How long have we needed to hear that drug and alcohol problems are not the ‘add-on’?
Problematic substance use rarely travels alone. The body of evidence keeps growing on the many strands that converge to make us lose direction, and we’re familiar with how drug and alcohol use can crash through Maslow’s hierarchy of needs.
We also talk a lot about revolving doors – to prison, debt, homelessness and a state of disconnection. So it’s heartening to hear that senior representatives from many health and social care sectors will be coming together to discuss joint action on complex needs (page 8). This follows a call for evidence from the Office for Civil Society – and a detailed questionnaire that keeps substance misuse problems at the heart of a shared agenda. How long have we needed to hear that drug and alcohol problems are not the ‘add-on’ but symbiotic with mental health problems and all number of signs of personal breakdown?
As a clear case study we focus on veterans this month, through talking to the charity Combat Stress (page 6). It’s hard to imagine the level of PTSD that drives many of those leaving the armed forces to self-medicate, but encouraging to hear that with the right dedicated support they can do ‘very, very well’.
And as the summer rolls on, so does the schedule of festivals that bring many young people face to face with the irresistible opportunity to experiment. Kevin Flemen’s article (page 14) should help to provide accurate advice, grounded in harm reduction.
We’re doing a combined July/August issue for the holiday period, but will be online, on Facebook and tweeting through the summer – and please keep emailing your letters to firstname.lastname@example.org. We’re looking forward to hearing from you!
Alcohol harm will cost the NHS £17bn over the next five years unless current trends are reversed, according to a report from the Foundation for Liver Research. The figure includes 63,000 deaths and 4.2m hospital admissions, as well as £638m for cancer treatment, the document says. Admissions have increased by around 17 per cent since 2010-11, while alcohol-related liver disease accounts for 60 per cent of all liver disease and 84 per cent of liver-related deaths.
There were also just under 58,000 claimants for employment support allowance and incapacity benefit/severe disablement allowance citing alcohol misuse as their primary medical condition in 2015, it says, up from less than 39,000 in 2011. Liver disease ‘has grown to become one of the most common causes of premature death in the UK and its burden continues to escalate’, says the report, which also looks at the impact of viral hepatitis and obesity alongside alcohol misuse.
With the latest appeal by the Scotch Whisky Association and others against the Scottish Government’s plans to introduce minimum pricing being heard by the Supreme Court this week, the document renews the call for a minimum unit price of 50p and argues that it would save more than £1bn in total direct costs and £3bn in ‘total societal value’ in the first five years. It also wants to see off-licence trading hours restricted to 10am-10pm, and alcohol availability for licensed premises limited after midnight, as well as tougher regulation of marketing and advertising and a higher duty band for cider with an alcohol content of between 5.5 and 7.5 per cent.
The report also calls for protection of public health budgets to ensure effective hepatitis testing and diagnosis in the community with a focus on ‘groups at greatest risk and/or not in regular contact with health services’, as well as protection for harm reduction services. The impact of liver disease on the poorest in society is ‘disproportionally severe’, the document states, and contributes to the ‘widening of socioeconomic health inequalities in the UK’.
The Alcohol Health Alliance welcomed the report’s ‘compelling new evidence’ on the effectiveness of minimum unit pricing (MUP). ‘This latest research suggests that after five years of MUP in England over 1,000 lives would be saved,’ said its chair, Professor Sir Ian Gilmore. ‘In addition, £700m is estimated to be saved in crime costs over five years, and with over £300m predicted to be saved in health costs over five years we would see the pressure taken off our hard pressed NHS and emergency services.’
The government has published its new tobacco control plan, outlining that its vision is ‘nothing less than to create a smoke-free generation’. Earlier this year more than 1,000 doctors and other health professionals wrote an open letter to Theresa May and Jeremy Hunt calling for a new control plan to be published ‘without delay’ as the previous one had expired at the end of 2015 (DDN, February, page 5).
While smoking rates have fallen from just under 20 per cent at the start of the decade to their lowest ever level (DDN, July/August, page 4) the plan’s objective is to reduce the ‘inequality gap’ in smoking prevalence, as smoking accounts for approximately half the difference in life expectancy between society’s richest and poorest. There are still 7.3m adult smokers in England and ‘smoking and its associated harms continue to fall hardest on some of the poorest and most vulnerable’, the document states. Among the plan’s other commitments are to improve data collection on smoking and mental health and provide access to training for all health professionals on how to help patients – especially those in mental health services – to quit.
Anti-smoking charity ASH welcomed the ‘step change in ambition’ represented by the vision of a smoke-free generation, but stressed that it was vital that the correct funding was in place to achieve it. Recent analysis by the King’s Fund found that reductions in local authority public health spending as a result of government cuts threatened smoking cessation alongside drug and alcohol services.
