INTEGRATED STRATEGIC NEEDS ASSESSMENT: ADULT DRUG MISUSE SUMMARY

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1 INTEGRATED STRATEGIC NEEDS ASSESSMENT: ADULT DRUG MISUSE SUMMARY INTRODUCTION Drug use matters to society given the impact this has on individuals, families, and communities. Drugs have a negative impact, from the crime impact on local neighbourhoods, the health impact on the individual, the social impact on families to the effect of international organised crime. Drug addiction goes hand in hand with poor health, homelessness, family breakdown, and offending. 1 in 20 adults use drugs frequently, about 1 in 10 adults have used drugs recently, and 1 in 3 adults have taken drugs at some point. There are 306,000 heroin and crack users in England with 1,200,000 people affected by drug addiction in their families mostly those in poor communities. Each year this is at a cost to society of 15,400,000,000 (NTA, 2011). KEY ISSUES Demand for drug treatment is driven by clients rather than by any particular referring agency. Just over half of clients are self-referrers a higher proportion compared elsewhere. There is a need to raise awareness about substance misuse and more work force training amongst universal services to ensure people who require specialist support are sign posted appropriately. In particular people working with the victims of domestic abuse have been highlighted by the DAT as a priority group. Workforce training in safe guarding agencies and drug services will also support the necessity of collaboration between agencies. Almost all clients engaged in treatment are for opiates and/or crack misuse (93% West Cheshire, 92% Cheshire). The penetration rates for crack-only users however is much lower than opiate only or opiate and/or crack users. The treatment system appears to miss those from the AACCE profile (amphetamines, alcohol, cannabis, cocaine, ecstasy), with just 5% of the treatment population in this category, and only 2% highlight adjunctive alcohol use in addition to their primary drug use. A significant proportion of new treatment journeys for clients that had not been in treatment before, are not using opiates and/or crack; 38% compared to just 8% of those who have been 1

2 in treatment. The treatment system must be able to cater for non-opiate and crack-only users if it is to engage these clients effectively. Emerging trends and substances such as performance and image enhancing drugs (PIEDs/- steroids), legal highs, prescription only medicine and over the counter demand will need to be met. Far fewer clients (6% West Cheshire, 8% Cheshire) are referred via the criminal justice system compared regionally and nationally (34% and 30% respectively). An Integrated Offender Management system (IOM) will continue to support the identification and support of priority offenders, including drug misusing offenders, and divert them away from drug use and crime. Over a half of clients say they want to be drug free within a year but over half of the in-treatment population have been engaged in specialist treatment for over two years (60% West Cheshire, 55% rest of Cheshire). The proportion of clients who have been in-treatment for at least 2 years has increased over the last 3 years. There is a need to focus on assisting clients in the 2-4 year and 4 year plus cohorts to move forward in their treatment journey and ultimately leave treatment. The model of care needs to move towards a recovery-orientated system. Figure Percentage of clients wanting to become drug-free Q11. I would like to become drug free (stopping your script) within the next... 40% 35% 30% 25% 20% 15% 10% 3 months 6 Months 12 Months 2 Years 5 Years Never 5% 0% Chester E-Port Vale Royal Source: Cheshire DAT survey 2011 Cheshire has a heavily medically assisted drug treatment system (adults). The vast majority of clients are receiving prescribing interventions (86%), while the level of psychosocial intervention provision is exceptionally low (0.3%). However it is recognised that Cheshire & Wirral Partnership Trust community drug teams do not accurately report all of their activity in terms of all the interventions they provide, this is particularly true for psychosocial interventions that compliment prescribing interventions. Service providers have highlighted difficulty in accessing psychosocial therapies via IAPT. The health needs assessment highlights that opiate and crack users needs are not currently met, given their apparent high prevalence in treatment and 2

3 poor outcomes, possibly relating to a gap in choice of treatment interventions. This is also similar for the low numbers of amphetamines, cannabis or cocaine users in treatment. Just over a quarter (29%) of clients that left treatment were referred on unsuccessfully, better links need to be made when referring clients on for further treatment, these clients are leaving treatment with unmet needs. Additional support should be provided to clients to ensure a smooth transition between services. Findings from a service user survey into clients perceptions of the barriers to the employment and training opportunities available to them indicate that there is a need for education provision among service users to assist them in finding employment. The majority of respondents did not feel particularly that they were confident they had the required qualifications/training or work experience to get the job they wanted. There is an approximate shortfall of over 50% in terms of housing floating support provision for substance misuse clients. There is a need for robust working between drug and alcohol treatment services, children s services, housing agencies, job centre and work programme initiatives, communities and prisons to support developments for recovery capital to grow. Stakeholders have identified that there is a gap locally in provision and support for families/carers across Cheshire. This is an area of work that has seen the development of a local safeguarding protocol between Children s Social Care and drug and alcohol services in 2011/12. The protocol outlines the agreed responsibilities of workers within each service area to ensure the risk management and safeguarding of children when working with parents with substance misuse issues. In 2010/11, the Ministry of Justice reported that there was a marginal increase in overall re-offending in Cheshire West and Chester compared to their prediction but the difference was not statistically significant. However, Cheshire Probation Trust report a more recent better direction of travel in the first quarter of 2011/12. Cheshire Probation Trust highlight a wide number of health issues amongst offenders locally with a third having drug-related issues in 2010/11. RECOMMENDATIONS FOR COMMISSIONERS AND POLICY MAKERS Provide quality workforce training with a focus on universal agencies (tier 1) Commission a greater choice of interventions to create a local Recovery Orientated Integrated System to increase the number of successful completions and reduce the number of representations. Develop aftercare provision to sustain recovery benefits and rebalance the system, building recovery and recovery capital; 3

