7.11 Substance misuse

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1 7.11 Substance misuse Substance misuse is defined by NICE as intoxication by or regular excessive consumption of and/or dependence on psychoactive substances, leading to social, psychological, physical or legal problems. It includes problematic use of both legal and illegal drugs (including alcohol when used in combination with other substances). Most substance misuse is illicit in nature, and therefore factual information on drug use is difficult to obtain, unless it relates to those people known to drug treatment services or the police. Some information is available from the adult psychiatric morbidity in England (2007) 1 report which provides projected prevalence estimates for people with drug dependence at a local authority level. Substance misuse treatment policy in England is guided by the National Drug Strategy published in The strategy sets out a fundamentally different approach to preventing drug use in our communities, and in supporting recovery from drug and alcohol dependence. Treatment for substance misuse in Barking and Dagenham is provided by a mixture of statutory and voluntary sector provision. Funding comes from Public Health England, the Mayor s Office for Police and Crime (MOPAC) and the Local Authority How many people misuse drugs Estimated prevalence of drug misuse (opiate and/or crack) is based on data from Police drug test data, substance misuse treatment data and National Probation data which is used to project how many Opiate and/or Crack users (OCUs) reside in each area of England. Figure shows the estimated prevalence of OCUs in Barking and Dagenham and comparisons with prevalence in England, London and comparator boroughs. The boroughs of Greenwich and Lewisham are used as comparators as these boroughs are both London Boroughs which fall into the same index of multiple deprivation decile as Barking and Dagenham. 1 Adult psychiatric morbidity in England, NHS Information Centre for health and social care ult%20psychiatric%20morbidity%2007/apms%2007%20%28final%29%20standard.pdf 2 Drug Strategy 2010: Reducing Demand, Restricting Supply, Building Recovery : Supporting People to Live a Drug Free Life HM Government ?view=Binary

2 Figure : 2011/12 prevalence of Opiate and Crack users (OCU) rate per 1,000 residents England Barking and Dagenham London Greenwich Lewisham Source: Glasgow Prevalence Estimates, released August 2014 The 2011/12 Glasgow Prevalence Estimates for Opiate and Crack Users are the latest available at time of writing this JSNA refresh (June 2015). According to the 2011/12 Glasgow Prevalence Estimates, there are around 1,079 opiate and crack users (OCUs) living in Barking and Dagenham (95% confidence interval 915 to 1,327). 490 OCUs (45% of the estimated number of OCU s residing in Barking and Dagenham) were engaged in treatment between April 2013 and March The estimated number of injecting OCUs residing in the borough is 278 (95% Confidence Interval of ). Locally there has been an 8.6% increase in the estimated number of OCUs residing in the borough when comparing the 2010/11 and 2011/12 estimates. In comparison there has been a 4.5% increase across London and 1.6% decrease in the national estimate of OCUs. From 2011 there has been a national drive led by Public Health England, to focus on recovery. The reason for this is because previous drives were to get people into effective treatment however this resulted in long term maintenance with no exit strategy to become abstinent. Figure gives a breakdown of the drug types used by individuals in treatment during 2013/14 in Barking and Dagenham. Note that this chart looks at drugs used and that one individual may be using up to three different substances and would therefore appear in this chart more than once.

3 Amphetamine users Benzodiazepines users Cannabis users Cocaine users Crack users Ecstacy users Opiate users Other drug users Prescription Medication users Number of individuals Figure : Individuals receiving drug treatment by drug used, Barking and Dagenham, 2013/ Individuals receiving drug treatment in 2013/ Substance Name Source: NDTMS 2013/14 Green report Economic consequences The latest findings from Public Health England show that each drug user not in treatment costs society 26,074. The findings also show that every 100 invested in drug treatment prevents a crime. Furthermore Public Health England s Local Value for Money Tool for Drug Treatment and Recovery 3 shows that for every 1 spent on drug treatment saves 2.56 to society Services and treatment for adults who misuse drugs Within Barking and Dagenham there are a number of services that make up the integrated treatment system. The Recovery Management Service is the open access entry where people can self refer or be referred for assessment for treatment or brief advice. The Recovery Management service also works with criminal justice clients. Clients are care coordinated by The Recovery Management service and can be referred to Horizon, the structured day programme where groups and counselling are offered. The prescribing service has a doctor on site daily and is able to offer substitute opioid prescriptions to clients within 48 hours. Treatment data shows that the Barking & Dagenham treatment system treated 55.5% (599) of the estimated local OCU population between April 2012 and March The remaining estimated OCU population (480) are not accessing services and they are described as treatment naïve Local VFM tool for drug treatment and recovery last updated 15/01/2014