‘Funding must be found if the government is to achieve its vision of a “smoke-free generation”,’ said ASH chief executive Deborah Arnott. ‘The tobacco industry should be made to pay a through a licence fee on the “polluter pays” principle. Tobacco manufacturers are some of the most profitable companies on earth; they can easily afford the costs of radical action to drive down smoking rates.’
The government has published the updated version of its Drug misuse and dependence: UK guidelines on clinical management, usually referred to as the Orange Book. While endorsing much of the 2007 guidelines, the 2017 version has a ‘stronger emphasis on recovery and a holistic approach to the interventions that can support recovery’, it states.
The updated version also includes new guidelines on NPS and club drugs, mental health, prison-based treatment and naloxone provision, as well as misuse of prescription and over-the-counter drugs and smoking cessation.
‘Guidelines guide – they are not intended to dictate the precise treatment for each patient,’ says Professor Sir John Strang – who chaired the working group that updated the 2007 version – in his introduction. While there had been positive developments in areas including peer support, mutual aid and hepatitis C treatment, there remained ‘marked weakness’ in support for social integration, such as housing and employment. The treatment landscape had also changed dramatically since the last version, he points out, with ‘NHS specialist providers much diminished’ and major independent or third-sector agencies now the main providers of treatment ‘in a variety of collaborative arrangements’.
The huge number of NPS and an aging cohort of people with long-term heroin dependence problems meant that treatment was ‘increasingly complex’, he states, making effective coordination between services vital. ‘This includes ever greater integration with mainstream physical and mental healthcare.’
Meanwhile, Ireland has launched its ‘health-led’ response to the country’s drug and alcohol use, Reducing harm, supporting recovery, which includes both the introduction of a pilot supervised injection facility in Dublin city centre (DDN, December 2015, page 4) and the establishment of a working group to look at ‘alternative approaches to the possession for personal use of small quantities of illegal drugs’. It also includes a commitment to expand treatment services and a targeted youth services scheme for disadvantaged young people, as well as a 50-point action plan from 2017 to 2020 and ‘scope to develop further actions’ until 2025.
‘Treating substance abuse and drug addiction as a public health issue, rather than a criminal justice issue, helps individuals, helps families, and helps communities,’ said Ireland’s Taoiseach, Leo Varadkar. ‘Ireland has a problem with substance misuse. Rates of drug use in Ireland have risen significantly over the past decade, with the greatest increases among younger people. These issues highlight the need to intervene effectively to reduce the harms associated with substance misuse, and combat the underlying reasons for the demand for drugs.’
To mark World Hepatitis Day, the I’m Worth… campaign is launching a survey – and needs your views.
In England, around 160,000 people are infected with hepatitis C, the majority of whom are from marginalised and under-served groups in society, such as people who inject drugs (PWID). (1)
If left untreated, hepatitis C can cause serious or potentially life threatening complications like liver cancer. (2)
To mark this year’s World Hepatitis Day on 28 July, DDN is partnering with the I’m Worth… campaign to conduct a survey of DDN readers. I’m Worth… aims to address the stigma that many people with hepatitis C face, encouraging and empowering people living with hepatitis C to access diagnosis, care and services no matter how or when they were infected.
The I’m Worth… survey aims to gain insight into the opportunities and challenges that you are faced with when working with those affected by hepatitis C. We are hoping to understand the barriers to patient engagement, the most effective channels of communication, the resources available and any unmet needs.
We want to hear from YOU, the people working day to day with PWIDs and other marginalised groups where there is a high prevalence of people with, or at risk of, hepatitis C.
2, Public Health England. Hepatitis C in England: 2017 Report.
http://www.hcvaction.org.uk/sites/default/files/resources/hepatitis_c_in_england_2017_report.pdf [Accessed: July 2017]
2, NHS Choices: Hepatitis C. http://www.nhs.uk/conditions/hepatitis-c/pages/introduction.aspx [Accessed July 2017]
The I’m Worth… campaign has been developed and paid for by Gilead Sciences Ltd, a science-based pharmaceutical company. Content development has been supported by input from numerous patient groups with an interest in hepatitis C in the UK.
A new drug strategy was released by the Home Office on 14 July – here are some responses and we will add more as they come in. To add yours, please email the editor.
Aspirational… but leadership and detail are missing
It has been a week since the new drug strategy has been published. Rather than rush to respond we have taken the time to read, consult and agree our views before outlining our considered response to the strategy.
The emphasis placed on prevention is also to be welcomed. It is far better that we aim to prevent drug use rather than wait for it to develop and then attempt to tackle it. What is worrying is the lack of detail on how this will be achieved and what extra resources will be available to undertake this. The same could be said for the emphasis on dealing with young people, unfortunately as budgets are cut young people’s services are increasingly being commissioned as part of the wider adult services. A clear statement from the government that young people’s service should be separate and distinct and incorporate a high degree of prevention work would have been reassuring.