4 Increase community detoxification interventions and promote reduction programmes Increase psychosocial interventions to balance heavy pharmacological model and strengthen IAPT pathways Improve criminal justice referrals and joint work arrangements Improve harm reduction joint working arrangements and processes Improve housing provision for those newly abstinent or on release from prison Refresh DRR (Drug Rehabilitation Requirement) programme of activity to achieve DRR targets and share with Courts Work with providers on solutions around local housing and employability options including better links with Work Programme and Job centre plus Continue to strengthen local safeguarding arrangements and improve support for families/carers. Conduct a mapping exercise to establish gaps in health provision for offenders. Develop an evidence based targeted health offender strategy. Improve data quality of commissioned providers particularly around treatment outcomes and drive performance improvement 4

5 INTEGRATED STRATEGIC NEEDS ASSESSMENT: DRUG MISUSE IN ADULTS INTRODUCTION MAIN REPORT Drug use matters to society given the impact this has on individuals, families, and communities. Drugs have a negative impact, from the crime impact on local neighbourhoods, the health impact on the individual, the social impact on families to the effect of international organised crime. Drug addiction goes hand in hand with poor health, homelessness, family breakdown, and offending. 1 in 20 adults use drugs frequently, about 1 in 10 adults have used drugs recently, and 1 in 3 adults have taken drugs at some point. There are 306,000 heroin and crack users in England with 1,200,000 people affected by drug addiction in their families mostly those in poor communities. Each year this is at a cost to society of 15,400,000,000 (NTA, 2011). Evidence shows for every 1 spent on drug treatment it saves 2.50 in costs to society. The Department for Education, 2011, concluded that young people s drug treatment is a cost effective intervention, estimating that for every 1 spent on young person s treatment, between 5 and 8 is saved by the NHS and other agencies. Nationally the drive is for making communities safer, protecting public health and helping drug users overcome addiction. Public support has shown 75% think drug treatment is a sensible use of public money, 66% fear crime would increase without drug treatment, and 80% believe drug treatment makes society better and safer (NTA, 2011). The national drug strategy Drug Strategy 2010 reducing demand, restricting supply, building recovery: supporting people to live a drug free life aims to reduce illicit and other harmful drug use and increase the numbers recovering from their dependence and is structured around three key themes: 1. Reducing demand creating an environment where the vast majority of people who have never taken drugs continue to resist any pressures to do so, and making it easier for those that do to stop. 2. Restricting supply - drugs cost the UK 15.4 billion each year. - making the UK an unattractive destination for drug traffickers by attacking their profits and driving up their risks. 3. Building recovery in communities working with people who want to take the necessary steps to tackle their dependency on drugs and alcohol, and offering a route out of dependence by putting the goal of recovery at the heart of all that we do. 5

6 The following schematic illustrates the local Cheshire Drug Action Partnership (DAT) proposed direction of travel. (Source: Cheshire DAT Direction of Travel ) This ISNA chapter relates to drug use amongst adults. Alcohol misuse is considered in a separate ISNA chapter as is drug use & alcohol use in the under 18s. This needs assessment includes information at a number of different geographies because at present it is not possible to present all the information at a CWAC geography. Hence some information is at a Cheshire level, some at a West Cheshire level (that is Chester and Ellesmere Port) and some at a Cheshire West and Chester level (Chester, Ellesmere Port & Vale Royal). The level of geography is specified in the text and tables. Next year we will be in a position to present the information at a CWAC level. 6

7 WHO S AT RISK AND WHY Drug use occurs across many groups within the population. Most people who use drugs be it legal or illegal substances do not come to serious harm (Home Office 2010). Harm associated with licit and illicit substance use is diverse. Drug-related harms vary according to the different types of drug or drugs being used; alongside this, it is the way a drug is used, the way it is used in combination with other substances, and the social context in which it is used that contribute to risk. There are also problems of dependence - the general principles of dependence do not apply equally to all psychoactive substances and the characteristics and severity of symptoms and signs of dependence vary by drug. In addition, harmful use may occur without a substance causing physical or psychological dependence Experience of serious drug-related problems is strongly correlated with economic disadvantage and many adult problem drug users have long histories of substance misuse which start before they are 18. There is an association between mental illness and drug dependence. The majority of lifetime mental illness starts before adulthood and associated behaviour including substance misuse often occurs in this period. Individuals with a background of child abuse, neglect trauma and poverty are disproportionately affected by drug misuse. Key vulnerable groups include: Children in care and care leavers Offenders Homeless people Children affected by parental substance misuse Those experiencing mental ill health The British Crime survey produce annual national statistics on adults aged years who report substance use. In 2010/11 this suggests that certain groups may be more likely to have used drugs in the last month including: Young people, 20% of year olds compared with 6% of year olds (4.2% and 1.8% respectively for class A drugs) Men, 12% of men compared to 6% of women Mixed race groups; 19% compared to 9% white, 4% Asian, 4% black CURRENT NEED IN THE POPULATION It is difficult to accurately estimate the full extent of drug use at a national or local level. The British Crime survey 2010/11 found that 36% of the adult population in England and Wales have ever used an illicit drug and 5% have used illicit drugs in the last month. Class A drug use is less common: 15% have ever used a Class A drug, with 1% having used a Class A drug in the last month. General population surveys estimate that around 3% of adults in England show signs of dependence on illicit drugs, most frequently cannabis (4% of 7