4 Table : Drug users in treatment, Barking and Dagenham, 2013/ /14 OCU Treatment Data Based on Smoothed Glasgow Estimate (2011/12) In treatment on 31/03/ In treatment during 2013/14 and discharged 141 Known to treatment but not treated in the year 109 Not known to treatment (Treatment naïve) 480 Total OCU estimate 1,079 Source: NDTMS Needs Assessment Data, 2013/14 Successful completions According to the National Drug Treatment Monitoring System (NDTMS) data, the successful completion rates for those who are treatment naïve is twice that of those who have had previous experience of treatment in their first year of engaging in services. In 2011/12 (see Fig ) the successful completion rate for treatment naïve clients was 19% in their first year compared to 9% for those who have had previous treatment episodes. This indicates that treatment services need to maximise the outcomes for first time entrants into drug treatment and to apply a different approach to service users who know the system. Figure : England Treatment Naïve Opiate Completion Rates for 2013/14 by length of time in treatment 20% 19% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 9% 9% 14% 8% 13% <1 year 1-2 years 2-3 years 3-4 years 7% 10% Non-naïve opiate clients Tx naïve opiate clients Source: NDTMS Recovery Diagnostic Toolkit

5 Re-presentations Public Health England uses NDTMS data for each borough and compares it to the 32 areas (called Local Outcome Comparators) that are most similar to them in terms of the complexity. The comparator areas are based specifically on the complexity of the populations in substance misuse treatment and not on broader similarity between the general populations of local authorities. Of those individuals who successfully completed treatment in Barking and Dagenham between 1 April 2013 and 31 March % of opiate users and 10% of non-opiate users re-presented to services within 6 months. In comparison the top quartile range for the cluster is 12% to 5% re-presentation rate for opiate users and 4% to 0% for non-opiate users indicating that more could be done to reduce the number of individuals re-presenting to treatment. The Recovery Support provision at all services has enabled individuals to access further support alongside their treatment journey aiding them with the transition from treatment back into the community. Recovery Support has been put in place to compliment an individual s ongoing recovery journey. Services have produced a joint timetable that all service users can access. The timetable offers interventions that support abstinence, introduce life skills and promote employment and education. Individuals can access as much or little support as they feel they need and this is discussed prior to treatment completion. However, the result of the aftercare provision will not be reflected in service data until the end of quarter 1 in 2014/15. At the time of writing this JSNA update (June 2015) this data was not available. Treatment outcome profile data A Treatment Outcome Profile (TOP) is completed with each service user at the start of drug treatment, at the care plan review stage(s) and at the point of discharge. Services ask the user a range of questions about their substance misuse and injecting behaviour, whether they are involved in any criminal activity or involved in education, training or employment as well as self ratings on their psychological health. Comparing TOP scores over time allows a longitudinal change in service user behaviour over time and the impact and effectiveness of substance misuse treatment. Main findings from 2013/14 TOP data The information obtained from TOP provides a clear picture of those people leaving treatment who are either abstinent or using occasionally. Given that the focus has moved from numbers in effective treatment to sustained treatment outcomes, TOPs are becoming a much more useful tool to use. As a result of the effectiveness of TOPs there is now a specific Young Person Outcome Records (YPOR) which was started on the 1 November 2013 this is the YP version of the TOP form. At the time of refreshing this JSNA section (June 2015) the outcomes data for this new tool is currently unavailable and will be included in future versions of the JSNA. The latest 2013/14 Quarter 4 TOP review data shows 391 individuals has a TOP review following 6 months of treatment. Overall the review data shows good levels of

