% 104 0% 133 0% % Major tranquiliser 112 0% 25 0% 25 0% % Barbiturate 78 0% 10 0% 19 0% % Alcohol 33,405 22% , % 89, % 150,640 51% Total number of individuals * 152, % 25, % 28, % 89, % 295, % *The total number of individuals will be less than the sum of the reported substances as an individual may present with more than one problematic substance **Percentages may equal 0% or not sum to 100% due to rounding Table presents a breakdown of substances that are categorised under a heading of club drugs and new psychoactive substances (NPS), a collective term for a number of different substances typically used by people in bars and nightclubs, at concerts and parties, before and after a night out. Mephedrone citations make up the largest proportion of club drug/nps presentations for all individuals in treatment in (1.0%), with 6% of non-opiate clients citing the substance and 0.4% of opiate clients. The second most common club drug cited was ecstasy (0.7%) followed by new psychoactive substances (0.5%). When NPS are broken down, the majority of presentations were for NPS that had cannabinoid or stimulant effects. 15

16 Table Club drug and new psychoactive substances breakdown of all clients in treatment Club drug and new psychoactive substances Opiate Non-opiate Non-opiate and alcohol n % n % n % n % Mephedrone % 1, % % 3, % Ecstasy % % % 2, % New psychoactive substances % % % 1, % Ketamine % % % 1, % Methamphetamine % % % % GHB/GBL % % % % Further breakdown of new psychoactive substances: Predominantly cannabinoid % % % % Predominantly stimulant % % % % Other % % % % Predominantly sedative/opioid % % % % Predominantly hallucinogenic 8 0.0% % % % Predominantly dissociative 2 0.0% % % % Total 152, % 25, % 28, % 295, % *Percentages may equal 0% or not sum to 100% due to rounding Total 16

17 4.2 Age of clients The age of individuals at their first point of contact with the treatment system in the financial year is reported in table and figure The median age (the middle number in an ascending list of all ages) of non-opiate clients in treatment in was 29 years, slightly younger than the median age for non-opiate and alcohol clients, 34 years. Opiate clients were older, with a median age of 38 years, but still younger than the projected median age for the population of England, which is 39 years (ONS mid-year population 2013). Only the alcohol only clients have a median age (45 years) older than the general population (www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3a ). Similarly, individuals in treatment only presenting with problematic alcohol use (alcohol only) have the oldest age distribution, with 68% of clients in treatment being 40 years and over and 11% 60 years and over. Individuals are most likely to start using drugs in their late teens and early twenties and, on average, seek treatment within eight years of initiation of their use. Non-opiates clients, both those who have presented with alcohol and those just using non-opiates, tend to be younger than individuals that have presented with opiates. The distribution of ages of individuals in treatment reflects patterns seen in estimates of prevalence. A large proportion of heroin/opiate users in treatment in will have started using heroin in the epidemics of the 1980s and 1990s and are now over 40 years of age, having been using heroin for a significantly long period of time. Those who use other substances tend to be younger, as can be seen in figures 1.2, 1.3 and 1.4 in the Crime Survey for England and Wales. This survey shows that cannabis, ecstasy and powder cocaine are the most commonly used substances for year olds with, for example, 16.3% having used cannabis in the last year (compared to 6.7% for the general population aged 16-59). (www.gov.uk/government/uploads/system/uploads/attachment_data/file/462885/drug-misuse pdf). 17

18 Table Age of all clients in treatment Age Opiate Non-opiate Non-opiate and alcohol Alcohol only Total n % n % n % n % n % % 1,234 5% 975 3% 262 0% 2,629 1% % 1,014 4% 577 2% 278 0% 2,150 1% ,910 3% 5,537 22% 3,707 13% 2,773 3% 16,927 6% ,597 10% 5,310 21% 4,843 17% 5,775 6% 31,525 11% ,198 20% 4,204 17% 4,779 17% 8,739 10% 48,920 17% ,176 22% 2,879 12% 3,990 14% 10,722 12% 51,767 18% ,598 19% 2,007 8% 3,624 13% 14,140 16% 49,369 17% ,233 13% 1,398 6% 2,912 10% 15,023 17% 39,566 13% ,142 7% 740 3% 1,682 6% 12,971 15% 25,535 9% ,174 3% 334 1% 725 3% 8,708 10% 13,941 5% ,869 1% 159 1% 231 1% 5,178 6% 7,437 3% % 86 0% 54 0% 2,865 3% 3,498 1% % 123 0% 29 0% 1,673 2% 1,960 1% Total 152, % 25, % 28, % 89, % 295, % *Percentages may equal 0% or not sum to 100% due to rounding Figure Age distribution of all clients in treatment % 20% 15% 10% 5% 0% Opiate Non-opiate Non-opiate and alcohol Alcohol only 18

19 4.3 Gender of clients Table presents the gender distribution for all clients in treatment, segmented by the four substance groups. Overall 30% of individuals in treatment are women, compared to 51% of the population in England (www.ons.gov.uk/ons/publications/re-referencetables.html?edition=tcm%3a ). The three drug groups, opiate, non-opiate and non-opiate and alcohol have a very similar distribution with about three quarters of each group being male. This is broadly comparable with figures reported in Crime Survey for England and Wales where 11.9% of males aged 16 to 59 had taken an illicit drug in the last year, compared to 5.4% of females (www.gov.uk/government/uploads/system/uploads/attachment_data/file/462885/drug-misuse pdf). Among those in treatment for alcohol problems only, males made up a lower proportion (62%). Table Gender of all clients in treatment Male Female Persons n % n % n % Opiate 111,779 73% 41,185 27% 152, % Non-opiate 18,867 75% 6,158 25% 25, % Non-opiate and alcohol 20,679 74% 7,449 26% 28, % Alcohol only 54,973 62% 34,134 38% 89, % Total 206,298 70% 88,926 30% 295, % 19

20 4.4 Ethnicity of clients Table reports the ethnicity of clients in treatment in Where reported, most individuals (85%) were white British compared to 80% of the English population, 4 ranging from 87% of alcohol only presentations to 79% of non-opiate clients. Other white was the next most common ethnicity, (4%) compared to 5% of the English population. No other ethnic group accounted for more than 2% of the total cohort. Within the non-opiate substance group, 3% of individuals had an ethnicity of Caribbean, compared to the other substance groups and the English population where the proportion is 1%. Table Ethnicity of all clients in treatment Ethnicity Opiate Non-opiate Non-opiate and alcohol Alcohol only Total n % n % n % n % n % White British 126,646 86% 19,516 79% 23,220 85% 75,998 87% 245,380 85% Other white 5,920 4% 832 3% 737 3% 2,979 3% 10,468 4% Not stated 1,487 1% 600 2% 349 1% 2,188 2% 4,624 2% White Irish 1,512 1% 213 1% 361 1% 1,317 2% 3,403 1% Indian 1,686 1% 192 1% 213 1% 1,135 1% 3,226 1% Caribbean 1,221 1% 696 3% 528 2% 530 1% 2,975 1% White and black Caribbean 1,330 1% 458 2% 408 1% 425 0% 2,621 1% Pakistani 1,691 1% 325 1% 176 1% 268 0% 2,460 1% Other Asian 1,404 1% 235 1% 137 0% 550 1% 2,326 1% Other 1,305 1% 224 1% 186 1% 511 1% 2,226 1% Other black 854 1% 437 2% 372 1% 412 0% 2,075 1% African 391 0% 434 2% 290 1% 570 1% 1,685 1% Other mixed 706 0% 256 1% 200 1% 271 0% 1,433 0% Bangladeshi 1,078 1% 147 1% 58 0% 82 0% 1,365 0% White and Asian 418 0% 92 0% 80 0% 163 0% 753 0% White and black African 252 0% 88 0% 98 0% 154 0% 592 0% Chinese 49 0% 14 0% 15 0% 31 0% 109 0% Unknown 5 0% 1 0% 1 0% 1 0% 8 0% Total 147, % 24, % 27, % 87, % 287, % Inconsistent/missing 5, ,522 7,495 Total 152,964 25,025 28,128 89, ,224 *Percentages may equal 0% or not sum to 100% due to rounding 4 For ethnicity data please see: 2011 Census: KS201EW Ethnic group, local authorities in England and Wales 20