8 men and 2% of women). For other illicit drugs, 0.4% show signs of dependence on cocaine and 0.1% each show signs of dependence on crack, ecstasy and heroin/methadone. However, general population surveys significantly underestimate the numbers of dependent drug users. Estimated prevalence of Opiate and Crack use in Cheshire A problematic drug user (PDU) has recently been re-defined as an OCU; an individual identified as using opiates and/or crack cocaine. Opiate and crack user (OCU) prevalence estimates are provided by the National Treatment Agency (NTA), and provide an estimate of the number of opiate and crack users in the Cheshire DAT partnership area. The latest prevalence estimates were produced in 2009/10, and are outlined below. Table 1 Estimated prevalence of opiate and crack users in Cheshire 2009/10 Category Estimate (95% confidence interval) Opiate and/or crack users (OCU) 3,062 (2,891-3,312) Opiate users 2,913 (2,721-3,237) Crack users 1,969 (870-3,173) Injectors 1,514 (1,295-1,799) Source: National Treatment Agency The estimated prevalence of opiate and/or crack use is low compared nationally (table 2). Table 2 National and regional comparisons in the estimated prevalence of opiate and crack users rate per 1,000 of the population aged years 2009/10 (95% confidence interval) Cheshire North West England Opiate and/or crack 6.88 ( ) ( ) 8.93 ( ) Opiate-only 6.55 ( ) 9.59 ( ) 7.70 ( ) Crack-only 4.43 ( ) 6.64 ( ) 5.37( ) Injectors 3.40 ( ) 3.91 ( ) 3.01 ( ) Source: National Treatment Agency Between 2008/09 and 2009/10, the estimated prevalence for opiate and/or crack use has declined by 300. The trend for the North West and England is the same. The prevalence for opiate use increased by around 100, while crack user prevalence decreased slightly by around 30 people. These estimates are for Cheshire, as the DAT Partnership is presently for this geographical area. Around 47% of the Cheshire population live in Cheshire West and Chester and therefore very crudely we could estimate that there are 1,400 opiate and crack users locally. This may be an underestimate as the 8

9 socio-economic profile of the two populations has not been taken into account. During 2010/11, a total of 2,264 individuals using opiates and/or crack were known to treatment services of which 1,998 were engaged in some form of structured treatment. Using the NTA prevalence estimate we can estimate that 74% were known to drug services and 65% were engaged in drug treatment. The proportion of crack only users engaged in drug treatment was considerably lower than that of opiate only clients (47% compared to 68%) (table 3) The proportion of opiate and/or crack users engaged in drug treatment services has increased between 2009/10 and 2010/11 (from 59% to 65%). The proportion of opiate only users engaged in drug treatment has remained relatively stable between 2009/10 and 2010/11 (from 67% to 68%). The proportion of crack only users engaged in drug treatment has increased between 2009/10 and 2010/11 (from 40% to 47%). Table 3 Drug treatment penetration rates Opiate and Crack users 2010/11 Treatment 2010/11 Opiate and/or crack Opiate Crack In drug treatment 65% 68% 47% Known to drug treatment 74% 76% 54% Treatment 2009/10 In drug treatment 59% 67% 40% Known to drug treatment 75% 75% 47% Source: National Treatment Agency Overall this means that 798 (26%) of individuals estimated using opiate and/or crack are not known to treatment services (or treatment naïve). This is better than the national average but the proportion of crack-only users that are not known to treatment service (treatment naive) is worse compared nationally and particularly regionally (table 4). Table 4 Percentage of opiate and/or crack users not known to treatment services 2010/11 Opiate and/or crack Opiate Crack Cheshire 26% 24% 46% North West 28% 18% 41% England 32% 25% 43% Source: National Treatment Agency 9

10 Other Drug Use The extent to which all drugs are used is unknown and difficult to estimate. There are different levels of drug use from experimental and recreational to addictions where the user continues a normal lifestyle and problematic where the user is causing serious harm to themselves or their communities. To estimate the extent of all drug use in Cheshire West we have used the British Crime Survey 20010/11 findings and extrapolated these to the CWAC population. It is likely that drug use in the crime survey is under reported. Table 5 Estimated drug use in the last year and month by age group CWAC Percentage from British Crime Estimated number CWAC Survey 2010/11 Drug use in last year Drug use in last month Drug use in last year Drug use in last month Age Group Any drug Class A drug Any drug Class A drug Any drug Class A drug Any drug Class A drug % 3% 4.8% 1.2% 16,290 5,550 8,880 2, % 6.6% 10.9% 2.6% 7,530 2,430 4, Source: British Crime Survey 2010/11 CWAC 2010 estimates (ONS) ,098.2; ,890.2 Between 1996 and 2010/11 the British Crime Survey has found that any drug use in the last month has fallen amongst adults including those aged years. Changing patterns of drug use The patterns of misuse are changing nationally according to the 2010 Drug Strategy. Data from treatment providers suggest that the heroin population is ageing with fewer people becoming dependent on the drug. However presentations for problems with crack cocaine continue to be high. In addition increasing numbers of people who would not fit the stereotype of a dependent drug user are presenting for treatment. These individuals are often younger and are more likely to be working and in stable housing. Poly-substance abuse is also increasingly the norm amongst drug misusers and their dependency commonly involves alcohol as well as drugs. There has been the emergence of legal highs as a new trend with young people taking new legal chemicals instead or as well as other drugs. Drug-related deaths There were on average 14 drug-related deaths per year between 2008 and 2010 in Cheshire West and Chester. As a rate of 4 deaths per 100,000 residents this is lower than the England and Wales average of 5.1 per 100,000 but not significantly so. The ICD10 classification codes for deaths included in this category are given below. These deaths include poisonings 10

