1 Islington JSNA 2010/11 Substance Misuse
2 INTRODUCTION Substance misuse is strongly associated with poverty and deprivation. Rates of substance misuse are particularly high in London compared with other regions. A range of problems are linked to substance misuse including risk of early death, poor physical and mental health including depression, anxiety, personality disorders and psychotic disorders, crime and poor family and social functioning. It is estimated that there are between 250,000 and 350,000 children of problem drug users in the UK (1). Most illicit use of drugs is on a recreational basis, with drugs such as cannabis and ecstasy now part of mainstream youth and leisure culture in London. According to the latest British Crime Survey, 8.6% of adults in 2009/10 had used an illicit drug in the last year. Although the vast majority of adults do not take drugs, this suggests that almost three million people do (2). Problem drug use is defined as injecting drug use or long duration or regular use of opiates, cocaine or amphetamines. The pattern of problem drug use has changed over time, with older problem drug users more likely to use opiates, such as heroin, while younger problem drug users are more likely to use a mix of drugs combined with heavy alcohol use. WHO ARE THE KEY GROUPS AFFECTED? There are a number of key groups who are at particular risk of developing or experiencing drug-related problems. Young people The highest proportion of drug use is in the year age group. The Government s 2008 Drugs Strategy emphasises the prevention of harm to children, young people and families affected by drug misuse and highlights a number of predictive factors for the misuse of drugs (3). Homeless people Drug misuse can contribute to homelessness; once homeless, people tend to be more vulnerable to developing patterns of problematic substance use. In research carried out by Crisis, 50% of homeless people cited drug use as a reason for becoming homeless and over 80% had started using at least one new drug since becoming homeless (4). Prisoners Levels of drug misuse are high among the prison population, and there are well-established links between drug use and offending behaviour. In a study looking at psychiatric morbidity, 41% of female and 43% of male sentenced prisoners and 54% of female and 51% of male
3 remand prisoners reported a measure of dependence on drugs in the year before entering prison (5). Pregnant women Women who have substance misuse problems are at greater risk of problem pregnancies and their care should be provided by an integrated multi-disciplinary and multi-agency team (6). Marsden et al (7) subdivided drug misusers into a number of groups according to pattern and experience of drug use. The sub-groups are not mutually exclusive, meaning that some individuals may appear in more than one group. Table 23.1: Subgroups within the drug misuse population Group Nature Description A Non-dependent People who experience drug-related problems but drug users who do not meet the criteria for dependence. B C D E F G Injecting drug users Dependent drug users Acutely intoxicated drug users Drug-users with co-morbidity Drug users in withdrawal Drug users in recovery * International Statistical Classification of Diseases ** Diagnostic and Statistical Manual of Mental Disorders Source: Marsden et al, 2004 (7) People who inject drugs are more likely to be dependent and to experience drug-related harm. People who meet ICD*/DSM** criteria for dependence. Most services for this group will be outside specialist drug or mental health services, for example Accident and Emergency (A&E). People who have concurrent drug-related and other psychiatric disorders. People who undergo psychological and sometimes physical symptoms of withdrawal. People who have achieved abstinence from their main problem or all drugs. THE ISLINGTON PICTURE The Home Office produces prevalence estimates every year for each area in England (Table 23.2). The most recent estimates (2008/09) revised the estimate of Islington s prevalence of problem drug users downwards to 2,760 problem drug users aged years old, with a rate of 19.3 per 1,000 adults aged in the borough. This rate was nearly twice as high as the London rate, and was the third highest out of all the London Drug Action Team areas (Table 23.2).
4 Table 23.2: Estimated number and prevalence (per 1,000 resident population) of problem drug users aged years, for selected Drug Action Team (DAT) areas in London, 2008/09 DAT area Number of problem drug users Crude rate per 1,000 resident population Lower 95% CI Upper 95% CI Tower Hamlets Hackney Islington Lewisham Camden Lambeth Hammersmith and Fulham Southwark Newham Haringey London Source: Hay, G. et al, (8) Analysis of the Islington drug treatment population shows that the proportion of men to women in treatment has remained steady, with men representing two thirds of all people in treatment (approximately 68% men and 32% women) in However, in the criminal justice context, the gender gap is more pronounced: 81% of prisoners identified through testing in the custody suite as part of the Drugs Intervention Programme in 2010 were men and 19% were women. National and local information indicates that there is an under-representation of individuals in treatment aged years and over representation of year olds in comparison to prevalence estimates of these groups within the local population. Table 23.2 shows the percentage of Islington residents in treatment broken down by age band. Residents aged years make up 9% of all people in treatment while people aged make up 63% of people in treatment. This is a common pattern across drug treatment services across England, and may in part reflect patterns of service provision more orientated around the needs and pattern of drug use of older problem drug users.