Where the strategy is strong is that it attempts to raise the profile of other drugs and also other marginalised groups affected by drug use. The sections on families, domestic abuse, sex workers, homeless, veterans, old users, the spread of NPS, chemsex, image and performance enhancing drugs and prescribed medication shows that the strategy is attempting to cover a wider remit and scope.
While the sections on dealing with drug users in the criminal justice system do outline a range of interventions from diversion through to sentence the greatest concern would be how much of this is achievable. Given the current state of the prison service and the problems with the CRCs is it realistic to expect any meaningful treatment to take place for those that involved in the criminal justice system and perhaps the ideas outlined are more aspirational than achievable.
It is good that the ring fence for funding for treatment services will remain till 2019 but disappointing that this isn’t for longer. It is good that the strategy highlights the risks associated with the tendering culture and reminds commissioners that there are other ways to enhance performance, quality and outcome that are more collaborative and do not require a re-tender.
I am pleased that the focus on recovery remains as I do believe that we should be encouraging, motivating, challenging and supporting people to change. A broader definition of recovery would have been useful so that stable clients on maintenance scripts aren’t excluded and measures to show reductions in medication were included. Both would have given a more nuanced overview of how treatment is working.
However the rise in drug related deaths is a major problem and the lack of detail or focus on harm reduction measures within the strategy is a worry. Harm reduction is the core of a quality drug treatment system and I would have welcomed a dedicated section outlining clear expectations on what harm reduction measures should be in place, rather than these being lost in other sections within the document.
I welcome the use of outcome data to show success and I welcome the focus on ensuring quality, it is good that the importance of high quality staff is recognised and that concerns about the residential sector have been highlighted. More detail in all these areas would have been good but it is helpful they form part of the strategy.
Overall the strategy attempts to cover a lot of ground. In doing so it doesn’t provide detail and some of the aims can be seen as unrealistic in a time of shrinking budgets and wider issues within the criminal justice system. However the establishment of a new Drug Strategy Board is welcomed in that we hope this brings a positive influence to bear on local government in protecting drug and alcohol budgets. Providers need to play a significant role on this with service users to ensure that the reality of the pressures on local authorities and providers in not diluted. Hopefully the new recovery champion appointed to the Drug Strategy Board will help with this process.
As a provider I don’t think it comprehensively addresses the core challenges of increasing treatment outcomes and reducing drug related deaths. It attempts to widen the focus of the drug policy but fails to provide the detail and leadership on how this can be achieved and therefore feels like a good, well intentioned effort but slightly disappointing.
Where’s harm reduction?
While many of the drug strategy’s ambitions are good, it frustratingly does not provide a realistic direction for how they will be delivered.
SMMGP welcomes many of the strategy’s ambitions including:
The emphasis on the importance of an evidence-based approach
The recognition of the importance of providing holistic services for those with complex needs
The importance of partnership working across a range of services, including housing, employment and mental health
Support for work with families
The importance of strong commissioning
However, it is difficult to remain positive about achieving many of the strategy’s good intentions working within the reality of the sustained and ongoing cuts to the drug and alcohol sector and the public and voluntary services in general.
One of the most concerning issues for those who work in the field in recent years is the rise in drug-related deaths in the UK. While this matter is raised in the new drug strategy, there appears to be an absence of support for evidence-based approaches to address this (for example drug consumption rooms, or consideration of decriminalisation of possession or use of drugs, or how to reach people who are not in treatment through for example harm reduction initiatives).
There is also an ongoing focus on the pursuit of abstinence without mention of the essential role that harm reduction fulfils in reducing drug-related deaths. So SMMGP believes that while the Drug Strategy’s ambitions are good, it frustratingly does not provide a realistic direction for how they will be delivered.
Resources are a must
We welcome the long-awaited drug strategy, for which we have been pressing this last year. We trust that the required resources will also be forthcoming, to make the objectives outlined in the strategy a reality.
A welcome emphasis on complex needs
Turning Point welcomes the release of the new drug strategy, especially as we face changing trends in people’s drug and alcohol use. People continue to use new psychoactive substances despite criminalisation last year; there is an increasing number of people using image- and performance-enhancing drugs; and an ageing population of heroin and crack users has resulted in a dramatic increase in the number of deaths as a result of drug misuse since 2012.
We welcome the emphasis on equity of access for a range of people with differing needs and recognition of those with the most complex needs, people with a dual diagnosis – defined as someone with two or more co-existing needs – as well as wider population based interventions. We also welcome the emphasis on supporting people through peer support or recognising the centrality of housing and employment to a sustained recovery.
Mental health is a key theme throughout the strategy, recognising that mental health and substance misuse are strongly interlinked. Partnership working with other agencies is important in order to develop resilience among young people, families, homeless people, serving military personnel and veterans.