11 from drugs not included in the 1971 misuse of drug act. Nearly half (18 over 3 years) however were recorded as caused by disorders due to drug use and poisonings from narcotics and psychodysleptics. Table 6 Number and age-standardised rate of drug-related deaths Cheshire West and Chester DSR per 100,000 Lower 95% CI Upper 95% CI No of deaths Annual Average Deaths England & ,553 2,851 Wales CWAC Source: ONS Populations and deaths in E&W in CWAC from ONS Annual Deaths Database Extract Drug- related deaths ICD10 codes Description Mental and behavioural disorders due to drug use (excluding tobacco and alcohol) Accidental poisonings by drugs, medicaments and biological substances Intentional self-poisoning by drugs, medicaments and biological substances Assault by dugs, medicaments and biological substances Poisoning by drugs, medicaments and biological substances, undetermined intent ICD10 codes F11-F16 F18-F19 X40 X44 X85 Y10 Y14 11

12 Hospital admissions 2010/11 In 2010/11 there were 258 hospital admissions with a primary or secondary diagnosis of drug related mental health and behavioural disorders. This is lower than the national average. There were 117 admissions with a primary diagnosis of drug poisoning. This is higher than the national average. Table 7 Hospital admissions for drug related conditions Cheshire West and Chester 2010/11 Admissions with primary or Admissions with primary secondary diagnosis of diagnosis of poisoning by drug-related mental health drug and behavioural disorders Number of admissions Crude rate per 100,000 Number of admissions CWAC North West 12, , England 51, , Crude rate per 100,000 Source: Hospital Episode Statistics, HES. The NHS Information Centre for health and social care; Cheshire ICT data warehouse Inpatient table Copyright The NHS Information Centre, Lifestyle Statistics. All rights reserved It is not known how many of these hospital admissions were for clients already engaged in treatment, or how many were referred on to structured drug treatment. Injecting During 2011/12, 58% of clients engaged in treatment with the West Cheshire Community Drug Teams (CDTs) had a history of injecting, either currently or previously. This rate is slightly higher than the North West and national levels (54% and 55%). Table 8 Injecting status of clients engaged with West Cheshire drug services 2011/12 Total clients engaged with a history of injecting Proportion of total caseload with injecting history Chester CDT % Ellesmere Port CDT % West Cheshire CDT s % Cheshire DAT 1,300 60% North West 19,378 54% England 109,338 55% Source: National Treatment Agency 12

13 Fifty four percent of all clients with a history of injecting have received a hepatitis C test. This is in line with regional performance, but much lower than England (66%). Table 9 Client uptake of hepatitis C testing with West Cheshire drug services 2011/12 % of clients tested for hepatitis C Chester CDT 52% Ellesmere Port CDT 59% West Cheshire CDT s 54% Cheshire DAT 58% North West 53% England 66% Source: National Drug Treatment Monitoring System During 2010/11, 98% of new client entering treatment were offered a hepatitis B vaccination in West Cheshire (6 individual clients were missed). Forty five percent of new treatment journeys accepted a hepatitis B vaccination. Performance in West Cheshire is better than nationally and regionally for both the offering and uptake of hepatitis B vaccinations. Table 10 Percentage offered and accepted hepatitis B vaccinations 2011/12 with West Cheshire drug services % new treatment journeys offered hep B vaccination % new treatment journeys accepted hep B vaccination Chester CDT 98% 52% Ellesmere Port CDT 97% 38% West Cheshire CDT s 98% 45% Cheshire DAT 95% 40% North West 90% 32% England 92% 34% Source: National Drug Treatment Monitoring System Accommodation Cheshire West and Chester supporting people data suggests that there is a short fall in floating support provision for substance misusing clients of minimum of 150 units, which represents a shortfall of over 50%. The types of accommodation need identified for this group are highlighted in the Supporting People Needs Assessment (2011) and includes: Improved housing needs assessments and housing plans for individuals Developing the role of the private rented sector as a sustainable option Support for those that have been excluded from a number of providers services. 13

