FALLING DRUG USE: THE IMPACT OF TREATMENT

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1 We have a policy which actually is working in Britain. Drugs use is coming down, the emphasis on treatment is absolutely right, and we need to continue with that to make sure we can really make a difference. Prime Minister David Cameron, December 2012 FALLING DRUG USE: THE IMPACT OF TREATMENT BUILDING RECOVERY IN COMMUNITIES

2 Falling drug use: the impact of treatment The problem of Illicit drug use has been one of the key concerns for society during the past 30 years. Many communities across England have experienced the debilitating effects of people using the most destructive substances, heroin and crack crime, drug litter, the spread of bloodborne viruses, drug-related deaths. These problems are still there, and may at times have felt intractable, but there is hope on the horizon, as the trend data, supported by the most recent figures, suggests that the situation is beginning to move in a more positive direction. Statistics show that illicit drug use is falling. For example, the Crime Survey for England and Wales (previously the British Crime Survey), has reported that the overall number of people who use drugs has fallen. While cannabis remains the most popular illicit substance by far, even its popularity has waned: whereas 11% of the population used it in 2001, this was down to just 7% in More importantly, the most recent prevalence figures estimate that heroin and crack use has fallen significantly in recent years: from a peak of 332,090 users in to 298,752 in These reductions in drug use are mirrored by a fall in the number of people entering treatment for drug dependency. The number of new treatment starts for heroin and/or crack addiction (i.e. people completely new to treatment or those returning) was 64,288 in, but 47,210 in The number of heroin addicts who start treatment for the very first time has declined even more sharply, from 47,709 in to 9,249 in Several factors are likely to have contributed to the decline in drug use in England, including criminal justice initiatives to prevent use and disrupt the supply chains. Changing demographics and fashions have also played their part. But while falling treatment numbers might at first glance appear to be a knock-on effect of reduced overall drug use, a closer look reveals they are also a cause for over the past 12 years England s drug treatment system has helped to shrink the pool of heroin and crack addicts. It has done this by getting increasing numbers of drug users into treatment and effectively taking them off the street and breaking the habits of entrenched drug use. At the same time the overall number of people who have successfully completed their treatment for any drug has gone up from around 11,000 in to just under 30,000 in To understand how drug treatment has achieved this and how far it has developed in recent years, we need to revisit how it worked in the past. England had a national drug treatment system of sorts in the 1990s, but it was uncoordinated and inconsistent, and the odds did not favour the dependent users who needed help these were the people who had been caught up in the drug epidemics of the 1980s and 1990s. To begin with, they had to take their place in a lengthy queue. This was routinely several months or even longer depending on where they lived. Once in, they were likely to find themselves on a reducing substitute prescription and would run the risk of being thrown out if caught using street drugs on top. Variable standards of treatment meant many dropped out before even coming close to completing their programme. Few actually made it to the end. Anybody who relapsed had to go to the back of the queue. And while they were outside the protection of the drug treatment system, they would be using drugs, committing crime to pay for them, spreading blood-borne viruses by sharing injecting equipment, and dying from drug-related causes. But if it wasn t working, how could it be put right? Drug treatment experts around the world agreed on what would work. And what would work for heroin dependency, said the evidence, was ready access to treatment that provided maintenance methadone alongside psychosocial interventions. The result of this should be that addicts would not need to use street drugs, they would stop committing 2

3 w NTA 2013 The most recent prevalence figures estimate that heroin and crack use has fallen significantly in recent years Estimated heroin and crack users in England 332, ,752 Estimated injecting drug users in England 129, ,401 Source: National and regional estimates of the prevalence of opiate and/or crack cocaine use , research from the Centre for Public Health, Liverpool John Moores University, Glasgow Prevalence Estimation Limited, and The National Drug Evidence Centre, University of Manchester, published by the NTA 3

4 Heroin and crack users in England starting or returning to treatment 64, ,210 Heroin users in England starting treatment for the very first time 47, ,249 4 Source: NDTMS annual treatment data and seven-year treatment population data