The establishment of a drug strategy board overseen by the home secretary should bring a much needed focus on drug treatment and help support local areas to ensure they are delivering safe and effective services. The focus on transparency of commissioning is also welcome and recognises the vulnerability of drugs treatment to local funding arrangements. It is essential that if basic standards of good treatment are to be maintained that there is monitoring of local spending on drug treatment.
We hope the emphasis on data collection and evidence-based support will highlight that investment in drugs services helps not only to save lives, but also to reduce the financial impact on the NHS, local authorities and the criminal justice system.
Clear call for decent housing
In the new drug strategy the government have announced their intention to appoint a national recovery champion who will report into a new drug strategy board, chaired by the home secretary and including representatives from the wider government departments. One of the important roles of the recovery champion will be to ‘seek to address stigma faced by people with drug or alcohol dependency issues’.
At Phoenix we are committed to giving people in treatment and recovery a voice. One area where people face significant stigma is in accessing decent appropriate housing that will support their recovery process. At Phoenix we know the difference housing can make to helping people keep well during and after treatment.
We are very pleased to see a clear recognition from the government in this strategy of the need for decent housing for people in recovery. The strategy says: ‘We will work with treatment providers, the homelessness sector and housing support services to identify and share best practice to support local authorities in identifying routes into appropriate accommodation for those recovering from a drug dependency.’
The new strategy sets out some important priorities for all concerned with the impact of drugs on our society. The government has made it clear that the ambitions of the strategy can only be achieved through effective partnership working. At Phoenix we are in no doubt our work helps people and their families recover from the devastating impact of substance misuse. We are glad to see the government committing to a number of critical measures that we hope will ensure everyone can get the vital help they need, when they need it, wherever they are in the country.
No mention of LGBT people
LGBT Foundation are glad to see chemsex recognised within the strategy.
For several years, we have been providing advice and support for people involved in chemsex and we have seen the importance of targeted harm reduction advice and a holistic approach to addressing drug use, sexual health and other underlying issues, such as mental ill health and internalised homophobia.
We welcome PHE taking a lead in building consensus and awareness of good practice and ensuring needs are met in all areas.
Even within MSM in Greater Manchester, we have found there to be huge diversity in drug use, including higher rates of using opiates and crack (www.lgbt.foundation/news).
Therefore, it is disappointing for there to be no mentions of LGBT people in the strategy as it is vital drugs and alcohol services are proactively engaging LGBT people, and staff are equipped to provide effective and appropriate support for LGBT people.
Continued investment is vital
We welcome the new drug strategy. Since the 1990s the investment into, and delivery of treatment has increased significantly and we hope this will continue. This investment has contributed to many thousands of people receiving high quality treatment and recovering from their addictions. We have also seen huge reductions in drug related crimes and other harms.
We welcome the fact that the home secretary is to have direct involvement in overseeing the roll-out of the new strategy and will directly chair an inter-ministerial group ensuring that the aims and benefits of treatment are understood and owned across government.
We have a treatment system in the UK that is often considered to be world leading and we welcome the consistency in approach that the new strategy brings, its focus upon a system that balances the reduction in harm with long term abstinence, that focuses investment on those most at risk, that is rooted in clinical evidence of effectiveness and which also promotes those measures that we know have transformative impacts upon our service users: employment, skills and housing.
If substance misuse is going to be tackled, there needs to be cooperation between a number of government ministries and local government departments including health, justice, employment and children’s services. Drug treatment is a complex issue that requires the correct level of attention and emphasis on both recovery and harm reduction.
The renewed focus on drug-related deaths is encouraging. We have been working on a number of prevention techniques to reduce the number of drug related deaths, including identifying and predicting those people who are most at risk of overdose, and it is vital this continues.
A renewed focus upon tackling the specific problems facing our prison system and the prisoner population as a result of new patterns of drug use and supply is also to be welcomed.
Drug use affects families and communities across the country and we will be working tirelessly to promote the benefits of treatment, to reduce the unfair stigma often faced by our service users and are committed to ensuring that all agencies pool their resources and expertise to generate long term benefits.
Whilst we welcome the focus on alcohol abuse, it is disappointing to see it treated as a subset of this long-awaited drug strategy. There is a lack of concrete strategy on mental health, dual diagnosis or joining up systems to treat those who need it, as the responsibility instead falls to local authorities to agree this approach. These are all factors which can play a part in substance misuse, and how it is treated, and we would look for clear national direction to effectively tackle these issues as a whole.
Although this strategy is encouraging, it is essential that all of these proposals are supported with relevant funding and investment. Everyone should have the best chance in life, but we are only able to continue our work to support these people with adequate support and investment.
A welcome commitment to evidence
We commend the government’s commitment to evidence-based drug treatment, as well as the introduction of a national recovery champion to drive improvements in rates of recovery from drug and alcohol dependence. Our experience at the frontline of drug services in both prison and the community shows that for successful recovery to truly happen, we need more evidence-based drug treatment programmes – such as our accredited prison substance misuse programmes.