6 reduction in substance misuse following 6 months of treatment compared to their level of use when the service users started treatment. Table : percentage of clients who became abstinent from each drug by six month review: No. of No. of individuals Expected Better / in line individuals % who have Drug type used using at range of / worse than who have stopped treatment performance expected? stopped start Opiates % 40% to 56% In line Crack % 42% to 63% Better Cocaine % 57% to 79% In line Amphetamines % 31% to 100% In line Cannabis % 34% to 49% In line Alcohol % 26% to 47% In line Injecting % 54% to 88% In line Source: NDTMS 2013/14 Quarter 4 TOPS review report available at: This reduction in use carries on throughout treatment as shown by the numbers of opiate and crack users who are abstinent from each drug by planned exit. However, further improvements are needed with the remaining Class A drug users and injecting drug users. Table : percentage of clients who stopped using by planned exit in 2013/14 Qtr 4 (N=271 individuals) No. of No. of individuals Better / in line / individuals % who have Expected range Drug type used using at worse than who have stopped of performance treatment expected? stopped start Opiates % 40% to 56% In line Crack % 42% to 63% Better Cocaine % 57% to 79% In line Amphetamines % 31% to 100% In line Cannabis % 34% to 49% In line Alcohol % 26% to 47% In line Injecting % 54% to 88% In line Source: NDTMS 2013/14 Quarter 4 TOPS exit report available at: TOPs data suggest, as in previous years, that some individuals increase their use of other drugs such as alcohol and cannabis when they reduce their main drug use. Although the numbers generated by the quarterly reports are low and only provide a snapshot (due to the short periods used) this has been a consistent trend across reporting periods as evidenced in the previous JSNA. For the individuals who commence alcohol use and continue to use alcohol, further analysis of TOPs data would be beneficial to ascertain the frequency of use and the level of units consumed. This will help to assess the level of harm and inform further treatment interventions.

7 Injecting drug users Analysis of the use of the tier 2 Gateway needle exchange showed that of the 360 individuals using the exchange in 2013/14, 122 (34%) were steroid users and 177 (49%) stated they have never been in treatment (this includes steroid users who are not expected to receive substance misuse treatment). Furthermore 162 (45%) were already in treatment at the time of using the needle exchange. The Substance Misuse Strategy Team work with the treatment providers to ensure that those drug users who are using the exchange but are not in treatment are supported to access treatment through the open access service if they accept. All individuals are provided with harm minimisation information and advice associated with injecting use including steroid users. Blood borne virus (BBV) All drug users are at risk of contracting a blood borne virus (BBV) if they share equipment. Many interventions such as needle exchange have gone some way in order to reduce the harm. In addition treatment providers offer screening and immunisation against Hepatitis B and screening for Hepatitis C and HIV with a view to refer to specialist treatment should a test be positive. Currently, in Barking and Dagenham, all drug users engaging in treatment are offered screening for Hepatitis B and C. According to data published by Public Health England 90% of individuals offered BBV screen accepted and had the test. However, fewer numbers are accepting and completing the vaccinations for Hepatitis B and this should remain a priority for services. There has been a 15% increase in the rate of individuals diagnosed with HIV in Barking and Dagenham between 2010 and The latest figures (2013) for Barking and Dagenham in relation to diagnosed prevalence is 6.07 per 1,000 adults (age range 15-59), which is above the London and England averages of 5.69 and 2.14 per 1,000 adults respectively. Clinical staff within the Recovery Service in Barking and Dagenham have been trained to test service users for HIV and provide appropriate support. All service users are offered this test as well as a medical review and appropriate onward referrals to specialist services are made depending on the outcome Young people and drug misuse The young people s substance misuse service, SubWize work with young people up to the age of 21 and can work with individuals up to the age of 25 where appropriate. The number of young people (under 18 years) receiving tier 3 structured drug and alcohol treatment has increased year on year. In 2013/14 Barking and Dagenham had the highest number of young people in treatment in London with 302 accessing services. Barking and Dagenham have consistently had the highest number of young people in treatment over the last three years. This is due to excellent partnership work to help raise awareness of the local services and improved referral pathways across all areas including schools, youth centres, social services and other partnership services. This has led to more young people accessing services.