21 4.5 Source of referral into treatment (new presentations) Table shows a breakdown of new presentations to treatment by source of referral (ie, the routes by which people accessed treatment). Information about source of referral was provided for 140,306 (99%) of all new presentations to treatment in Of all recorded referral sources, self-referrals were the most common for all individuals and within the four substance groups (ranging from 48% for non-opiate clients to 45% for alcohol only clients). For alcohol only clients, the next most common referral source was through health services (33%). This was made up of GP referrals (20%), hospital (6%), social services (2%) and other health services (5%). In comparison health services only accounted for 10% of opiate client referrals. The criminal justice system was the second most common referral source for opiate clients (28%), made up of prison/carat referrals (14%), arrest referrals/dip (8%), probation (3%) and other criminal justice system referral routes (2%). By contrast, only 8% of referrals for alcohol only clients were from the criminal justice system. Overall, substance misuse services accounted for 9% of referrals into treatment (ranging from 5% for non-opiate clients to 12% for opiate clients). A further breakdown of referral routes into treatment can be found in the supporting tables. 21

22 Table Source of referral into treatment, new presentations to treatment Referral Source Opiate Non-opiate Non-opiate and alcohol Alcohol only n % n % n % n % n % Self, family and friends Self 20,572 47% 8,191 48% 8,522 46% 27,335 45% 64,620 46% Other family and friends 176 0% 236 1% 240 1% 623 1% 1,275 1% Self, family and friends subtotal 20,748 47% 8,427 49% 8,762 48% 27,958 46% 65,895 47% Health GP 2,884 7% 1,333 8% 2,112 11% 11,950 20% 18,279 13% Health other 698 2% 807 5% 870 5% 3,175 5% 5,550 4% Hospital 449 1% 147 1% 407 2% 3,722 6% 4,725 3% Social services 213 0% 524 3% 384 2% 1,104 2% 2,225 2% Health subtotal 4,244 10% 2,811 16% 3,773 20% 19,951 33% 30,779 22% Criminal justice Arrest referral/dip 3,640 8% 1,612 9% 1,042 6% 883 1% 7,177 5% CARAT/Prison 6,291 14% 304 2% 239 1% 268 0% 7,102 5% Probation 1,326 3% 1,119 7% 1,129 6% 2,063 3% 5,637 4% Criminal justice other 1,012 2% 697 4% 659 4% 1,405 2% 3,773 3% Criminal justice subtotal 12,269 28% 3,732 22% 3,069 17% 4,619 8% 23,689 17% Substance misuse service Drug service non-statutory 3,058 7% 522 3% 665 4% 1,929 3% 6,174 4% Drug service statutory 2,222 5% 300 2% 470 3% 1,322 2% 4,314 3% Community alcohol team 97 0% 8 0% 256 1% 1,981 3% 2,342 2% Substance misuse service subtotal 5,377 12% 830 5% 1,391 8% 5,232 9% 12,830 9% Other 1,142 3% 1,370 8% 1,440 8% 3,163 5% 7,115 5% Total 43, % 17, % 18, % 60, % 140, % Missing or unknown ,338 Total 44,356 17,338 18,548 61, ,646 Total *Percentages may equal 0% or not sum to 100% due to rounding 22

23 4.6 Age and presenting substance (new presentations) Table shows the substance distribution for individuals presenting to treatment in , reported by the four substance groups. Forty-two per cent of opiate new presentations also presented with crack cocaine, the next highest adjunctive substance alongside opiate use, was alcohol (20%). For non-opiate only clients, the majority of individuals cited cannabis as a problematic substance (61%), this was followed by just under a third (32%) of non-opiate clients presenting with cocaine. Cannabis was also the main drug non-opiate and alcohol clients presented with, 58% having done so, with cocaine the next most cited substance (41%). Overall, 63% (88,904) of individuals starting treatment in presented with problematic alcohol use, of these 61,404 cited alcohol as the only problematic substance. The next most commonly cited substance was opiates (31%), followed by cannabis which was cited by 20% of individuals. Table Substance breakdown of new presentations to treatment Substance Opiate Non-opiate Non-opiate and alcohol Alcohol only Total n % n % n % n % n % Opiate and/or crack cocaine use Opiate (not crack cocaine) 25,799 58% ,799 18% Both opiate and crack cocaine 18,557 42% ,557 13% Crack cocaine (not opiate) - - 1,414 8% 1,471 8% - - 2,885 2% Other drug use Cannabis 7,205 16% 10,630 61% 10,837 58% ,672 20% Cocaine 2,154 5% 5,627 32% 7,678 41% ,459 11% Amphetamine (other than ecstasy) 1,985 4% 2,852 16% 1,916 10% - - 6,753 5% Benzodiazepine 3,938 9% 917 5% 749 4% - - 5,604 4% Other 1,168 3% 2,711 16% 1,681 9% - - 5,560 4% Alcohol Total number of individuals* Alcohol 8,952 20% , % 61, % 88,904 63% 44, % 17, % 18, % 61, % 141, % *The number of individuals will be less than the total of the reported substances as an individual may present with more than one problematic substance 23

24 Table and figure report the distribution of the substances by age for new presentations to treatment in For younger clients presenting to treatment (those aged 18-24), the main substances cited were cannabis (52%, 7,369), alcohol (44%, 6,290) and cocaine (23%, 3,272), with only 19% (2,729) have presented using opiates. The percentage of individuals presenting with problems with alcohol use increased with age, with 66% (13,376 of those aged citing alcohol as problematic and 93% (3,756) of those age A further breakdown of clients aged can be found in the supporting tables. Table Age and presenting substance of new presentations to treatment Substance Total Opiate and/or crack cocaine use Opiate (not crack cocaine) Both opiate and crack cocaine Crack cocaine (not opiate) Other drug use Cannabis Cocaine Benzodiazepine Amphetamine (other than ecstasy) Alcohol Other Alcohol Total number of individuals* 1,718 3,677 5,625 5,427 4,386 2,793 1, ,799 12% 21% 25% 25% 21% 16% 11% 7% 5% 3% 18% 1,011 2,778 4,495 4,138 3,072 1, ,557 7% 16% 20% 19% 15% 11% 7% 3% 2% 1% 13% ,885 2% 3% 3% 2% 2% 2% 1% 1% 1% 0% 2% 7,369 5,364 4,812 3,830 3,075 2,321 1, ,672 52% 30% 21% 18% 15% 13% 10% 7% 4% 1% 20% 3,272 3,814 3,295 2,181 1, ,459 23% 21% 15% 10% 7% 5% 3% 2% 1% 0% 11% ,211 1, ,604 4% 5% 5% 5% 4% 3% 2% 1% 1% 3% 4% 1,271 1,303 1,335 1, ,753 9% 7% 6% 5% 4% 3% 2% 1% 1% 0% 5% 1,702 1, ,560 12% 6% 4% 3% 3% 2% 1% 1% 1% 2% 4% 6,290 8,629 11,248 11,951 13,736 13,033 10,376 6,489 3,756 3,396 88,904 44% 48% 50% 55% 66% 75% 83% 90% 93% 93% 63% 14,178 17,866 22,417 21,544 20,769 17,452 12,470 7,241 4,060 3, ,646 *The number of individuals will be less than the total of the reported substances as an individual may present with more than one problematic substance **Percentages may equal 0% or not sum to 100% due to rounding 24