5 Table 23.3: Percentage of Islington residents in treatment broken down by age band, 2009/10 Percentage Age in years Percentage of total number in treatment Opiate & crack users in treatment Opiate & crack users in effective treatment Aged Aged Aged Source: NDTMS statistics 2010 An audit of the death certificates from the Office for National Statistics (ONS) showed that there were 35 drug-related deaths (DRDs) from illicit drug use among Islington residents reported in , or nine on average each year. These deaths exclude suicides and deaths categorised as undetermined injury caused by poisoning with controlled drugs. Almost all of these deaths were in men, with 91% aged between years and 81% UKborn. In two-thirds of cases, opiates were implicated as the cause of death with a third of deaths featuring mixed drug toxicity of opiates and alcohol. National Surveys The 2009/10 British Crime Survey estimated that 8.6% of adults had used illicit drugs and that 3.1% had used a Class A drug in the previous year. Just over 3% of adults aged 16 to 59 were defined as frequent drug users in the last year, that is, using a drug more than once a month on average in the last year, equivalent to around one million people. As in previous years, cannabis was the most commonly used type of drug, followed by powder cocaine. Drug use is likely to be underestimated by the survey. The Smoking, Drinking and Drugs Use among Young People in England survey is undertaken annually in participating schools across England. The 2009 survey included a sample of 7,674 pupils aged between 11 and 15 years in 247 schools. Fifteen percent of pupils said they had taken drugs in the previous year (Table 23.4) and 8% in the previous month. Boys were more likely than girls to have taken drugs (16% and 14% in the last year respectively). Drug use became more common with age; the percentage of pupils who had taken drugs in the last year increased from 5% of 11 year olds to 30% of 15 year olds. The reported prevalence of Class A drug use was 3.6% of pupils (having used at least one Class A drug) and the percentage has remained relatively stable since Drug taking was found to be associated with other hazardous behaviours such as smoking and drinking alcohol (9).
6 Table 23.4: Proportion of pupils who have taken individual drugs in the last year by age, England, 2009 Type of drug taken in last year Percentage of pupils (England, 2009) Age (years) Total Cannabis Any stimulants Any psychedelics Any opiates other drugs Any class A drug Any drug Source: The Health and Social Care Information Centre (2010) Smoking, drinking and drug use among young people in England in SERVICES CURRENTLY PROVIDED IN ISLINGTON Adult drug treatment services Islington s strategy for drug treatment is to ensure an integrated treatment system that promotes easy access to and retention in structured treatment. While services across all tiers aim to reduce the level of harm incurred as a result of drug misuse, the ultimate aim is to support individuals in decreasing and abstaining from drug use and activities associated with problematic drug use (10). Services are provided across four tiers: Tier one Provision of drug-related information and advice, screening and referral for specialised drug treatment. Tier two - Triage assessment and referral into structured, local treatment systems, harm-minimising interventions, brief interventions for specific target groups and aftercare support and outreach services. Tier three Community-based specialised drug assessment, coordinated care planned treatment and drug specialist liaison. Tier four - Residential specialised drug treatment. Effective substance misuse treatment is defined as the completion of 12 or more consecutive weeks of treatment or a planned discharge following successful completion of their treatment within 12 weeks. Eighty-two per cent of problem drug users and 82% of all drug users who engaged in treatment in 2009/10 were in effective treatment (Table 23.5).
7 Percentage Table 23.5: Effective engagement of new treatment journeys in Islington, resident population, 2009/10 Problem Drug Users (all ages) All Drug Users (18+) Total new treatment journeys Retained over 12 weeks 555 (79%) 691 (78%) Completed treatment (planned discharge before 12 weeks) 22 (3%) 32 (4%) % in effective treatment 82% 82% Source: NDTMS statistics 2010 Figure 23.1 shows a breakdown of effective engagement of new clients in 2009 for Islington, with regional (London) and national (England) comparators. Islington was generally performing the same as London and England in retaining drug users in treatment for at least 12 weeks from a number of key groups including crack users, BME communities, parents, criminal justice system clients and under 25 year olds. Figure 23.1: Effective engagement of new clients in Islington compared to London and England, selected risk groups, Jan - Dec Effective engagement of new clients in Islington compared to London and England (Jan - Dec 2009) Crack drug users Black & Minority Ethnic groups Parents Criminal Justice System Clients Under 25s Users Islington London National Source: NDTMS statistics 2010
8 Children and young people s substance misuse services in Islington The Islington Young People s Drug and Alcohol Service (IYPDAS) provides an integrated service across four tiers, with a multi-disciplinary team working across Children s Services and the Children and Adolescent Mental Health Service (CAMHS) working with young people under 19 years. During 2009/10 there were 99 young people in treatment, 72 of whom were new presentations. The majority of the service users, 60%, were referred through the Youth Offending Team. Tier 1 - Universal services concentrating on working closely with healthy schools and high quality Personal Social Health and Economic (PSHE) education. Some work also goes on in secondary schools. Tier 2 - Targeted services working with young people and acts as a direct referral into specialist services. Tier 3 - Specialist IYPDAS provides a comprehensive assessment and treatment service for young people who are using drugs or alcohol at levels that impact on their ability to function emotionally, socially and at age appropriate manner. Tier 4 - Specialist intensive services providing case management with the support of CAMHS, including nurse and psychiatrist input. This includes arrangements for supervised consumption of drugs and paying for placements in specialist residential drug and alcohol treatment facilities in England. A planned redesign of services has been consulted on and is currently being implemented in Islington. The changes have been prompted by issues such as the need to reach a wider range of risk groups, changes in model of service and reductions in funding levels (11). The main changes proposed are as follows: The proposed model will provide a new Drugs and Alcohol Structured Treatment Programme meeting the needs of abstinent and non-abstinent clients aged over 18 years. There will be an extension of service delivery beyond the current focus on drug users involved in the criminal justice system to better address the needs of groups who do not currently access services in the borough.