14 Education, training, and employment needs At the end of quarter four 2011/12, 17% of Cheshire clients that left treatment in a planned way reported working on 10 days or more in the last 28 days of their treatment, this compares with 21% nationally. The proportion is slightly higher for the non-opiate cohort, where 27% of Cheshire clients that left treatment in a planned way reported working on 10 days or more in the last 28 days of their treatment, which is on par with national the figure of 28%. Family & Carers In the autumn of 2011, the Local Safeguarding Children s Board (LSCB) commissioned a report to review drug and alcohol and child protection services in Cheshire West. In particular the report focussed on two aspects: (i) the ability and responsiveness of Drug and Alcohol Services to identify and respond to potential child safeguarding concerns in families with whom they work; and (ii) the effectiveness of working relationships between practitioners working in Drug and Alcohol Services and Children s Social Care. The findings from the report found that there was a lack of understanding and consistency in practice amongst Drug and Alcohol teams in understanding and identifying when there are potential safeguarding concerns regarding a child due to parental substance misuse. Furthermore, there was confusion about thresholds for intervention for safeguarding and child protection. There were case examples of children being subject to Child Protection Plans, but where practitioners from Drug and Alcohol Services were not an intrinsic part of the multi-agency response in protecting that child. The LSCB has identified as one of its key priorities for 2012/13, the Hidden Harm agenda, ensuring there is a much more integrated multi-agency response to children who live in families where their parents misuse substances. Level of need in Cheshire Police custody suites Data collected in October 2011 by Cheshire Police shows that it is largely not known if detained persons have issues with drugs but, of those who admit to drug use, none appeared to be in contact with drug services to obtain support for their problem. 14

15 Table 11 Number of persons detained and seen by Reliance Medical Services in October 2011 with Drug issues (based on a 10% sample of records) Custody Suite Heroin Cannabis Cocaine Other None Not known In contact with Drug Services Blacon Middlewch Source: Cheshire Police Constabulary Level of need for residents subject to Multi-agency Risk Assessment Conferencing (MARAC) For Cheshire West and Chester, the MARAC report states that there were 365 adults with 478 children who were subject to MARAC in 2009/ % of the 365 adult cases were referred by substance misuse services. The table below indicates that out of the 129 cases with additional issues, 20 had drug problems and 52 had alcohol problems. Alcohol was the most common additional issue out of a range of issues. Table 12 MARAC clients with additional issues in Cheshire West 2009/10 Areas of referral Chester Ellesmere Winsford Northwich Port MARAC Clients with additional issues (Total 129) Mental health Drugs Alcohol Source: Cheshire West and Chester Council 15

16 CURRENT SERVICE PROVISION Cheshire DAT Partnership The Cheshire DAT partnership is a multi agency partnership with a responsibility to deliver the national drugs strategy locally. It is presently accountable to the Home Office, Department of Health, and the National Treatment Agency. The DAT partnership comprises the following member organisations include: Central and Eastern Cheshire Primary Care Trust Cheshire East Council Cheshire Constabulary Cheshire West and Chester Council Western Cheshire Primary Care Trust Cheshire Probation Trust HMP Styal National Treatment Agency The overarching principles of Cheshire DAT are: Improving access to early and preventative interventions, where recovery from addiction is positively initiated through accessible and efficient drug treatment; Treatment is recovery-orientated, effective, high quality and protective; Treatment delivers continued benefits and achieves appropriate recovery-orientated outcomes, including successful completion from drug dependency, reduces re-presentation rates and tackles intergenerational transmissions; Treatment supports people to achieve sustained recovery in their local community and gives wider savings in the long term through crime reduction, health improvement, successful reintegration, and safeguarding. The Cheshire DAT aims to improve the following outcomes for individual s families and communities: Reduction in crime and re-offending; Ability to access and sustain suitable accommodation; Capacity to be an effective and caring parent; Freedom from dependence on drugs or alcohol; encouraging individuals to take responsibility for their own health; 16

17 Giving the best chances for young people and young adults; Improvement in relationships with family members, partners and friends; Improvement in mental and physical health and wellbeing; Prevention of drug related deaths and blood borne viruses; Development of prospering communities; The Cheshire DAT commission a range of different drug services across Cheshire. The current treatment system is configured of a mix of services; open access, engagement, outreach, harm reduction, criminal justice focused, structured treatment which includes pharmacological, community detoxification and recovery programme interventions, in patient detoxification and rehabilitation provision, recovery oriented aftercare services and access to mutual aid/peer support services. The location of different types of drug services across Cheshire is shown below. Figure 1 Drug Services in Cheshire 17

18 Tier 1 - Universal services These services provide brief advice, information, and signposting to substance misuse specific services. Universal services include GP s and other health professionals. Tier 2 These services include open access services and the delivery of harm reduction, and reintegration. These services are the front of the treatment system and are to provide brief interventions, access to structured treatment, harm reduction initiatives and services to reintegrate service users back to the community following structured drug treatment, detox, and/or residential rehabilitation. Harm reduction interventions are to improve health and reduce communicable disease (including overdose prevention, needle exchange, blood borne virus testing and vaccination and harm reduction and advice). Harm reduction interventions are also available throughout the rest of the treatment system There are 43 pharmacies in Cheshire West and Chester engaged in the provision of shared care schemes, 21 provide needle exchange services and all 43 provide supervised consumption. Table 13 West Cheshire pharmacy provision July 2012 Pharmacies providing needle exchange Pharmacies providing supervised consumption Chester 8 14 Ellesmere Port 5 14 Northwich and Winsford 8 15 Cheshire West Structured Drug treatment (Tier 3) During the past year 498 individuals from Cheshire started a new treatment journey. A total of 2,375 individuals from Cheshire were in contact with structured treatment services in the past year. Overall demand appears to be declining as the total number of individuals starting a new treatment journey in Cheshire has declined in 2010/11 compared to the previous year (2009/10). Eighty three fewer clients were referred in to treatment which equates to a 14% decline. This could indicate there are fewer clients in the community that either have a need for drug treatment or that are not currently engaged with drug treatment. Within West Cheshire (Chester & Ellesmere Port), 177 clients started a new treatment journey, with a total of 852 clients engaged in structured drug treatment. 18