25 Figure Age and presenting substance distribution of new presentations to treatment % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Opiate or opiate and crack cocaine Cannabis Cocaine Other Alcohol 4.7 Injecting behaviour (new presentations) Injecting status at presentation for treatment was recorded for 134,685 individuals (95%) who entered treatment in The majority of individuals presenting to treatment have never injected (76%), though there was variation by substance with 96% of alcohol only clients having never injected any substance compared to 38% of opiate clients. Just over a quarter (26%) of individuals using opiates were currently injecting, compared to 3% and 1% in the non-opiate and non-opiate and alcohol clients respectively. The majority of non-opiate clients who inject are likely to be individuals using methamphetamine and mephedrone. Sharing of injecting equipment is the single biggest factor in blood-borne virus transmission among individuals who use and inject drugs. It also elevates mortality risk and those who inject have a more complex profile, and are therefore harder to treat. 25

26 Table Injecting status of new presentations to treatment Injecting Status Opiate Non-opiate Non-opiate and alcohol Alcohol only Total n % n % n % n % n % Never injected 16,593 38% 14,909 89% 16,195 90% 54,361 96% 102,058 76% Previously injected 15,632 36% 1,197 7% 1,474 8% 1,696 3% 19,999 15% Currently injecting 11,372 26% 522 3% 223 1% 127 0% 12,244 9% Declined to answer 137 0% 46 0% 32 0% 169 0% 384 0% Total 43, % 16, % 17, % 56, % 134, % Missing/inconsistent ,051 6,961 Total 44,356 17,338 18,548 61, ,646 *Percentages may equal 0% or not sum to 100% due to rounding 4.8 Housing situation (new presentations) Table presents the housing status of individuals at the time that they presented for treatment. Of the 137,765 individuals (97%) who provided their housing status, 7% reported an urgent housing problem, usually No Fixed Abode (NFA), with a further 12% reporting some form of current housing problem (such as staying with friends or family as a short term guest or residing at a short-term hostel). Opiate clients had the highest rates of urgent housing problems (12%) and alcohol only clients the least (3%), reflecting the generally more chaotic nature of individuals presenting to treatment for opiates compared to those presenting with alcohol only. Table Housing situation of new presentations to treatment Housing situation Opiate Non-opiate Non-opiate and alcohol Alcohol only Total n % n % n % n % n % No problem 31,232 72% 13,569 80% 14,000 77% 52,253 88% 111,054 81% Housing problem 6,672 15% 1,841 11% 2,460 13% 5,036 8% 16,009 12% Urgent housing problem (NFA) 5,358 12% 725 4% 1,105 6% 1,867 3% 9,055 7% Other 61 0% 723 4% 683 4% 180 0% 1,647 1% Total 43, % 16, % 18, % 59, % 137, % Inconsistent/missing 1, ,068 3,881 Total 44,356 17,338 18,548 61, ,646 *Percentages may equal 0% or not sum to 100% due to rounding 26

27 5. Access to services 5.1 Waiting times for first and subsequent treatment interventions Overall, nearly all individuals (97%) waited three weeks or less from when they first presented for treatment to starting an intervention. There was marginal variation in waiting times between the four substance groups. Similarly, for individuals that started a subsequent intervention, the vast majority (96%) did so within three weeks. The average (mean) waiting time for all individuals was 3.3 days, this ranged from 2.4 days for opiate clients to 4.2 days for alcohol only clients. Table Waiting times, first and subsequent interventions First intervention Subsequent intervention Intervention 3 weeks or Average 3 weeks or Over 3 weeks under waiting time under Over 3 weeks n % n % days n % n % Opiate 64,152 98% 1,312 2% ,483 97% 2,783 3% Non-opiate 17,599 98% 392 2% 2.8 1,919 97% 53 3% Non-opiate and alcohol 18,648 96% 722 4% 3.7 6,679 92% 601 8% Alcohol only 60,593 95% 2,938 5% ,599 93% 1,608 7% Total 160,992 97% 5,364 3% ,680 96% 5,045 4% 5.2 Treatment interventions As part of a treatment journey, an individual may receive more than one intervention (ie, more than one type of treatment) while being treated at a provider and may attend more than one provider for subsequent interventions. Before 1 November 2012 there were six structured treatment intervention types. However, from 1 November 2012 the way in which interventions were recorded on NDTMS was changed to include three high-level intervention types: psychosocial, pharmacological and recovery support, an intervention setting and a series of sub-interventions. Table shows the number of clients who received each intervention in their latest treatment journey for individuals receiving interventions that commenced prior to 1 November Individuals are only counted once for each intervention type they received. 27

28 Table Interventions received by clients in treatment , old interventions Intervention n Inpatient detoxification 3,907 Structured day programme 8,914 Residential rehabilitation 1,097 Structured intervention 24,671 Old YP intervention 68 Table provides information on interventions commenced after the changes to the core dataset introduced on 1 November 2012 (see section 9.2 for more detail on this change). It shows the number of clients who received interventions starting on or after 1 November 2012 based on the new intervention codes and intervention setting. If an individuals intervention features in table 5.2.2, and can be directly mapped between tables, it is not featured in table above to avoid double counting. 28

29 Table Interventions received by clients in treatment , new interventions Substance group Opiate Non-opiate Non-opiate and alcohol Alcohol only Total Intervention type Setting Psychosocial Prescribing Total* n % n % Community 131,765 93% 131,970 92% 144,940 Inpatient unit 4,680 3% 5,918 4% 6,102 Primary care 17,861 13% 32,581 23% 33,615 Residential 2,919 2% 1,363 1% 3,082 Recovery house 176 0% 51 0% 190 Missing 2 0% 1 0% 2 Other 4,196 3% 13,498 9% 15,092 Total 141, % 143, % 152,964 Community 23,622 97% 1,989 90% 23,789 Inpatient unit 88 0% 102 5% 111 Primary care 608 2% 181 8% 714 Residential 163 1% 21 1% 167 Recovery house 37 0% 2 0% 37 Missing 43 0% 1 0% 43 Other 40 0% 33 1% 62 Total 24, % 2, % 25,025 Community 26,432 97% 3,020 64% 26,576 Inpatient unit 1,198 4% 1,544 33% 1,583 Primary care 558 2% 294 6% 727 Residential 1,297 5% 382 8% 1,347 Recovery house 86 0% 2 0% 87 Missing 32 0% 2 0% 33 Other 76 0% 16 0% 88 Total 27, % 4, % 28,128 Community 80,706 95% 13,452 67% 81,580 Inpatient unit 4,153 5% 5,806 29% 6,037 Primary care 3,209 4% 1,420 7% 3,972 Residential 2,256 3% 929 5% 2,414 Recovery house 138 0% 1 0% 139 Missing 4 0% 0 0% 4 Other 41 0% 9 0% 49 Total 84, % 20, % 89,107 Community 262,525 94% 150,431 88% 276,885 Inpatient unit 10,119 4% 13,370 8% 13,833 Primary care 22,236 8% 34,476 20% 39,028 Residential 6,635 2% 2,695 2% 7,010 Recovery house 437 0% 56 0% 453 Missing 81 0% 4 0% 82 Other 4,353 2% 13,556 8% 15,291 Total 278, % 170, % 295,224 *This is the total number of individuals receiving each intervention type and not a summation of the psychosocial and prescribing columns. **Percentages may equal 0% or not sum to 100% due to rounding 29