9 The service will deliver a modular time limited programme which can be built around the individual needs of each client wherever they are in the treatment system. There will be a change in operational hours and greater flexibility in terms of the locations from which the programme is delivered. THE FUTURE Patterns of drug misuse are changing. The latest estimate of the number of individuals using heroin in England shows a small reduction from 273,000 in 2006/07 to 262,000 in 2008/09(8). Data from treatment providers shows that the heroin using population is ageing, with fewer young people becoming dependent upon the drug. Those aged 40 and above now make up the largest proportion of those newly presenting for treatment (12). Presentations for problems with crack cocaine continue to be high. Also, groups of people who would not fit the traditional stereotype of a dependent drug user are presenting for treatment in increasing numbers. These individuals are often younger and are more likely to be working and in stable housing. Whilst drug dependence can affect anyone, poverty, unemployment and homelessness are established risk factors for substance misuse. Therefore, during periods of increased unemployment particularly among younger adults, the numbers at risk of substance misuse may increase. NATIONAL DRIVERS FOR SERVICE PROVISION The National Treatment Agency (NTA) made recommendations on local models for service delivery for adults in 2002 (13). They suggested the key aspects to any model are: Having a four-tiered model of commissioning (described earlier) Developing local screening and assessment systems Putting care planning and coordination of care at the centre of structured drug treatment Developing integrated care pathways This framework for drug treatment services is currently in the process of being updated by the NTA so that there is a greater emphasis on outcomes and recovery. In addition the NTA s Treatment Effectiveness Strategy (14), combined with the 2005/06 Business Plan, provided a greater focus on improving clients experience of drug treatment,
10 increasing the effectiveness of treatment and rehabilitation and reintegration into local communities. The NTA has since published Commissioning for Recovery, which is a guide for drug action teams in England and summarises the best of current commissioning practice in the drug treatment field. The Government s new drug strategy Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life (15) sets out a vision for tackling drug dependence with a focus on treatment and recovery. It represents a change in emphasis away from the previous targets on drug treatment which centred more on harm minimisation and reduction. The strategy: puts more responsibility on individuals to seek help and overcome dependency places emphasis on providing a more holistic approach, by addressing other issues in addition to treatment to support people dependent on drugs or alcohol, such as offending, employment and housing aims to reduce the demand for drugs by education for all, early intervention, intensive support for service users and tackling the link between crime and substance misuse aims to restrict supply of drugs through a co-ordinated response across Government, including the creation of the new National Crime Agency which will be responsible for fighting organised crime and the security of UK s borders, creating drug-free environments in prisons and strengthening international partnerships. THE VOICE The key issues raised in the service re-design consultation in 2010 for adult treatment services included the need for better aftercare, peer support, childcare and promotion of services. Linked to the concept of the need for more than just treatment, service users said that access to support, advice, information and advocacy around life skills, housing, benefits and employment, training and education were key parts of a holistic approach to help, support and recovery. The findings from the consultation will be used to re-design or recommission some aspects of the local treatment system.