19 A Tier 3 treatment map is included in appendix. Just over a third (35%) of new treatment journeys and total in-treatment population in Cheshire were in West Cheshire (35%). The table below gives the number of Cheshire residents engaged in services by service and location. Table 14 Cheshire residents engaged in treatment 2010/11 New treatment journeys Total in treatment Addaction Central CDT Chester CDT East CDT Ellesmere Port CDT Turning Point Chester 0 1 Central YP CDAS 4 9 Chester YP CDAS 2 2 East YP CDAS 1 4 Ellesmere Port YP CDAS 1 3 Cheshire YOS 9 15 Chester alcohol service 0 2 Out of are CDT 3 30 Out of area detox 8 50 Out of area rehab 8 28 Out of area YP 1 1 Total 498 2,375 Source: National Drug Treatment Monitoring System Demographic profile of clients Most clients of specialist substance misuse drug treatment in Cheshire are white (97%, 2,304) with 3% from an ethnic minority (71). This is in line with Cheshire population figures. Clients are predominately male (78%), with women comprising 22% of the drug treatment population. Within West Cheshire 76% of the treatment population are male, 24% female. The proportion of women is low compared regionally and nationally (28% and 27% respectively). In West Cheshire almost half of the clients (49%) engaged in structured drug treatment are aged between 35 and 44. Older clients are likely to have been in treatment a long time. 19

20 Table 15 Length of time in treatment by age group in West Cheshire 2010/11 100% 80% 20% 4% 17% 1% 28% 60% 40% 49% 52% 54% 20% 0% 25% 29% 17% 6% 3% 1% All in treatment In treatment 2-4 yrs In treatment 4+ yrs Source: National Treatment Agency Referral routes years years years years 65+ The demand for treatment is clearly driven by clients rather than by any particular referring agency. Just over half of clients are self-referrers (56%). More clients entering new treatment journeys are self-referrers in Cheshire and particularly West Cheshire (66%) compared to regionally and nationally (38%) Far fewer clients (6% West Cheshire, 8% Cheshire) are referred via the criminal justice system compared regionally and nationally (34% and 30% respectively). The referrals from Arrest Referral Service/DIP are particularly low. Following a local tender exercise it is anticipated referrals from the Drug Intervention Programme (DIP) will increase in 2011/12. A new national service provider (ADS) commenced delivery in April Table 16 Referral source for new drug treatment journeys 2010/11 Referral source Cheshire West North Cheshire West England Self 56% 66% 38% 38% Other 12% 9% 10% 10% Drug services 10% 5% 13% 15% CARAT 8% 6% 10% 9% GP 5% 7% 5% 7% Arrest Referral / DIP 4% 3% 11% 10% Criminal Justice System other 4% 3% 7% 6% Probation 1% 1% 6% 5% Total 100% 100% 100% 100% Source: National Treatment Agency 20

21 Treatment naïve cohort New treatment demand is made up of treatment naïve clients, i.e. those that have not had any previous contact with the treatment system, and non-naïve clients. Within Cheshire 41% of the demand for new treatment journeys comprised treatment naïve clients. Forty two percent of the new treatment journeys in West Cheshire were treatment naïve clients. In West Cheshire over a third of new treatment journeys for the treatment naïve cohort highlighted cannabis, cocaine, or amphetamines as their primary substance (38%), compared to just 8% of the non-naïve cohort. Treatment interventions The vast majority of individuals received prescribing interventions (86%), while the level of psychosocial intervention provision is exceptionally low with just 0.3% of all clients in treatment were reported to receive psychosocial interventions. It is known that the Cheshire & Wirral Partnership Trust community drug teams do not accurately report their activity in terms of interventions provided. Specialist prescribing and GP prescribing are accurately reported, however the supplementary interventions that are provided along with prescribing interventions have not been recorded/reported as robustly as they should. This is particularly true for psychosocial interventions. The Trust has been tasked with improving recording and reporting practices immediately, future data will reflect this. Table 17 Interventions individuals received in drug treatment (for 2+ years cohort) 2010/11 Intervention % of total treatment population Specialist prescribing 70% GP prescribing 16% Structured day programme 8% Inpatients 2% Other structured modality 2% Residential rehab 1% Psychosocial 0.3% Missing 1% Source: National Treatment Agency Drug use The Cheshire drug treatment system is very efficient in attracting clients that are Opiate and Crack Users, 92% of all clients engaged in treatment identify 21

22 either opiates and/or crack cocaine as their primary substance, 93% in West Cheshire. As highlighted earlier although a significant proportion of the in treatment population are opiate and crack users, it should be noted that primary crack users engaged in treatment only represent a small proportion of the total estimated crack-only prevalence rate. Table 18 Presenting substance for those in treatment 2010/11 All in treatment In treatment 2-4 In treatment 4+ years years Opiates only Opiates and crack Crack only Cocaine Amphetamines Cannabis Benzodiazepines Other Missing Total 2, Source: National Treatment Agency This trend is even more significant for clients that have been in treatment for two years or more. In West Cheshire, 97% and 99% of the 2-4 year cohort and the four year plus cohort presented as opiate and/or crack users respectively. Table 19 Opiate and/or crack users as % of the in-treatment cohort 2010/11 West Cheshire All in treatment In treatment 2-4 In treatment 4+ years years Opiate and/or crack % of treatment cohort 93% 97% 99% Cheshire All in treatment In treatment 2-4 In treatment 4+ years years Opiate and/or crack % of treatment cohort 92% 97% 98% Source: National Treatment Agency 22