30 Data from tables and can be summed where overlap in definition exists to arrive at the total number of individuals receiving each intervention in No overlap exists for structured day programmes or other structured interventions thus the total number of clients can only be reported up to the 31 October A count of the total number of individuals by setting / intervention where it is possible to sum the overlap between tables and 5.2.2, can be found in table below. Table Total individuals in settings (overlap between and 5.2.2) Setting Total number of individuals Inpatient unit 17,740 Residential 8,107 Table below provides a breakdown of clients receiving a prescribing intervention, by the length of time that they had been in receipt of it either when they exited treatment during the year, or at the 31 March Just under half of individuals (48%) had been in receipt of prescriptions for less than 12 months, with variation between substance groups (40% for opiate clients to 94% for alcohol only clients). Nearly a quarter of opiate clients (24%) received prescribing treatment for over five years compared to less than 1% for those receiving interventions for alcohol only. The majority of individuals will either be receiving prescriptions as part of opiate substitution therapy or to enable safe withdrawal from alcohol dependence. Those receiving scripts to help with relapse prevention will make up the majority all of the remaining prescriptions. Table Length of time in prescribing for clients in continuous prescribing treatment Opiate Non-opiate Non-opiate and alcohol Alcohol only Total n % n % n % n % n % Less than 12 months 57,230 40% 1,634 74% 4,282 90% 18,986 94% 82,132 48% 1-2 years 22,829 16% % 278 6% 857 4% 24,206 14% 2-3 years 13,212 9% 99 4% 80 2% 173 1% 13,564 8% 3-4 years 8,368 6% 63 3% 31 1% 67 0% 8,529 5% 4-5 years 7,468 5% 23 1% 16 0% 24 0% 7,531 4% 5 years + 34,619 24% 157 7% 47 1% 28 0% 34,851 20% Total 143, % 2, % 4, % 20, % 170, % *Percentages may equal 0% or not sum to 100% due to rounding 30

31 5.3 Engagement Of the 295,224 individuals in contact with treatment services during (295,224), (91%) were either retained for more than 12 weeks, or if leaving treatment before 12 weeks, did so free of dependence. Opiate clients are most likely to be retained in treatment for at least 12 weeks or complete treatment successfully before this time (95%) compared to non-opiate (87%), non-opiate and alcohol (88%) and alcohol only clients (87%). Table Clients retained to treatment for at least 12 weeks or completing treatment earlier Substance Number in contact with treatment services Number retained in treatment for at least 12 weeks or completing treatment earlier n n % Opiate 152, ,875 95% Non-opiate 25,025 21,857 87% Non-opiate and alcohol 28,128 24,687 88% Alcohol only 89,107 77,469 87% Total 295, ,888 91% 31

32 6. Treatment and recovery outcomes 6.1 Treatment exits and successful completions Table shows the reasons for clients exiting treatment in There were 130,609 individuals who left treatment during the year and were not in treatment on 1 April Of these, 67,788 (52%) were discharged as treatment completed. This is determined by clinical judgement that the individual no longer has a need for structured treatment, having achieved all the care plan goals and having overcome dependent use of the substances that bought them into treatment. Figure represents the percentage of successful completions among the four substance groups. Opiate clients have the lowest rate of successful completions (30%), compared to the other three substance groups (ranging from 58% for non-opiate and alcohol clients to 64% for non-opiate clients). Despite 32% of opiate clients being transferred for further treatment within the community (17%) or while in custody (15%), they still had the highest proportion of incomplete treatment (38%). In comparison, around a third of clients in other substance groups exited treatment incomplete, with non-opiate clients having the lowest proportion (29%). On average (mean), individuals who completed treatment did so after days. However, the average number of treatment days ranged from days for opiate clients to under 210 days for all the other substance groups (172.8 for non-opiate clients, 208 for non-opiate and alcohol clients and for alcohol only clients). During , 2% of clients died while in contact with treatment. Most of these were opiate clients (61% of all deaths) with a median age of 43 years. A further 792 (34% of all deaths) alcohol only clients died while accessing treatment. The majority were aged 40 and over, with the greatest median age among the substance groups of 49 years. In comparison, non-opiate and alcohol (4%) and non-opiate clients (2%) made up only a small percentage of deaths while in contact with treatment services. Non-opiate and alcohol deaths had a median age comparable to opiate clients (43 years), whereas non-opiate clients had the lowest median age, with the majority aged under 40 (35 years). Full definitions of all the treatment exit reasons below can be found in the NDTMS business definitions: 32

33 Table Treatment exit reasons for clients not retained in treatment on 31 March 2015 Treatment exit reason Opiate Non-opiate Non-opiate and alcohol Alcohol only Total n % n % n % n % n % Completed free of dependence no drug or alcohol use 10,148 26% 6,307 38% 5,914 33% 20,354 35% 42,723 33% Completed free of dependence 1,537 4% 4,261 26% 4,462 25% 14,805 26% 25,065 19% Treatment completed free of dependence subtotal 11,685 30% 10,568 64% 10,376 58% 35,159 61% 67,788 52% Dropped out/left 11,363 30% 4,181 25% 5,162 29% 15,038 26% 35,744 27% Transferred not in custody 6,535 17% 657 4% 1,076 6% 4,017 7% 12,285 9% Transferred in custody 5,563 15% 565 3% 507 3% 547 1% 7,182 5% Treatment declined 550 1% 332 2% 440 2% 1,587 3% 2,909 2% Died 1,428 4% 39 0% 101 1% 792 1% 2,360 2% Prison 689 2% 111 1% 136 1% 167 0% 1,103 1% Treatment withdrawn 438 1% 73 0% 117 1% 360 1% 988 1% Exit reason inconsistent 85 0% 39 0% 44 0% 82 0% 250 0% Total 38, % 16, % 17, % 57, % 130, % *Percentages may equal 0% or not sum to 100% due to rounding Figure Proportion of exits that are successful by the four substance groups % 60% 50% 40% 30% 20% 10% 0% Opiate Non-opiate Non-opiate and alcohol Alcohol only 33

34 6.2 Six-month outcomes Introduction The Treatment Outcomes Profile (TOP) is a clinical tool that enables clinicians and key workers to keep track of the progress of individuals through their treatment journeys. It consists of 20 questions focusing on substance use, injecting risk behaviour, housing, employment, crime and health and quality of life. In November 2013, the Alcohol Outcomes Record (AOR) was introduced to NDTMS. The AOR is a four-item condensed version of the TOP, which monitors change in the frequency and quantity of alcohol consumption, as well as physical health and psychological health. Treatment providers can utilise either the TOP or the AOR to monitor alcohol only clients. For all other clients, the TOP is expected. This report includes an analysis of all TOP/AOR review data received in that complies with the TOP reporting protocols and for which there is also corresponding treatment start TOP information The AOR is not specifically required to be completed for six-month in-treatment outcomes monitoring, but such instances are included here where the data is available. The reporting protocols stipulate that an individual can have a review completed between 29 and 182 days following their initial assessment. A total of 90,194 individuals had a review TOP/AOR occurring in and also had corresponding TOP data at treatment start, and the outcomes of these individuals are reported here. Methods A statistical approach known as the Reliable Change Index (RCI) is used here to classify the changes in substance use between the start of treatment and six-month review into one of four categories: abstinent, improved, unchanged and deteriorated. This is based on the application of the methodology advanced by Jacobson and Truax (1991) 5 and verified for use in the substance misuse field by Marsden et al (2011). 6 5 Jacobson N. S., Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology 1991; 59: Marsden, J., Eastwood, B., Wright, C., Bradbury, C., Knight, J., Hammond, P. How best to measure change in evaluations of treatment for substance use disorder. Addiction 2011: 106(2): onlinelibrary.wiley.com/doi/ /j x/pdf 34

35 Results Table presents the change in substance use between the start of treatment and the sixmonth review. It is segmented by the four substance groups and reports on the substances that individuals presented to treatment with. Opiate clients that were not also citing crack cocaine reported the largest reductions in average number of days of opiate use, 15 days (from 21.7 days to 6.7 days), this compared to a reduction of 11.3 days for those also using crack (from 20.2 days to 8.9 days). Forty-seven per cent of opiate clients not citing crack had stopped using illicit opiates by the time of their six-month review, and for individuals also citing crack, 34% achieved abstinence from illicit opiates by six-months. For non-opiate clients, the largest reduction of average days use was observed in individuals citing cannabis (11.1 days non-opiates only and 9.9 days non-opiates and alcohol clients),. Those clients citing cocaine reported the highest rates of abstinence at six months (67% nonopiate only and 69% non-opiate and alcohol clients). For individuals presenting for alcohol only, the average number of drinking days was 21.2 days at the start of treatment and fell to 10.9 days by the time of six-month review. Being abstinent or improved at the six-month review is associated with eventual successful completion from treatment. Individuals treated for powder cocaine and cannabis typically have better outcomes than individuals that use opiates. They are likely to have fewer associated social problems, draw on greater personal resources, and receive more social support. As a result, their prospects of overcoming dependence are usually better than those of opiate clients. 35