8 Cannabis Alcohol Amphetamines Solvents Opiates Nicotine Other Figure : Number of Young People accessing structured treatment 2013/ Barking and Dagenham Lewisham Greenwich Source: Public Health England, 2013/14 NDTMS Quarter 4 green report Nationally young people s treatment services have reported an increase in cannabis use, however locally alcohol is reported as the most prevalent. When services for young people begin to use the Young People Outcome Records the information obtained will give a clearer picture of young people s offending behaviour and drug use on discharge from treatment. Figure : Young people in drug and alcohol treatment, London boroughs, 2013/14 Barking and Dagenham England 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: NDTMS 2013/14 Needs Assessment data, YP partnership information

9 Rate per 100,000 Hospital Admissions for substance misuse for young adults (15-24) are compared below with Greenwich and Lewisham. Barking and Dagenham rates are significantly higher than the regional and England rates. 2013/14 is the latest data available at the time of refreshing this section of the JSNA (July 2015). Figure : Hospital admissions due to substance misuse, age years, Outer North East London boroughs, regional and England, 2011/ /14, rate per 100,000 London England Barking and Dagenham Greenwich Lewisham Borough Source: Child and Maternal Health Observatory, Table : Hospital admissions due to substance misuse, age years, Barking & Dagenham, statistical neighbouring boroughs, regional and England, 2011/ /14. Local Authority 2011/ /14 Significance Number Barking and Dagenham 79.7 none 20 Greenwich 92.9 none 33 Lewisham 96.1 none 36 London 65.2 N/A 711 England 81.3 N/A Source: Child and Maternal Health Observatory:

10 Hidden harm The Hidden Harm report produced by the Home Office in estimated that 2-3% of children under the age of 16 years had one or both parents with serious drug problems. If this ratio were applied to the borough today it would equate to between 966 and 1,448 children living with or being affected by their parent s drug misuse. This is an increase from last year s ratio between 767 and 1,150 children. The key predictors of drug use are a lack of parental discipline, family cohesion and lack of parental monitoring. Some aspects of family structure such as large family size and low parental age are also linked to adolescent drug use. Of the 1,667 individuals assessed across all drug and alcohol treatment services (tiers 2 and 3 treatment interventions) during 2013/14, 821 (49%) were identified as parents. Further analysis showed that 262 individuals in treatment had some or all of their children living with them. The remaining 584 had children but the children were not residing with the service user, such as children living with a carer and this also includes being cared for by the local authority. Often grandparents have a significant role in caring for grandchildren when their sons or daughters are unable to provide daily care and meet basic parenting requirements. Since the hidden harm service was introduced in 2012 within Children s Services, there has been a high number of referrals for children of substance abusers and also their families. As a result of the positive work carried out within this area additional resource has been given to enhance the service Areas for development Legal highs New Psychoactive Substances (NPS), also known as Novel Psychoactive Substances and Legal Highs are intoxicating substances that are not prohibited by UK law or have only recently been illegalised. Although the issue of NPS is not new, in recent years due to developments in chemical technologies, market availability, internet supply, trends in substance misuse, price and others it has become much more prominent. The issue of NPS is particularly significant in the UK. According to the United Nations Office on Drugs and Crime, the UK has the largest market for legal highs in the European Union Currently, NPS are readily available online and in Head Shops, which can be found on most UK high streets. Legislating against these sellers is a challenge, as enforcers must prove that the vendor is selling the product for human consumption. Further to this, many of the online sites used to sell NPS fall outside of UK jurisdiction making it almost impossible to legislate against them. Like all psychoactive substances, NPS can have a significant detrimental impact on the user s mental and physical health. As the majority of NPS are initially legal they are readily accessible and often cheaper than illegal substances, making them an attractive alternative for drug users. 4 Hidden Harm Responding to the needs of children of problem drug users, Home Office,