5 NTA 2013 These reductions in drug use are mirrored by a fall in the number of people entering treatment for drug dependency crime to pay for them, they would not have to inject or share equipment that might harbour and spread blood-borne viruses, and because they were safer in treatment they would be less likely to die from overdoses. In all, a drug treatment system based on the evidence promised a significant positive impact on a societal level. But up to that point the UK had not been willing to invest in a treatment system with a national scope. That changed in 2001 when the government decided to invest in a drug treatment system for England that was based on the best available evidence and to create the National Treatment Agency for Substance Misuse (NTA) to oversee the project. And so a drug treatment system began to develop that would offer better access to everyone who needed it, and would provide a more consistent and coordinated approach to treatment. Sure enough, the situation began to improve. The number of drug users in treatment shot up from around 100,000 in 2001 to 210,815 in Waiting times fell significantly: in 2001 the average wait for a first appointment was nine weeks, but by it was just five days. Today, the drug treatment system in England is among the best in the world in terms of reach and accessibility. Blood-borne viruses have also been kept in check. The estimated number of people who inject drugs has fallen from 129,977 in to 93,401 in , while the percentage of these who share equipment has gone from 33% in 2001 to 17% in As a result, and despite having one of the largest populations of injecting drug users in the western world, England has one of the lowest rates of HIV among injectors 1.3% in 2011 compared to 3% in Germany, 12% in Italy, 16% in the US and 37% in Russia. However, the biggest viral threat remains hepatitis C, which is much more prevalent in England than HIV. Around 45% of injecting drug users currently carry the virus, though this figure has been broadly stable since 2002 and is still lower than in many other European countries (for example, the Netherlands at 65% or Sweden at 84%). Drug-related deaths have also stabilised after rising for several years and are now beginning to fall. All this has been achieved because England s treatment system has managed to reach out to a large proportion of its heroin and crack users. Next to other countries, the proportion of heroin addicts in treatment was good at 49% in and even better at 63% in Few comparable national drug treatment programmes can get near these figures for example, Italy s rate is 45%, the Netherlands 37%. In all just under 165,000 people were in treatment for heroin and/or crack dependency in England during While being in treatment is clearly a protective factor for all these individuals, offering them a refuge from the chaos of addiction and providing a foundation for their recovery, their communities also feel the benefit. Drug-related acquisitive crime in particular (burglaries, robbery, shoplifting, etc) has fallen: drug treatment prevented an estimated 4.9 million offences in The public have seen the improvements for themselves: 80% believe drug treatment makes society better and safer, and 66% fear crime would increase if drug treatment was not readily available in their communities. So the evidence suggests that the drug treatment system can claim some credit for containing and then reducing the number of heroin and crack addicts in England a trend that has become increasingly tangible over the past few years (there are a few notable regional variations: the decline in use appears to be happening quicker in those areas where the heroin epidemics took hold first, such as London and the north west, and slower in areas where it happened later, such as the north east). But it is also telling that figures for heroin use are dropping all over western Europe. Its status and popularity are clearly waning. Part of this might be because young people have seen the long-term consequences the drug has wrought on older generations and have decided to steer clear. But again treatment may be a factor, because it takes heroin and crack addicts off the streets, making them less likely to become the wrong sort of role models for younger people. Whatever the explanation, the figures for young heroin and crack users are compelling. The latest estimates say that the number of heroin and crack users aged under 25 has 5

6 plummeted from 66,161 in to 41,508 in Those coming into treatment for heroin alone has also fallen sharply, from 11,309 in to 5,532 in This has had a shrinking effect on the pool of heroin and crack users in England fewer young people are being added to it and at the same time more of those users already in treatment are overcoming their dependence. But another effect is that the treatment population is getting older. These older users tend to be more entrenched in their drug problems, more vulnerable to all the associated health and social problems, and find it more difficult to recover from their dependency. The over 40s now make up almost a third of the entire drug treatment population in England, and 90% of those are in for heroin and/or crack. It will become increasingly challenging to help these people get better, which in turn will make it more difficult to maintain the trend we have seen in recent years of rising numbers of people successfully leaving the treatment system. Perhaps the biggest challenge will be to maintain a consistent and integrated system. Local authorities are now charged with delivering drug treatment, but many other groups are also involved, such as police and crime commissioners, clinical commissioning groups, health and wellbeing boards, and so on. Finding a way to ensure all these bodies and interests share the same goals and priorities, and actually move in the same direction at the same time, will be one of the key tasks ahead. Clear and committed leadership will of course be vital to this. Local authorities will need to be accountable for the reach and quality of treatment in their communities, and drug treatment as a whole must continue to demonstrate that it provides value for money and works to the benefit of individuals, local communities and wider society. Only If this remains the case will drug treatment attract the resources it needs to carry on addressing drug addiction. There will be other challenges. One of the main threats is complacency assuming that drug users will continue to have rapid access to evidence-based treatment, come what may. In this case, we need to remember the situation before 2001 and be determined that we don t allow it to slip backwards. This will be vital given the heavy competition for public health money from a range of other pressing issues and concerns. The risk of disinvestment is real and the stakes are high for society as a whole, so the treatment sector will need to continue to work hard to show it is efficient and effective in order to secure the investment that will help to maintain and build on the gains of recent years. It will also be a challenge to continue building the evidence base and to develop policy and practice on what it tells us. The government followed the evidence in 2001, and did so again with the 2010 Drug Strategy. Public Health England is about to become responsible for coordinating drug treatment and is well placed to keep its focus fixed on the evidence and what works. Its guiding principle will be to develop a system that addresses every aspect of an individual s health and social needs, and that offers them a clear and achievable path to recovery. 6

7 NTA 2013 Fewer young people are being added to the pool of heroin and crack users and more of those users already in treatment are overcoming their dependence Heroin users in England who have successfully completed their treatment and not since returned , , , , ,384 2, total 45, ,589 Source: NDTMS seven-year treatment population data 7

8 The National Treatment Agency for Substance Misuse 6th Floor Skipton House 80 London Road London SE1 6LH T F E [email protected] March 2013