The Forward Trust (formerly RAPt) have been supporting people to build and maintain a life without drugs and alcohol for more than ten years through our Recovery Support Service. This continued care can help build the resilience and strength needed to maintain recovery from addiction and live a positive and productive life with a job, family and community. Our dedicated employment services help people to break the cycle of reoffending and addiction through training and employment activities that are grounded in the real world of work. We believe that anyone is capable of transformational change, no matter how entrenched their addiction or prolific their crimes, and we hope that this new strategy will give more people the support they need to move forward with their lives.
Focus on families
Adfam welcomes the strategy and draws attention to the following points.
Commitment to evidence: Adfam is driven by what works and therefore endorses the strategy’s commitment to evidence-based interventions, in terms of both treatment options and support for families.
Inter-relatedness of problems: For most of the families we work with the substance use of their loved one is not the only issue they face. The challenges of mental ill health, domestic abuse, offending and bereavement sadly often go hand-in-hand with problematic relationships with drugs or alcohol. We therefore welcome the strategy’s acknowledgement that ‘there are families where substance misuse is just one of a number of other complex problems’ and the driving force social inequalities play in the development of all these issues.
Support for and work with families: We welcome the strategy’s recognition of the key role families and parents can play in prevention, the inclusion of the need to support families in their own right, with the suggestion that ‘evidence-based psychological interventions which involve family members should be available locally and local areas should ensure that the support needs of families and carers affected by drug misuse are appropriately met’. The strategy’s highlighting of the efficacy of peer support in the recovery journey of both drug and alcohol users and their families resonates with the experiences of the families and practitioners we work with, and is therefore welcome.
From our experience, much of the support families value can include broader work encompassing one-to-one practitioner support based on listening, signposting and the provision of information – the structured therapeutic approaches mentioned can be expensive or impractical for voluntary and community groups to deliver.
Harms experienced by adult family members: The main focus of the strategy’s coverage of families is driven by the desire to protect the children of those parents who use drugs or alcohol problematically. This desire is laudable. However the realities of the harms experienced by the families of substance users are significantly wider: many of the people Adfam supports are adults profoundly harmed by the substance use of partners, friends and children, both under and over 18. The focus on children within policy discourse means that sometimes the needs of adult family members are overlooked; we would therefore have liked to see a wider focus in the strategy.
Resourcing: The acknowledgement in the strategy of the important role played by the voluntary sector is good to see, as are the commitments to supporting those with substance use issues and their families. Adfam joins others in the sector in noting that the long-term challenge will be ensuring there is sufficient resourcing and political will to meet those commitments.
The government’s long-awaited drug strategy has finally been published, and includes both a new ‘national recovery champion’ role and a cross-government drug strategy board to be chaired by the home secretary, Amber Rudd. The UK will ‘drive global action and enhance its leadership in the international response to drugs’, the government states.
Perhaps unsurprisingly, there is a focus on a ‘strong law enforcement approach’ to restrict supply and dismantle trafficking networks, as well as action to strengthen border controls and share intelligence internationally. The national recovery champion role, meanwhile – to be appointed by the Home Office and Department of Health – will ‘make sure adequate housing, employment and mental health services are available to help people turn their lives around’, while efforts to reduce demand include continued expansion of the Alcohol and Drugs Education and Prevention Information Service (ADEPIS).
The strategy also includes changes to the way the ‘long-term success of treatment’ is determined, with a requirement on services to ‘carry out additional checks to track the progress of those in recovery at 12 months, as well as after six, to ensure they remain drug-free’ as part of the National Drug Treatment Monitoring System (NDTMS).
While rates of drug use are falling, there are significant and growing problems around NPS, ‘chemsex’ drugs, performance and image enhancing drugs and misuse of prescription drugs, the document states. A new NPS intelligence system being developed by Public Health England (PHE) will help to reduce the length of time between NPS-related health harms emerging and effective treatment responses, while data from the Report Illicit Drug Reactions (RIDR) system will be analysed to identify patterns of harm and agree clinical responses.
The home secretary’s chairing of the new cross-government drug strategy board will help to ‘drive action and ensure the strategy is delivered by all partners’, says the Home Office, and police will be encouraged to refer drug-misusing offenders to ‘appropriate services to maximise the significant benefits that investment in treatment can have on reducing crime and anti-social behaviour’. The financial cost of the UK’s drug problem stands at almost £11bn a year, the strategy says, with drug-related theft alone accounting for £6bn.
The document also includes a commitment to ‘supporting prison officers to play a bigger role in the recovery process of drug offenders’ and ‘maintaining our world-leading drug and alcohol treatment system’, although analysis by The King’s Fund published earlier this week identified reductions to local authority public health spending of £85m compared to the previous financial year.