11 Due to changes in legislation, it is now illegal to suggest that substances may be used for human consumption at point of sale. Where previously substances have included safety information and dosage guidance, packaging now simply states not for human consumption. This has led to individuals being uninformed about what they are consuming and, in some circumstances, over-dosing. Further to this, as NPS mimic other illegal drugs, individuals may be inclined to consume them in the same way, however NPS can often be more potent than the drugs they mimic and have increased side effects. For example, there are over 300 synthetic cannabinoids, which have been seen to induce psychosis. It is estimated that one new psychoactive compound is created every week, this heightens risks, as newer substances have had less testing and thus both their short and long-term effects on humans are unknown. To further build the local NPS picture, work can be done to scope potential NPS vendors and to use legislation where possible to reduce the selling of NPS to residents. Education can be used to build factual awareness for young people about the risks associated with using NPS, as well as harm reduction advice for those using NPS. CRI for example, offer training and awareness building workshops in other boroughs, which have been reported as an effective way of spreading the important information concerning NPS. Training can be delivered to substance misuse and school staff to ensure that they are up-to-date on information around NPS and can disseminate this to young people and service users. Ensuring that schools are informed is essential to ensure that they can identify signs that a young person may be consuming legal highs and make appropriate referrals. It would be beneficial to have an NPS lead in every secondary school in the borough. Work can also be done with hospitals to identify admissions who present toxic symptoms and drug induced psychosis and to ensure that they are referring these individuals to the appropriate services. At the time of writing (June 2015) the House of Lords have yet to decide to ban legal highs. If a decision is made to ban legal highs then the Substance Misuse will need to adapt service provision in the borough. For example whether to introduce drug testing of legal highs in police stations. Potential abuse of pregabalin and gabapentin The recent publication of national prescribing guidance 5 in relation to the prescription only medicines pregabalin and gabapentin is welcome. Pregabalin and gabapentin are valuable medications prescribed for a number of long-term conditions including neuropathic pain, generalised anxiety and epilepsy. There is concern however, 5 Advice for prescribers on the risk of the misuse of pregabalin and gabapentin. Jointly published by Public Health England and NHS England December 2014 accessed on 12/05/2015 at NHS_England_pregabalin_and_gabapentin_advice_Dec_2014.pdf

12 across London s drug and alcohol services, with regards to abuse of these drugs, particularly pregabalin, by people attending substance misuse services. Pregabalin enhances the effects of other drugs, including opiates, leading to increased risk of intoxication (together with associated accidents and aggressive incidents) and potentially fatal overdose. Drug services locally have raised concerns about the potential abuse of pregabalin amongst its treatment cohort. The extent of the problem in Barking and Dagenham is not fully understood currently. Barking and Dagenham s Substance Misuse Strategy Team will conduct a scoping exercise to determine the extent of the issue within Barking and Dagenham in order to formulate a treatment response, if required. The scoping exercise will include contact with current drug and alcohol users in treatment, service providers, the police and other stakeholders. It is planned to report back to the Substance Misuse Strategy Board in December 2015 with the scoping exercise s findings and recommendations. Additions to medicines Barking and Dagenham is Public Health England s addiction to medicines pilot area in London. Addictions to medicines cover a wide range of prescribed and over-thecounter medicines including the so-called z- drugs and opioid based pain relief. The new drug treatment services, which started in July 2015, have a dedicated treatment pathway able to provide advice and information to local GPs, assessment and follow-up services. Data collection and analysis of the new treatment pathway is a key task for The aim is to discern patterns of use in Barking and Dagenham with regards to addiction to medicines and effectiveness of treatment options. These findings will also feed into the national agenda of this issue as well as informing future commissioning needs at a local level. Shared care Shared care, consisting of GPs and community pharmacies working in partnership with the specialist community drug services, is a vital component to drug treatment services in Barking and Dagenham. Up to 40% 6 of opiate dependent drug users in treatment will access supervised consumption from local community pharmacies in Barking and Dagenham reducing the risk of misuse and diversion of medication. During the number of client places in GP shared care will increase enabling more clients to be treated within the context of Primary Care allowing specialist services to focus on the clients new to treatment or those with more complex needs. Shared care requires adequate training provision to support GPs and pharmacists in their role. During a review of training provision will be conducted by the Substance Misuse Strategy Team which will include the feasibility of funding training places to provide baseline training for prescribing GPs. 6 Local data Qrt Barking and Dagenham s Recovery Substance Misuse Service