23 In West Cheshire just 5% of the treatment population fit the ACCE profile (amphetamines, cannabis, cocaine, ecstasy). A total of 45 clients (5%) highlight their primary problematic substance as amphetamines, cannabis, or cocaine use, no clients highlighted ecstasy as their primary problematic substance. Across Cheshire 8% of the total treatment population fit the AACCE profile. An additional 2% of clients in West Cheshire highlight adjunctive alcohol use in addition to their primary drug use, whereas 22% of all new presentations to drug treatment in the North West and 17% nationally report adjunctive alcohol use. The low proportion of adjunctive alcohol use in West Cheshire, and Cheshire, could be a reporting issue. Cheshire and Wirral partnership Trust are known to be under reporting on second and third drug of use for clients engaged in the community drug teams across Cheshire. Table 20 AACCE clients as a % of in-treatment cohort West Cheshire 2010/11 All in treatment In treatment 2-4 In treatment 4+ years years Total AACCE clients % of treatment cohort 5% 1% 1% Alcohol (adjunctive) 2% 2% 1% Source: National Treatment Agency Service performance Key national indicators require no waits longer than three weeks for an individual to enter specialist drug treatment. The waiting times target has been achieved in all services across Cheshire. Almost half of the clients leaving drug treatment in Cheshire had a planned exit (49%), within West Cheshire 48% of clients that left treatment did so in a planned way; national target 45%. Around a quarter of treatment exits were referred on unsuccessfully and just over a quarter had an unplanned discharge. This is comparable to the regional and national picture. Table 21 Treatment exits 2010/11 Total exits Planned exits Planned exit rate Chester CDT % Ellesmere Port CDT % West Cheshire % Cheshire DAT % Source: National Treatment Agency 23

24 Gaps in Cheshire misuse treatment system data There are a number of gaps in the data used for the needs assessment which need to be addressed with providers to ensure complete and accurate data is submitted to the National Drug Treatment Monitoring System, as this information is used for commissioning decisions and future planning. In particular, there is a large number of missing data items in relation to the: Housing status of clients Parental status Injecting status Interventions provided, particularly psychosocial interventions Ethnicity Presenting substances Treatment Outcome Profile (TOP) Lack of second and third drug of use The partnership was not eligible to receive annual treatment outcome information due to poor compliance against the TOP completeness targets. This information would be invaluable to the partnership in determining outcomes of treatment. The issue of poor reporting is currently addressed on a monthly basis with providers in performance meetings, and although there has been an improvement, this has not been in time for the needs assessment. It is anticipated this information will be complete to be included in the needs assessment next year. Shared care Fifty five percent of GP practices in West Cheshire are involved in the provision of shared care, with 77% of GP s in Chester involved, 54% of GP s in the Northwich area and just 14% in Ellesmere Port. There are no waiting times for shared care in Cheshire, as clients are transferred into shared care from the Community Drug Teams when they are sufficiently stable. Thirty percent of the West Cheshire drug treatment population are engaged in shared care. 24

25 Table 22 Shared Care provision in West Cheshire Ellesmere Port Chester Vale Royal Number of clients in shared care Number of GP practices providing shared care Total number of GP practices % GP practices providing shared care 14% 77% 54% Source: Cheshire and Wirral Partnership Trust Drug Rehabilitation Requirements (DRR) DRR s are part of a community sentence for offenders. They are a way to address problem drug use and how it affects offenders and others. DRR s last between six months and three years, and get the offenders to: Identify what they must do to stop offending and using drugs Understand the link between drug use and offending, and how drugs affect health Identify realistic ways of changing their lives for the better Develop their awareness of the victims of crime Between April 2011 and March DRR s were completed in West Cheshire. Tier 4 Residential rehabilitation The table below outlines the number of clients that have received residential rehabilitation as part of their latest treatment episode, in each year from 2005/06 to 2010/11. This information is only available at a pan Cheshire level. Each client is counted only once in the year, based on their latest treatment episode. Across Cheshire, 2% of clients in treatment during 2010/11 accessed residential rehab during the reporting period. This is on par with the North West and England where 2% of clients in treatment accessed residential rehab in the year. 25

26 Table 23 Residential rehabilitation access in Cheshire 2005/06 to 2010/11 Period Clients with All clients in % of clients with residential rehab treatment residential rehab 2005/ ,093 1% 2006/ ,171 1% 2007/ ,145 2% 2008/ ,210 3% 2009/ ,202 2% 2010/ ,152 2% Source: National Drug Treatment Monitoring System (NDTMS) Inpatient detox The data reported here is provided to the DAT on a monthly basis by the Community Drug Teams as part of local monitoring procedures, it therefore may differ to information reported by NDTMS. During 2010/11, 53 clients started a detox, 45% successfully completed their detox (24 clients). Unfortunately just over quarter did not complete (28%, 15) and no outcome data was reported for the remaining quarter (26%, 14). The number of clients accessing inpatient detox has increased over the past three years, and continues to do so into 2011/12. Table 24 Inpatient detox activity in Cheshire April 2008 to November / / / Total successfully completing (14%) (53%) (45%) Total unsuccessful completions (15%) (28%) 4 Total on-going 0 0 (8%) Total no outcome reported (86%) (33%) (19%) Total Detoxes Actually Started Source: Cheshire Drug Action Team As at 30 November (41%) 9 (20%) 2 (5%) 15 (34%) Within West Cheshire, 50% of inpatient detoxes were successful (7) one was unsuccessful (7%), and no outcome data was reported for 6 (43%). 26