‘This government has driven a tough law enforcement response in the UK and at our borders, but this must go hand in hand with prevention and recovery,’ said Amber Rudd. ‘This new strategy brings together police, health, community and global partners to clamp down on the illicit drug trade, safeguard the most vulnerable, and help those affected to turn their lives around. We must follow through with our commitment to work together towards a common goal – a society free from the harms caused by drugs.’
‘The government’s recognition that evidence-based treatment, recovery, and harm reduction services need to be at the heart of our collective response to drug misuse is very welcome,’ said Collective Voice chief executive Paul Hayes. ‘Investment in treatment has reduced levels of drug use, cut drug-related crime, enabled tens of thousands of individuals to overcome dependence, and is crucial in combating the recent increase in drug-related deaths. The home secretary’s commitment to personally lead this cross-government effort, and the increased transparency of local performance provide the political energy and focus needed to turn the strategy’s aspirations into outcomes.’
The new drug strategy represents a ‘balanced approach’ to enforcement and support, says Sarah Newton, minister for crime, safeguarding and vulnerability.
The shocking pictures of people using ‘spice’ in Manchester earlier this year reminded us just how harmful and dangerous drugs can be. They can devastate whole families, and the communities around them – the same communities where we all live, work and bring up our children.
Tireless work goes on every day to provide treatment services to individuals suffering from substance misuse problems, but the challenges are constantly evolving. ‘Spice’, like all synthetic cannabinoids, is part of a changing picture that also includes the rapid emergence of other psychoactive substances, image and performance enhancing drugs, ‘chemsex’ drugs, and misuse of prescription medicines. The pressing needs of an ageing cohort of heroin and crack cocaine users add to the problem.
As minister for crime, safeguarding and vulnerability it is my responsibility to ensure that we do everything we can to tackle illegal drugs. This government’s new drug strategy, launched today by the home secretary, is testimony to our commitment to protecting the most vulnerable in society from the harms drugs cause.
In the strategy, we continue to stress the importance of a tough law enforcement response, across the UK and at our borders, where record seizures have recently taken place. This government has ensured police forces continue to have the resources they need to keep our communities safe.
I know the police already do a great deal to prevent drug crime on our streets. On patrol with officers I have seen first hand the good work to stamp out anti-social behaviour and enforce the law, by testing people for substance abuse and taking appropriate action. Drug testing on arrest is an indispensable tool for the police to monitor new patterns around drugs and crime and provides an early opportunity to refer offenders into treatment and help prevent further reoffending.
Enforcement is just one element of our response and we remain determined to pursue a balanced approach and to achieve a society free from the harms of drugs. Our efforts must continue to focus on recovery and prevention.
Our strategy seeks to prevent drug misuse in the first place by building confidence and resilience in our young people through targeted interventions for those who are most at risk. For this reason I am particularly pleased that we are continuing to fund the Alcohol and Drug Education and Prevention Information Service (ADEPIS) programme to raise awareness in schools.
The strategy identifies those most vulnerable to ensure they receive the specialist support they need. For example, specific measures will be taken to protect those in prison. It is essential that drugs do not destroy the rehabilitation role of our prisons. Governors will have more powers to extend searches to prevent smuggling. Longer term, we want to focus on continuity of drug treatment, putting offenders on a path to recovery so that they can integrate in society when they are released.
Drug misuse is also common among people with mental health problems: research indicates that up to 70 per cent of people in community substance misuse treatment also experience mental illness and there is a high prevalence of drug use among those with severe and enduring conditions such as schizophrenia and personality disorders. In the strategy we acknowledge this and I want all those vulnerable to mental illness and drug misuse to be able to access the care they need.
Since I became a Minister I have had the opportunity to visit several recovery centres where former drug users are helped to turn their lives around. It was truly inspiring to meet so many people, both staff and service users, who clearly feel passionate about what they do.
The stories I have heard are powerful. I have met people whose lives had been filled with hardship, sometimes with violent abuse, and who had been exposed to drugs for too long. Yet by accessing the right support tailored to their needs, they regained hope and a lasting sense of purpose.
When I visited a recovery centre in Durham, I was particularly impressed by the initiative in place for service users who wished to give something back by becoming apprentices and later ambassadors in a peer-led system. Peer-led support works and I am confident more and more partners will replicate similar community-based models to improve treatment outcomes and challenge stigmatising views of drug users.
Crucially, the new strategy also sets out how we can, by bringing the right partners together, work towards sustaining recovery for all. This requires that we support those in need in all aspects of their new life free from drugs. The National Recovery Champion, together with Public Health England, will lead our response, making sure all partners across the country work towards our overarching goals: to reduce drug use, and boost recovery.