11 OPPORTUNITIES FOR DEVELOPMENT The main opportunities for development include increasing the proportion of underrepresented groups in drug services, specifically young people, young parents and people from BME groups. There is also need for work to be done on improving key worker coordination and reducing unplanned discharges, completion of TOPs at discharge from drug treatment, and improvement in reintegration and rehabilitation rates. Accurate and timely data collection and recording should also continue to improve, ensuring that NDTMS, commissioners and service providers have a true picture of substance misuse treatment in Islington. This will assist in planning and targeting future services. The service re-design consultation in 2010 for adult treatment services has also offered some opportunities for development. The main issues raised during the exercise were aftercare, peer support, childcare and promotion of services. Linked to the concept of the need for more than just treatment, service users said that access to support, advice, information and advocacy around life skills, housing, benefits and employment, training and education were key parts of a holistic approach to help, support and recovery. The findings from the consultation will be used to re-design or re-commission some aspects of the local treatment system. A recently conducted substance misuse workforce development audit found that while there was very highly skilled workforce, there were some gaps in knowledge and skills. It identified the following for the partnership to take forward Strengthen current relationships with partnership agencies such as Jobcentreplus to assist the workforce s development Ensure there is training for those who would like to train or coach others. Enabling those who are highly skilled to share those skills More training on mental health issues especially related to dual diagnosis (substance misuse and enduring mental illness) More training and updates to do substance and alcohol misuse work such as welfare benefits updates, psychosocial interventions, drug and alcohol updates, harm reduction and other case management tools.
12 RECOMMENDATIONS The key priorities for adult treatment, based on the Islington Needs Assessment for the Drug Treatment Plan (16) are: Implement new Drugs and Alcohol Structured Treatment Programme meeting the needs of abstinent and non-abstinent clients aged over 18 years Increased attention to abstinence-focussed treatment with recovery, integration and social inclusion at the heart of all services. This needs to include a shift in focus from numbers in treatment to outcomes of treatment and recovery, while recognising that recruitment and retention in effective treatment is necessary as a precursor to those goals. Greater support and aftercare for individuals leaving treatment, to support longer term recovery and reduce risk of relapse. Greater completeness of recording of discharge and outcome data in order to assess the impact and quality of local services. The key priorities for children's treatment services based on the Young People s Specialist Substance Misuse Treatment Plan 2010/11 are To implement a new model for the delivery of substance misuse services for young people and families in Islington that maintains the principles of integrated working, service quality and safeguarding, in the context of reduced funding. To continue to improve the referral pathways from universal and targeted services, with a particular focus on Children and Families and CAMHS, to increase access to substance misuse and hidden harm services by young people and their families. To further develop the transitional arrangements from young people to adult treatment and Integrated Offender Management services. To strengthen the links between hidden harm and domestic violence and mental health services in order to improve support to families with complex
13 needs who are affected by parental substance misuse, including young carers. To increase awareness of substance misuse services for young people and their families in Islington particularly among BME and LGBT communities and third sector organisations. REFERENCE LIST (1) Advisory Council on the Misuse of Drugs. Hidden Harm; Responding to the needs of children of problem drug users. London: Home Office; (2) Hoare, J. and Moon, D. Drug Misuse Declared: Findings from the 2009/10 British Crime Survey England and Wales. Home Office Statistical Bulletin 13/10. London: Home Office; 2010 (3) HM Government. Drugs: protecting families and communities. The 2008 drug strategy. London: Home Office; (4) Fountain J, Howes S. Home and dry? Homelessness and substance misuse in London. London: The National Addiction Centre; (5) Singleton N, Meltzer H, Gatward R. Psychiatric morbidity among prisoners. London: Office of National Statistics, (6) Department of Health. National Service Framework for Children, Young People and Maternity Services: Maternity services. London: Department of Health; (7) Marsden J, Strang J, Lavoie D, et al. Drugs needs assessment. In: Stevens A, Raftery J, eds. Health care needs assessment, 2nd edn. Oxford: Oxford University Press, (8) Hay G, Gannon M, Casey J, Millar T. Estimates of the prevalence of opiate use and/or crack cocaine use (2008/09) London Region. Sweep 5 report. London: National Treatment Agency; (9) Fuller, E. and Sanchez, M (eds). Smoking, Drinking and Drug Use Among Young People in England in London: NHS Information Centre: 2010 (10) Safer Islington Partnership, London Borough of Islington. Harm Reduction Strategy (3 rd draft). London: London Borough of Islington; 2008 (11) NHS Islington. Substance Misuse Service Redesign Treatment System Consultation. London: NHSI; isuse_service_redesign.rtf downloaded 10 January (12) National Treatment Agency (NTA). Drug treatment in 2009/10. London; NTA;2010 (13) National Treatment Agency for Substance Misuse, Models of care for treatment of adult drug misusers: Update London; NTA; 2006
14 (14) National Treatment Agency. National Treatment Agency business plan 2005/06. Towards treatment effectiveness. London; NTA; 2005 (15) Home Office. Drug Strategy 2010 Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life. London: Home Office; 2010 (16) NHS Islington. Draft Islington Needs Assessment for Drug Treatment Plan London: NHSI; 2011 FURTHER INFORMATION DRUG STRATEGY 2010 Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life 2010?view=Binary Drugs: Protecting families and communities strategy. Home Office Updated Drug Strategy. 2002, Home Office Models of Care for treatment of adult drug misusers, NTA Drugscope Talk to Frank National Treatment Agency National Drug Treatment Monitoring System