27 Table 25 Inpatient detox activity in Cheshire West and Chester 1 April to 30 November 2011 Chester Ellesmere Port Vale Royal Cheshire West & Chester Total successfully completing Total unsuccessful completions Total on-going Total no outcome reported Total Detoxes Actually Started Source: Cheshire Drug Action Team Community detox The data reported here is provided to the DAT on a monthly basis by the Community Drug Teams as part of local monitoring procedures, it therefore may differ to information reported by NDTMS. Provision of community detox across West Cheshire is historically low. Community detox is expected to increase in the next year in line with the recovery pathway and increased focus on the recovery agenda. The number of community detoxes completed in West Cheshire increased last year to 13, up from four in the previous year. Table 26 Community detox completions in West Cheshire 2008/09 to 2011/ / / / /12 Chester CDT Ellesmere Port CDT Total Source: Cheshire and Wirral Partnership Trust Recovery interventions The DAT is working closely with Cheshire West and Chester (CWAC) Council and Supporting People to get a four bedroom property ready for clients to access upon completion of detox and rehab. Acorn Treatment and Housing were successful in securing this contract and have a recovery house in Ellesmere Port. Acorn is now looking to secure additional housing in the Vale Royal and Chester areas. 27

28 Reducing Crime & Re-offending Reducing Re-offending Using Ministry of Justice data there was a marginal increase in 2010/11 in the overall re-offending rate against their prediction in Cheshire West and Chester although this is not considered statistically significant. The Ministry of Justice report that analysis of the cohort s demographics, re-offending crime categories and related factors yields no data of statistical significance when comparing the current data set with the previous report. However local and more detailed analysis by Cheshire Probation Trust notes that over the past year the move to delivering Probation Trusts via the Local Delivery Units has been a success. This has enabled Probation managers and staff to develop better quality links with key partners including the local authority and police. The Cheshire Probation Trust further comment that although the % reoffending difference from the predicted baseline was a 10.7% increase at Q4 10/11, the latest % difference at Q1 11/12 is a lower 5.2% increase. This equates to 18 more re-offenders than predicted as against 38 more at Q4 10/11. The direction therefore is now one headed nearer to the predicted reoffending baseline. Re-offending Drivers The Cheshire Probation Trust observes the following changes in their cohort OAYSIS scores: Item 2009/10 Refresh 2010/11 Refresh % variance Alcohol related issues / 61% 50.4% -10.6% dependencies Psychiatric issues 16% 15.7% -0.3% Using psychiatric medication 15.5% 15% -0.5% Drug related issues 30% 33% +3% Self harming (female) 42% 44.7% +2.7% Self harming (male) 26% 28.7% +2.7% Lifestyle 46% 66% +20% Relationships 48% 49.8% +1.8% Attitude Not 53% - measured Behaviour & thinking 68% 80.5% +12.5% Source: Cheshire Probation Trust Reducing supply and demand Within Cheshire, Warrington and Halton, 27 Organised Crime Groups (OCG s) involved in the supply of Class A and B controlled drugs have been identified; most OCG s supply cross commodity drugs. The majority are 28

29 involved in the supply of Heroin, Cocaine, and Cannabis. Although intelligence links supply networks to many surrounding force areas by far the strongest link is via Merseyside supply networks. Cannabis production: (and associated risks/threats) is clearly identified as the emerging risk area for Cheshire. This problem is consistent with the national picture as this area of criminality is regarded as low risk and high gain. Consequently the cannabis supply market is thriving. It has been identified that many OCG s that have historically focussed on the supply of Class A drugs are now also involved in Cannabis production; this phenomenon has also led to an increase regionally in violence associated with that criminality. A key factor in the violence centres on drug debts involving users and dealers; clearly linked to the increase in availability of the commodity. Frequently users are forced into further criminality (production) as a means of addressing their debts. Intelligence exists that supports the potential for addiction to certain forms of cannabis: Some users are believed to be committing acquisitive crime to fund use. Increased availability of skunk with a higher Tetrahydrocannibinol (THC) content which has higher psychoactive ingredients has the potential for addiction and links to mental health issues. Class A: seizures of heroin, cocaine, crack cocaine, and MDMA continue within Cheshire. The average purity of seizures is quite high which is suggestive of a reasonable success rate around the interception of drugs at a high level within the network. It also suggests that application of cutting agents may occur locally. Class B: supply networks centre on Cannabis, Amphetamine, and MCAT. Class C: seizures include: Piperazine (legal high alternative to Ecstasy) - Tranquillisers (Diazepam, Temazepam, and Phenazepam) and Steroids Others include: Sildeafil (similar to Viagra); Buprenorphine (heroin substitute); Ephedrine (often mixed with Ketamine); Ketamine (powerful anaesthetic); Gabapentic (treatment for epilepsy) and Mirtazapine (Anti depressant). Common cutting agents: Recent seizures of cutting agents in Cheshire include Benzocaine, Caffeine and Paracetamol. 29