To get tangible results, we have created a Drug Strategy Board, which the home secretary will chair and I will attend. The Board will oversee the development of innovative joint measures so that all partners play their part in ensuring those in recovery can access stable employment or meaningful activity, safe housing, and overcome the mental health issues they may face. Multi-layered support is what we intend to continue developing so that vulnerable people and those most at risk of relapsing stay on the path to recovery.
Building on the success of the Psychoactive Substances Act 2016, we have worked to design a comprehensive plan that addresses the complex and evolving problems that continue to emerge from changing drug use habits. We will ensure clinicians benefit from the latest intelligence gathered by frontline specialists. This collaborative system driven by Public Health England will play a decisive role to keep on top of worrying patterns in drug use, and provide appropriate treatment interventions.
I am well aware that achieving the aims of the strategy will require strong and effective partnership working, at local, national and international levels.
In the lead-up to today’s launch, we consulted extensively with key partners working in the drugs field, including health and justice practitioners, commissioners, academics and service users, as well as our independent experts, the Advisory Council on the Misuse of Drugs.
So I am confident that it will have the operational impact we want to see, because in a Britain that works for everyone, there is no place for drugs.
Local authorities have been forced to reduce planned public health spending on services including drug and alcohol treatment by £85m as a result of government cuts, says The King’s Fund.
Councils in England will spend £2.52bn on public health services in 2017-18 compared to £2.6bn the previous year, according to the think tank’s analysis of Department of Communities and Local Government data. ‘Once inflation is factored in, we estimate that, on a like-for-like basis, planned public health spending is more than 5 per cent less in 2017-18 than it was in 2013-14,’ says the organisation.
While some services, such as promoting exercise, will actually see increased funding, money for tackling drug misuse in adults will face a 5.5 per cent cut of £22m, with specialist drug and alcohol services for children and young people, sexual health and smoking cessation also facing substantial reductions. Services are already struggling with the impact of a £200m cut to the 2015-16 public health budget (DDN, September 2015, page 4), as well as planned ongoing reductions until the end of the decade. Although some local authorities have been ‘innovative in contracting and in seeking efficiencies’ in their public health budgets, there is ‘little doubt that we are now entering the realms of real reductions in public health services’ says The King’s Fund.
‘These planned cuts in services are the result of central government funding cuts that are increasingly forcing councils to make difficult choices about which services they fund,’ said senior fellow in public health and inequalities at The King’s Fund, David Buck. ‘Reducing spending on public health is short-sighted at the best of times. The government must reverse these cuts and ensure councils get adequate resources to fund vital public health services.’
Chair of the BMA’s public health committee, Dr Iain Kennedy, said the cuts signified ‘a huge step backwards for public health’ that would ‘inevitably’ cost the NHS far more in the long term, while RSPH chief executive Shirley Cramer said the scale of the reductions would be ‘devastating’ for the nation’s health. ‘Short-sighted cuts to sexual health, drug misuse and stop smoking services are a false economy – saving money in the short term but costing far more over coming decades, while jeopardising precious gains we have made to cut the number of smokers and efforts to tackle our growing crisis of drug-related deaths,’ she stated.
Summer brings the festivals – and a new young crowd experimenting with MDMA. Kevin Flemen gives the guide to staying safe
‘Who is Leah Betts?’ The question, from a recently qualified social worker on an NPS course, brought home to me some important issues. Leah died in 1995, aged 18, after using MDMA and drinking a large quantity of water. Campaigns by her family, the media and advertising agencies saw her posthumously become the ‘poster girl’ for the dangers of MDMA.
That was 1995, and my newly-qualified social worker was a baby when this happened. She and a whole cohort of children and young adults have not grown up in the shadow of Leah’s death. They didn’t read about it in the papers, see the video at school or learn about it from earnest drug educators.
This matters now more than ever. This MDMA-naïve generation are going out at a time when MDMA pills have never been as strong, cheap, or widely available. Alongside the pills containing dangerous adulterants, powder and crystal MDMA may also be adulterated or misidentified.
Alongside the Leah question, I hear another: ‘Frank – is that still going?’ The days when the drugs helpline enjoyed TV adverts and a budget allowing for innovative cross-platform promotion are long gone. It became a casualty of cuts along with the club outreach that helped reduce the risks to a generation of young people. So with exams coming to an end and the festival season underway, it is imperative that those MDMA harm reduction messages are dusted off, refreshed and communicated to the new generation of users.
As ever, drug terms and slang vary from place to place and over time. The drug MDMA is variously known as Mandy, Molly, ecstasy, E and XTC and some young people may not be aware of its ‘proper’ name. Terms may link to form (‘ecstasy’ had referred primarily to pills, MDMA to powder and crystals) but this isn’t always the case.
Pill strength has increased significantly over the past couple of years and has become a key concern. There is no routine, consistent monitoring of available pill strengths in the UK, so comparisons are partly estimates. Back in the late ’80s and early ’90s, MDMA pills contained around 80mg per pill and would retail for £5-10.