36 Table Change in use of cited substance for clients with a review TOP/AOR in the year who reported using at the start of treatment Substance START OF TREATMENT Reviewed Average clients days of using at use at start start AT SIX MONTH REVIEW Abstinent Improved Unchanged Deteriorated Average days of use at review n mean % % % % mean Opiate Opiate use (all opiate clients) 22, % 25% 30% 4% 7.7 Opiate use (in opiate only clients) 12, % 24% 26% 3% 6.7 Opiate use (in opiate and crack clients) 10, % 26% 35% 5% 8.9 Crack use (in opiate and crack clients) 8, % 13% 34% 6% 6.0 Cocaine use % 3% 19% 2% 1.6 Amphetamine use % 6% 36% 7% 5.4 Cannabis use 3, % 9% 34% 8% 8.7 Alcohol use 5, % 14% 48% 10% 13.1 Injecting 7, % 14% 28% 4% 6.7 Non-opiate Crack use % 9% 27% 3% 3.8 Cocaine use 2, % 11% 20% 1% 2.1 Amphetamine use % 10% 29% 2% 5.3 Cannabis use 5, % 19% 39% 3% 10.8 Injecting % 6% 31% 1% 4.3 Non-opiate and alcohol Crack use % 7% 30% 1% 3.9 Cocaine use 3, % 9% 20% 1% 2.1 Amphetamine use % 7% 28% 1% 4.1 Cannabis use 4, % 11% 36% 3% 9.1 Alcohol use 10, % 17% 47% 3% 9.4 Injecting % 3% 26% 3% 4.5 Alcohol only Alcohol use 32, % 19% 44% 3%

37 The table below presents the six-month outcomes in employment, education and housing status by the four substance groups. Opiate clients were much more likely not to be in paid work, have issues with housing and less likely to be in education compared to individuals presenting with other substances. Sixteen per cent of opiate clients reported some paid employment in the 28 days before treatment commenced compared to 29% for non-opiate clients and 27% for non-opiate and alcohol clients and alcohol only clients. There was a small increase in the proportion of opiate clients in paid work by the time of the six-month review (16% to 19%), with the average days of paid work not changing during this time. Non-opiate clients saw a similar increase in the proportion reporting paid work, (29% to 33%), while non-opiate and alcohol and alcohol only clients demonstrated only marginal change in paid employment. Nineteen per cent of opiate clients reported an acute housing problem at the start of treatment, this fell to 13% by the time of the six-month review. Similar improvements were seen in individuals presenting with other substances. Table Change in employment, education and housing status between the start of treatment and sixmonth review Opiate Non-opiate Non-opiate and alcohol Alcohol only Total Employment n 30,814 10,791 11,347 32,793 85,745 Baseline work Review work % 16% 29% 27% 27% 23% Mean days % 19% 33% 28% 27% 25% Mean days Education n 30,703 10,707 11,250 32,333 84,993 Baseline education % 1% 4% 3% 2% 2% Mean days Review education % 2% 5% 3% 2% 3% Mean days Housing problems acute n 30,693 10,695 11,225 32,076 84,689 Baseline % 19% 11% 14% 7% 13% Review % 13% 6% 8% 4% 8% Housing problems risk n 30,506 10,678 11,150 31,942 84,276 Baseline % 8% 6% 7% 4% 6% Review % 6% 3% 4% 2% 4% Housing problems any n 30,462 10,652 11,132 31,854 84,100 Baseline % 20% 12% 15% 8% 14% Review % 14% 6% 8% 5% 9% 37

38 Adult substance misuse statistics from NDTMS 7. Trends over time 7.1 Trends in numbers in treatment Table and figure show the change in this measure between and by the four main substance groups. The proportion of opiate clients who have been in contact with treatment has gradually decreased from 55% in to 52% in The proportion of individuals in treatment for the other main substance groups has remained relatively stable over the last six years, with the proportion of alcohol only clients increasing slightly by 2% since Table Trends in numbers in treatment Year Opiate Non-opiate Non-opiate and alcohol Alcohol only Total n % n % n % n % n % ,032 55% 24,557 8% 28,992 9% 88,086 28% 311, % ,144 55% 23,613 8% 28,223 9% 88,020 28% 309, % ,435 54% 22,982 8% 27,732 9% 86,416 29% 299, % ,959 53% 23,975 8% 27,627 9% 87,544 29% 297, % ,852 52% 25,570 8% 28,871 10% 91,651 30% 301, % ,964 52% 25,025 8% 28,128 10% 89,107 30% 295, % Figure Trends in numbers in treatment 180, ,000 Opiate 140, , ,000 80,000 Alcohol only 60,000 40,000 20,000 - Non-opiate and alcohol Non-opiate Opiate Non-opiate Non-opiate and alcohol Alcohol only 38

39 7.2 Trends in age group and presenting substances Figures 7.2.1, (on the following page) and appendix B show trends in the substances cited as problematic among new presentations from to The number of individuals presenting with any opiate citation (total opiates only and opiates and crack ) has fallen from 55,493 in to 44,356 in , a reduction of 20%. The number of individuals presenting with crack cocaine (without opiate use) has also fallen significantly since from 4,241 to 2,885 in , a decrease of 32%. This decline in the use of these substances broadly reflects the trends seen in the estimated prevalence of opiates and crack cocaine (www.nta.nhs.uk/facts-prevalence.aspx). The trends in presentations for other substances have remained relatively stable since with the exception of benzodiazepine, where the number of individuals citing this substance has fallen by 29% over this time. The largest percentage decrease in presentations for opiates and/or crack cocaine since has been in individuals under 25. The number of under-25s citing opiates (total opiates only and opiates and crack ) fell by 60% between and (6,860 to 2,729). For crack cocaine (without opiate use), the numbers under 25 citing the substance reduced from 738 to 292, also a reduction of 60%. This fall in younger opiate users presenting for treatment mirrors the trends seen in the estimated prevalence of opiate and/or crack cocaine use among individuals aged 15-24, where the estimated (midpoint) number has fallen from 72,838 ( ) to 32,628 ( ). Estimates for can be found at and estimates can be found at The number of citations for other substances also fell, reflecting the general reduction in the total number of younger individuals presenting for treatment over the last six years (see figure 7.2.4). The greatest percentage reductions were seen in citations for benzodiazepines (997 to 535, a reduction of 46%) and alcohol (9,574 to 6,290, a reduction of 34%). The fall in the latter reflects a general downward trend in young people s drinking, as reported in the Smoking, Drinking and Drug Use Among Young People in England survey for 2014, 7 which reported that 38% of year olds had tried alcohol at least once, the lowest proportion since the survey began. Trends in age and presenting substances among all clients in treatment can be found in the supporting tables, shown in Appendix D. 7 HSCIC. (2015) Smoking, Drinking and Drug Use Among Young People in England [Online] Available from: [Accessed: 1 st December 2015]. 39

40 Other drugs Alcohol Adult substance misuse statistics from NDTMS Figure Number of new treatment presentations for opiates and / or crack cocaine 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 - Both opiate and crack cocaine Crack cocaine (not opiate) Opiate (not crack cocaine) Figure Number of new treatment presentations for other substances 35,000 30,000 25,000 20,000 15,000 10,000 5,000 - Cannabis Alcohol Cocaine Benzodiazepine Amphetamine (other than ecstasy) 100,000 90,000 80,000 70,000 60,000 50,000 40,000 Opiate (not crack cocaine) Crack cocaine (not opiate) Both opiate and crack cocaine Cannabis Benzodiazepine Alcohol Cocaine Amphetamine (other than ecstasy) Figure Presenting substances of under 25s for opiate and/or crack 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Both opiate and crack cocaine Crack cocaine (not opiate) Opiate (not crack cocaine) Figure Presenting substances of under 25s for other substances 12,000 10,000 8,000 6,000 4,000 2,000 - Alcohol Cannabis Cocaine Amphetamine (other than ecstasy) Benzodiazepine Opiate (not crack cocaine) Crack cocaine (not opiate) Both opiate and crack cocaine 40 Cannabis Benzodiazepine Alcohol Cocaine Amphetamine (other than ecstasy)