13 Pathways for female offenders Reducing reoffending amongst the female offenders has exceptional challenges compared to their male counterparts, such as being single parents, in an abusive relationship, sexually exploited and/or using drugs or alcohol. Reducing female offending is a priority for LBBD and partners, such as the Metropolitan Police, National Probation, and the Community Rehabilitation Company, as well as partners who support women that find themselves in situation as mentioned above, such as the Domestic Abuse and Substance Misuse services. LBBD has a dedicated Integrated Offender Management Female Pathways Coordinator post who works in partnership with all the criminal justice services and partners to reduce offending rates amongst female offenders. In the current austerity climate this continues to be a challenge; however every effort is being made to divert female offenders into education, training or employment. Two local private enterprises, Ghost Academy and Maidie Create were funded for short term projects to deliver training to help raise service users confidence and provide training and qualifications leading to either further education or employment. Ghost Academy delivered hair dressing training and qualifications, level 1 and 2 and opportunities for the women to experience working in a hair dressing saloon, some went on to work on a part-time bases. Maidie Create designed and delivered a 12 week fashion and vocational programme called Sew Successful for 10 vulnerable women, who were also in recovery from alcohol and substance misuse. The aim of the programme was to educate and inspire service users, teaching them new skills, giving confidence and self esteem to help improve their personal development. Maidie Create was able to create employment through work placements and two of the women went on to paid apprenticeships. Maidie Create introduced women to entrepreneurship showing them how to set up their own businesses, within the community and provided sewing machine which enabled them to achieve this. Due to the lack of funding LBBD are unable to sustain these training programmes and are exploring how these can be delivered, either through partners funding the programme or through co-funding. The Substance Misuse Board has asked if the Trouble Families programme can be used to support these programmes as most of the women will meet the criteria.

14 Recommendations To prevent substance misuse in young people, commissioners need to ensure that relevant and up to date drug and alcohol education will be delivered by Physical, Social, Health and Economic (PSHE) leads in schools. The PSHE leads will be trained by the School Drug and Alcohol Advisor. In order to establish gaps in pupil knowledge a survey needs to be carried out when the autumn term starts in September. Services need to look at tailored drug treatment provision. Services should offer a menu of treatment with explanations of what the options of treatment are. This will ensure that drug treatment is bespoke to the individual as opposed to a one size fits all approach. This should include interventions that are offered off site in premises that are more appropriate for service users. This may help to keep people in effective treatment and therefore complete treatment successfully. According to Treatment Outcome Profile (TOPs) data, a number of users are still using Class A drugs at the point of successful discharge from treatment. The Substance Misuse Strategy Team s vision is for all service users to be free from Class A drug use at point of planned exit and this should be included in future service specifications. TOPs data also shows that where individuals are still using alcohol at the point of planned treatment exit, their daily use has not significantly reduced compared to when they first started treatment. Furthermore in some cases individuals have commenced using alcohol at the end of their treatment journey. Further analysis is required to ascertain the frequency of use and the level of alcohol units consumed. This will help to assess the level of harm and inform further treatment interventions. The Substance Misuse Strategy Team will conduct a scoping exercise into the extent of any abuse of Pregabalin and Gabapentin within its drug and alcohol treatment population. The findings and recommendations from the scoping exercise will be reported back to the Substance Misuse Strategy Board in December The Substance Misuse Strategy Team to assess the demand for, and effectiveness of the new treatment pathway for addictions to medicines and report back to LBBD s Substance Misuse Strategy Board and Public Health England. The new prescribing services will look to increase the numbers entering GP shared care during and to review training provision generally across shared care and to consider the feasibility of funding training places for shared care GPs. The Substance Misuse Strategy Team to explore additional funding streams either through partners or co-funding so that training programmes for female offenders with substance misuse issues such as Maidie Create and Ghost Academy can continue to be delivered in the future.

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