41 7.3 Trends in club drug and new psychoactive substance (NPS) use Table and figure report the number of individuals aged 18 or over presenting to treatment in each of the years to , where the individual reported using an NPS or one or more club drug(s). Club drugs and NPS brings together a number of different substances typically used by people in bars and nightclubs, at concerts and parties, before and after a night out. The number of individuals presenting to treatment for a club drug or NPS has increased from 2,727 to 5,532 since The largest increases in the number of citations has been for mephedrone, rising from 953 in to 2,024 in , however, it only started to be widely used around 2009 and recorded in NDTMS in So in part, the trend is likely to reflect increased availability and the time it takes recording practice changes to embed in. Similarly, NPS was only introduced into NDTMS in and will not have been fully implemented by all treatment providers at the beginning of that year. Therefore the increase between and , while reflecting greater need, will also be due to better recording of NPS presentations. The number of individuals citing ecstasy has fallen from 1,756 in to 1,284 in , a decrease of 27%. Figure Trends in number of new presentations to treatment citing club drug use 2,500 2,000 Mephedrone Ecstasy 1,500 1, Ketamine New psychoactive substances - GHB/GBL Methamphetamine Ecstasy Ketamine GHB/GBL Methamphetamine Mephedrone New psychoactive substances 41

42 Table Trends in number of new presentations citing club drugs or new psychoactive substances Club drug and new psychoactive substances Ecstasy 1,756 1,284 1,267 1,329 1,214 1,284 Ketamine , GHB/GBL Methamphetamine Mephedrone ,044 1,836 1,895 2,024 New psychoactive substances ,154 Further breakdown of new psychoactive substances: Predominantly stimulant Other Predominantly cannabinoid Predominantly hallucinogenic Predominantly sedative/opioid Predominantly dissociative Total number in treatment 147, , , , , ,646 *A code for mephedrone was added to the NDTMS core dataset in Any clients reporting mephedrone prior to this are included in the total but no separate total is given for mephedrone. **Codes for NPS were added to NDTMS core dataset in Any clients reporting NPS prior to this are included in the total but no separate figure is given for NPS. 7.4 Trends in treatment exit reasons Table reports treatment completed free of dependence for individuals in the years to broken down by the four main substance groups. Overall, the proportion of individuals completing treatment free of dependence increased between and from 43% to 53%. Since then the rate has remained stable, falling slightly to 52% in However, despite a 10% increase in treatment completed free of dependence from to among opiate clients, since then there has been a decrease from 37% to 30% of clients completing treatment free of dependence. In comparison, the proportion of alcohol only clients in treatment exiting free of dependence has gradually increased from just under half (49%) in to 61% in Trends in all treatment exit reasons can be found in the supporting tables. 42

43 Table Trends in treatment completed free of dependence Year Opiate Non-opiate Non-opiate and alcohol Alcohol only Total n % n % n % n % n % ,832 27% 8,023 55% 8,414 51% 24,862 49% 52,131 43% ,636 33% 9,144 60% 9,418 56% 29,566 56% 61,764 49% ,792 37% 9,568 64% 10,060 59% 31,102 59% 65,522 53% ,834 36% 9,917 64% 10,186 60% 33,839 60% 67,776 53% ,882 33% 10,939 63% 10,578 58% 36,164 61% 70,563 53% ,685 30% 10,568 64% 10,376 58% 35,159 61% 67,788 52% 7.5 Trends in waiting times for first intervention Table presents trends in the number and proportion of individuals that waited three weeks and under to commence their treatment following the date of referral. Overall, the proportion waiting three weeks or less has increased from 88% in to 97% in The largest improvements in waiting times have been seen in individuals presenting with problematic alcohol use, either alone or in conjunction with non-opiates. Table Trends in waiting times of three weeks and under for first intervention Year Opiate Non-opiate Non-opiate and alcohol Alcohol only Total n % n % n % n % n % ,911 94% 15,062 95% 15,832 88% 42,483 78% 131,288 88% ,848 96% 14,952 96% 16,219 90% 46,954 82% 131,973 90% ,018 97% 15,800 97% 17,545 92% 48,978 85% 133,341 92% ,812 98% 17,032 97% 18,079 94% 54,550 89% 144,473 94% ,994 98% 18,279 98% 19,625 96% 62,140 93% 164,038 96% ,152 98% 17,599 98% 18,648 96% 60,593 95% 160,992 97% 43

44 8. A ten-year treatment population analysis This section presents an analysis of treatment histories for individuals across ten years of treatment data, starting from (the furthest back NDTMS data is considered to be sufficiently robust for comparison with subsequent years). See Quality and methodology Information for information on the methodological implications of this analysis compared with analysis elsewhere in the report where each year s figures are calculated independently. Appendix C reports all individuals that have been in contact with substance misuse treatment on or after 1 April The table is split into three sections: the first section reports the number of individuals that start treatment in any given year after 1 April 2005, and who are in treatment on 31 March 2015 the second section reports all individuals who were in contact with treatment in any given year after 1 April 2005 and reports the number of these from each year who were not in treatment on 31 March 2015, and whose records indicated that treatment was incomplete at the time of discharge (treatment incomplete) the third section looks at all individuals who were in contact with the treatment system on or after 1 April 2005 and who are no longer in contact with the treatment system, due to completing their treatment and being discharged in a planned way (treatment complete) and not having returned for treatment during this time Over the ten years, 779,554 unique individuals have been recorded in contact with substance use treatment of whom, 157,306 (20%) were retained in treatment on 31 March Thirtyeight per cent (296,309) had exited (treatment incomplete) while a further 325,939 (42%) had completed treatment and not since returned. 44

45 Figure Last status of all clients in treatment since Retained at 31/03/15 20% Treatment complete 42% Exited treatment incomplete 38% Of the 157,306 individuals who were retained in treatment on the 31 March 2015, a third (33%) were on their first attempt at treatment and had been in continuously since their initial commencement. Just under a quarter (22%) were on their second treatment journey and 29% had more than three attempts at treatment. Figure Number of previous treatment journeys for those retained in treatment 31 March 2015 More than three journeys since first presentation 29% First attempt at treatment 33% Three journeys since first presentation 16% Two journeys since first presentation 22% 45

46 Table and figure report on all individuals referred to treatment since 1 April 2005 and give a breakdown of individuals treatment status at 31 March 2015 by drug group and by the year of the initial contact with the treatment system. There have been 273,898 opiate users in contact with the treatment system since , with the majority starting treatment for the first time (known as treatment naïve) in or before (59%, 162,875). The numbers presenting for the first time have decreased year on year, with only 6,942 treatment naïve individuals presenting in The trend in individuals presenting for the first time is different for users of other substances, with the general trend across the two non-opiate groups being relatively stable since and an increase in alcohol treatment naïve presentations up until However, this will be in a large part due to only partial data being collected on alcohol treatment, with full coverage implemented during and Since then the number of alcohol only clients has fallen gradually from 34,108 to 28,

47 Figure Number of clients starting treatment for the first time ever by substance group and year of initial contact * Prior to Opiate clients Non-opiate clients Non-opiate and alcohol clients Alcohol only clients *complete coverage of alcohol treatment in England was not achieved until

48 Table Treatment contact status at 31 March 2015 by main substance groups for clients commencing treatment since Substance group Opiate clients Prior to Year of first presentation Total % Retained at 31 March ,181 20,605 12,399 9,083 7,629 5,573 4,175 3,338 3,217 3,332 4, ,062 42% Subtotal exited (treatment incomplete) 23,182 18,497 12,755 10,047 8,448 6,609 4,820 3,522 2,907 2,665 1,512 94,964 35% Subtotal treatment complete 16,466 10,900 7,890 6,926 6,027 4,893 3,935 2,863 2,184 1, ,872 24% Total clients in treatment since 1 April ,829 50,002 33,044 26,056 22,104 17,075 12,930 9,723 8,308 7,885 6, , % Non-opiate clients Retained at 31 March ,845 5,510 6% Subtotal exited (treatment incomplete) 2,524 5,810 5,096 4,766 4,018 3,209 2,733 2,701 3,028 3,049 2,049 38,983 41% Subtotal treatment complete 1,643 3,125 3,642 4,725 4,868 5,164 5,292 5,691 5,865 6,222 3,632 49,869 53% Total clients in treatment since 1 April ,284 9,009 8,826 9,591 8,992 8,475 8,159 8,548 9,133 9,819 9,526 94, % Non-opiate and alcohol clients Retained at 31 March ,127 1, ,209 3,725 12,770 10% Subtotal exited (treatment incomplete) 2,441 5,638 5,164 5,841 6,468 5,368 4,469 3,925 3,615 3,544 1,991 48,464 40% Subtotal treatment complete 2,248 4,958 5,505 6,832 7,868 7,186 6,525 6,144 5,536 5,161 2,789 60,752 50% Total clients in treatment since 1 April ,093 11,410 11,456 13,646 15,463 13,580 11,909 10,955 10,055 9,914 8, , % Alcohol only clients Retained at 31 March ,449 1,368 1,440 1,615 1,970 2,971 11,749 24,964 9% Subtotal exited (treatment incomplete) 3,954 8,866 8,499 11,090 15,965 14,585 12,462 10,997 10,440 10,447 6, ,898 39% Subtotal treatment complete 3,472 7,166 8,446 12,857 18,357 18,155 18,594 17,822 17,658 17,645 10, ,446 52% Total clients in treatment since 1 April ,683 16,582 17,543 24,944 35,771 34,108 32,496 30,434 30,068 31,063 28, , % 48

49 Opiate Non-opiate Non-opiate and alcohol Alcohol only Total Adult substance misuse statistics from NDTMS Substance group Total clients Prior to Year of first presentation Total % Retained at 31 March ,959 22,043 13,872 11,153 10,311 8,069 6,664 5,995 6,331 8,060 23, ,306 20% Subtotal exited (treatment incomplete) 32,101 38,811 31,514 31,744 34,899 29,771 24,484 21,145 19,990 19,705 12, ,309 38% Subtotal treatment complete 23,829 26,149 25,483 31,340 37,120 35,398 34,346 32,520 31,243 30,916 17, ,939 42% Total clients in treatment since 1 April ,889 87,003 70,869 74,237 82,330 73,238 65,494 59,660 57,564 58,681 53, , % Figure Treatment contact status for the four main substance groups in % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Retained at 31 March 2015 Subtotal exited (treatment incomplete) Subtotal treatment complete Figure presents the status of clients that have been in contact with treatment since by the four substance groups. Just under a quarter (24%) of all opiate clients in treatment since had completed treatment and not returned by 31 March This compared to the other substance groups where the rate of completion and non-representation ranged from 50% (nonopiate and alcohol clients) to 53% (non-opiates). 49

50 9. History This report presents information relating to drug treatment in England. The statistics are derived from data that has been collected through NDTMS. NDTMS collects activity data from drug and alcohol treatment services so that: the progress of individuals entering treatment may be monitored and their outcomes and recovery assessed trends and shifts in patterns of drug use and addiction can be monitored, to inform future planning locally and nationally service users journeys from addiction to recovery can be tracked the impact of drug treatment as a component of the wider public health service may be measured they can demonstrate their accountability to their service users, local commissioners and communities costs can be benchmarked against data from comparable areas to show how efficiently they use resources and how they are delivering value for money Drug treatment activity has been collected nationally for nearly 25 years and has been routinely collected through NDTMS since April NDTMS is currently managed by PHE. NDTMS has been reorganised over the years, bringing the definition of drug treatment recorded by the system further into line with Models of care for treatment of adult drug users (see Since data collection has been consistently collected by treatment services, submitting a core data set of their clients information as a database extract. The dataset and data collection methods have also changed. Code sets for the core data set can be found in NDTMS reference data document (see NDTMS figures for England are collated by The National Drug Evidence Centre (NDEC), along with those for Scotland, Wales and Northern Ireland, and combined into a UK return for use by the European Monitoring Centre for Drugs and Drug Addiction (see and for the United Nations. This statistical release covers England only. Information on drug treatment in Wales, Scotland and Northern Ireland is also available: (Wales) (Scotland) (Northern Ireland) 50

51 NDEC is part of the Centre for Epidemiology, which is one of six centres in the Institute of Population Health, University of Manchester. While comparisons to alcohol treatment statistics from other countries can be made, care needs to be taken as the data is unlikely to be directly comparable due to differences in the definitions and methodologies that are used in collecting the data and in subsequently reporting it. 9.1 Relevant web links and contact details Monthly web-based NDTMS analyses National Drug Evidence Centre (NDEC) Public Health England General enquiries For media enquiries, please call or For technical enquiries, please Policy Evidence application team, PHE Data and Statistics Jonathan Knight head of evidence application team, PHE Patrick Horgan senior information analyst, PHE Peter Willey senior information analyst, PHE Bethan Hamilton information analyst, PHE 51

52 Andrew Jones research fellow, National Drug Evidence Centre 9.2 Comparability of data to previous reports Since 1 November 2012, PHE made substantial changes to the core dataset with regards to the coding of intervention type. Prior to this, intervention codes were restricted to the six broad categories: inpatient, residential rehabilitation, prescribing, psychosocial, structured day programme and other structured treatment. These categories did not allow the distinction to be easily made between the setting where the interventions were being delivered and the interventions themselves. Following consultations with clinicians, treatment providers and other key stakeholders a new method of recording intervention types and setting separately was introduced alongside the ability for providers to record the non-structured recovery support interventions that they were delivering. As part of the changes in the coding of intervention type, from 1 November 2012 all registered treatment providers are registered with a setting type. There are six settings: community, inpatient, residential, recovery house, prison and primary care, which have now been incorporated to PHE s regular reporting. Clients in a prison setting are not reported on in this document. Definitions of these settings can be found in section 10.2 and the implementation guide can be found at Intervention types have been split in to three high-level categories; pharmacological interventions, psychosocial interventions and recovery support interventions. Recovery support interventions are not reported on in the present report. Due to these implemented changes, most reporting of interventions is limited to those occurring on or after 31 October Therefore, the validity of comparing data to previous years, particularly in tables 5.2.1, and 5.2.3, is limited. In a further consultation was undertaken on combining alcohol and drug treatment journeys. Prior to this, when an adult presented to treatment with a primary alcohol treatment episode concurrent with, or followed by, a primary drug treatment episode, this was reported as two separate treatment journeys. A combined treatment journey methodology removes this anomaly and was supported by a majority of respondents to the consultation. As a result of the new reporting framework, comparisons of data in this report with previous adult drug and alcohol statistics are not valid. Interested parties are referred to trend tables 7.1 to 7.5, appendix B and the accompanying more detailed spreadsheets published alongside this report. A more detailed explanation of this methodological change can be found in section 2 of this report. 52

53 9.3 Drug treatment collection and reporting timeline 1989-March 2001 Regional Drug Misuse Database (RDMD) statistics reported in six monthly bulletins by the Department of Health from 1993 to webarchive.nationalarchives.gov.uk/ /http://www.dh.gov.uk/en/publicationsand statistics/statistics/statisticalworkareas/statisticalpublichealth/dh_ April 2001-March 2004 National Drug Treatment Monitoring System (NDTMS) statistics reported annually by the Department of Health. April 2004-March 2013 National Drug Treatment Monitoring System (NDTMS) managed by the National Treatment Agency (NTA) reporting statistics annually up to March April 2013 to date National Drug Treatment Monitoring System (NDTMS) managed by Public Health England (PHE) reporting statistics annually from April Other sources of statistics about drugs Prevalence of drug use An annual estimate of the prevalence of drug use is undertaken through the Crime Survey for England and Wales (CSEW, formerly the British Crime Survey (BCS)). This section of the survey has been in place since 1996, annually since 2001, and has tracked the prevalence of the use of different drugs over this time. A second method is used to produce estimates for the prevalence of crack cocaine and heroin use for each local authority area in England. Estimates are available for , , and The estimates are produced through a mixture of capture-recapture and Multiple Indicator Methodology (MIM), and rely on NDTMS data being matched against and/or analysed alongside Probation and Home Office data sets. The data and further information are available at: 53

54 9.4.2 Young people Information is also available relating to the prevalence of drug use among secondary school pupils aged 11 to 15 from the Smoking, Drinking and Drug Use Survey among young people in England. This is a survey carried out for the NHS Information Centre by the National Centre for Social Research and the National Foundation for Educational Research. The survey annually interviews school pupils, and has been in place since The data and further information are available here: NDTMS collects data on drug and alcohol treatment for young people, and produces official statistics bulletins, which can be found at: It should be noted that young people s treatment figures are not comparable with statistics relating to adult treatment. This is because access to treatment for young people requires a lower severity of drug use and associated problems Criminal justice statistics The Ministry of Justice produces a quarterly statistics bulletin that provides details of individuals in custody and under the supervision of the probation service. These can be found at: The Ministry of Justice also produces statistics relating to aspects of sentencing, including trends in custody, sentences, fines and other disposals. These can be found at: data.gov.uk/dataset/sentencing_statistics_england_and_wales 8 Drug Misuse and Dependence - UK Guidelines on Clinical Management, p85, London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive. 54

55 9.4.4 International comparisons The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) publishes an annual report that describes and compares aspects of drug use and drug policy within European states, as well as providing detailed comparative statistics. This can be found at: The centre also produces a treatment demand indicator (TDI), which is a collection of comparative statistics relating to individuals seeking treatment. This can be found at: While comparisons to alcohol treatment statistics from other countries can be made, care needs to be taken as the data is unlikely to be directly comparable due to differences in the definitions and methodologies that are used in collecting the data and subsequently in reporting it Drug-related deaths The Office for National Statistics publishes an annual summary of all deaths related to drug poisoning (involving both legal and illegal drugs) and drug misuse (involving illegal drugs) in England and Wales. This can be found at: 55

56 10. Abbreviations and definitions 10.1 Abbreviations CARAT CJIT CJS CQC DP DIP DRR NDEC NDTMS NTA PCT PHE RDMD YP Counselling, assessment, referral, advice and throughcare Criminal justice intervention team Criminal justice system Care Quality Commission Drug partnership Drug interventions programme Drug rehabilitation requirement (formerly DTTO) National Drug Evidence Centre (University of Manchester) National Drug Treatment Monitoring System National Treatment Agency for Substance Misuse Primary care trust Public Health England Regional drug misuse database Young people 10.2 Definitions Agency/provider Agency/provider code Adjunctive drug use Attributor Client A provider of services for the treatment of alcohol misuse. It may be statutory (ie, NHS) or non-statutory (ie, third sector, charitable). A unique identifier for the treatment provider (agency) assigned by the regional NDTMS centres eg, L0001. Substances additional to the primary drug used by the client. NDTMS collects secondary and tertiary substances. A concatenation of a client s initials, date of birth and gender. This is used to isolate records that relate to individual clients. A drug user presenting for treatment at a structured treatment service. Records relating to individual clients are isolated and linked based on the attributor and drug partnership of residence. 56

57 Community setting Discharge date Drug partnership Episode Episode of treatment In contact Inpatient setting Intervention A structured drug and alcohol treatment setting where residence is not a condition of engagement with the service. This will include treatment within community drug and alcohol teams and day programmes (including rehabilitation programmes where residence in a specified location is not a condition of entry). Usually the planned discharge date in a client s treatment plan, where one has been agreed. However, if a client's discharge was unplanned, then the date of last face-to-face contact with the provider (agency) is used. Partnerships responsible for delivering the drug strategy at a local level (also known as drug and alcohol action team, or DAAT). A period of contact with a treatment provider (agency): from referral to discharge. A set of interventions with a specific care plan. A client may attend one or more interventions (or types) of treatment during the same episode of treatment. A client may also have more than one episode in a year. A client is considered to have been in contact during the year, and hence included in these results, if any part of an episode occurs within the year. Where several episodes were collected for an individual, attributes such as ethnicity, primary substance, etc, are based on the first valid data available for that individual. Clients are counted as being in contact with treatment services if their date of presentation (as indicated by triage), intervention start, intervention end or discharge indicates that they have been in contact with a provider during the year. An inpatient unit provides assessment, stabilisation and/or assisted withdrawal with 24-hour cover from a multidisciplinary clinical team who have had specialist training in managing addictive behaviours. In addition, the clinical lead in such a service comes from a consultant in addiction psychiatry or another substance misuse medical specialist. The multidisciplinary team may include psychologists, nurses, occupational therapists, pharmacists and social workers. Inpatient units are for those alcohol or drug users whose needs require supervision in a controlled medical environment. A type of treatment, eg, structured counselling, community prescribing, etc. 57

58 First/subsequent intervention Opiate Presenting for treatment Primary care setting Primary care trust Primary drug Recovery house setting Referral date 'First intervention' refers to the first intervention that occurs in a treatment journey. 'Subsequent intervention' refers to interventions within a treatment journey that occur after the first intervention. A group of drugs including heroin, methadone and buprenorphine. The first face-to-face contact between a client and a treatment provider. Structured substance misuse treatment is provided in a primary care setting by a general practitioner, often with a special interest in addiction treatment. A PCT was a type of NHS trust, part of the NHS in England. PCTs were largely administrative bodies, responsible for commissioning primary, community and secondary health services from providers. The substance that brought the client into treatment at the point of triage/initial assessment. A recovery house is a residential living environment, in which integrated peer-support and/or integrated recovery support interventions are provided for residents who were previously, or are currently, engaged in treatment to overcome their drug and alcohol dependence. The residences can also be referred to as dry-houses, third-stage accommodation or quasi-residential. The date the client was referred to the provider for this episode of treatment. Residential rehab setting A structured drug and alcohol treatment setting where residence is a condition of receiving the intervention. A residential programme may also deliver an assisted-withdrawal programme. Structured drug treatment Structured drug treatment follows assessment and is delivered according to a care plan, with clear goals, which are regularly reviewed with the client. It may comprise a number of concurrent or sequential treatment interventions. Treatment journey A set of concurrent or serial treatment episodes linked together to describe a period of treatment based on the clients attributors and DAAT of residence. This can be within one provider or across a number of different providers. 58

59 Triage Triage date Waiting times An initial clinical risk assessment performed by a treatment provider. A triage includes a brief assessment of the problem as well as an assessment of the client s readiness to engage with treatment, in order to inform a care plan. The date that the client made a first face-to-face presentation to a treatment provider. This could be the date of triage/initial assessment though this may not always be the case. The period from the date a person is referred for a specific treatment intervention and the date of the first appointment offered. Referral for a specific treatment intervention typically occurs within the treatment provider at, or following, assessment. Note: full operational definitions can be found in the NDTMS core data set documents on 59

60 Appendix A Diagram to show flow through treatment This diagram illustrates a typical user journey through the treatment system. It is provided to give an indication of a possible treatment pathway and the interventions received. All pathways will vary depending on the substances used and the clinical requirements of the client, their general health needs and any other relevant issues they may have that will impact on the clinical care provided. 60

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