Looking at the range of pills currently available on dark web sites such as Dream Market, there are a few at the 160mg mark but most claim strength of between 220mg and 250mg, so average pill strength has probably trebled.
New production methods and the massive marketplace that is the dark web have seen manufacturers competing on strength and price, so low cost is no longer indicative of a low-dosed pill. For older users accustomed to swallowing two or three pills at a time, or for younger users with no tolerance, these high dose pills can cause fatal overdoses.
CRYSTAL CONTAMINATION Just as pills can vary significantly in terms of dose and composition, the same is true for products sold as powder or crystal MDMA. Alternative substances or adulterants may be present and whereas one can check online for pill warnings, powders and crystals are harder to identify visually.
Looking at submissions to the Welsh testing site WEDINOS, samples bought as powder or crystal MDMA contained a range of compounds including previously legal NPS such as methylone, mephedrone and a-PVP, alongside cocaine, caffeine, speed and a host of other compounds.
There is no easy way for end users to assess pill strength, or the content of powders and crystals. The claimed strength of dark web retailers cannot be relied on, and as fast as ‘genuine’ pills are sold online, fake ones are likely to appear on the streets.
Other options for information include Erowid’s Ecstasy Data (www.ecstasydata.org) the user-run Pill Report (pillreports.net) and WEDINOS, (www.wedinos.org) from Public Health Wales. Each carries useful information on components or user experience, but little on pill strengths.
Thanks to the efforts of The Loop (wearetheloop.org), club and festival pill testing has increased, and at a small but growing number of events it is now possible to have drugs tested and results passed back to users and health professionals in a short timeframe.
HOUSE PARTIES AND TEDDY BEARS The emergence of online and festival-based resources are welcomed. They are, however, most accessible to tech-savvy club and festival-goers who are interested in harm reduction and aware that they are taking MDMA.
Young people taking pills and attending house parties are at very high risk and fall outside these information channels. Pills are cheap, well-pressed, colourful and increasingly attractive with designs such as Instagram, Snapchat or teddy bears that inevitably resonate with younger people.
At £2-3 a pill (strong enough to share) it’s cheaper than cider or a bag of weed, and teenagers may not associate this Molly, Mandy, E – or whatever the pill is called – with MDMA and the risks that it entails.
Incidents of young teenagers taking MDMA pills in atypical settings demonstrate why websites and festival testing need to be backed up by high quality education and awareness-raising. Young people at house parties, with no access to the festival or club welfare services, need to be equipped with the knowledge and skills to respond to MDMA-related incidents for themselves.
For young people contemplating use, key messages include general risks around strong stimulants and hallucinogens, especially in unfamiliar settings, and should include information about potency, overdose prevention and managing emergencies.
Crush – dab – wait has become a key message about starting with low doses of MDMA. Developed by the Loop, it is a field-appropriate method of taking a smaller drug dose on a moistened finger and waiting for one to two hours before taking further doses. In practice it can be hard to crush dense tablets in festival settings and if the drug in question is highly potent (such as a SCRA or a fentanyl) even dabbing could be a risk.
Starting with low tablet doses – quarter to half a tablet – will reduce risk, although a quarter of a tablet for a young user is still a potentially dangerous dose when tablet strengths are possibly 220mg+. In groups, one person taking a very low ‘tester’ dose can help reduce risk to the rest of the group.
Anxiety and panic are common especially for new users, so it is helpful to have more experienced, sober friends who can reassure and calm the person. As ever, set and setting matter, so using when feeling well in a familiar, safe environment is protective.
Serotonin syndrome, caused by excessively high levels of serotonin, could be caused by high doses of MDMA. Risk increases where other serotonin-elevating drugs are used, including some antidepressants, tramadol, some antihistamines and many other compounds. Indicators of serotonin syndrome include agitation, delusions, fast heart rate, elevated body temperature, muscle twitching, seizures and convulsions, and it can be fatal. Where serotonin syndrome is suspected, an ambulance should always be called.
Convulsions: safe management of people convulsing means always calling an ambulance, allowing the person to convulse unrestrained, removing things in the vicinity that could cause injury where possible, and protecting but not restraining the head. Nothing should be placed in the mouth as it increases risk of choking.
Overheating caused by elevated serotonin levels is highly dangerous. Chilling out from dancing and staying hydrated can help reduce the risk. If a person feels excessively hot, complains of feeling too hot, is panicked, complains of headaches, has excessive sweating, or conversely stops sweating, these could be indicators of overheating. Reduce body temperature by spraying their unclothed torso with tepid water, under moving air, but always seek medical help as overheating can lead to blood clotting and organ failure. Don’t try to give the person cold drinks or immerse them in cold water.
Hydration and over-hydrating: Excess water consumption, combined with MDMA’s anti-diuretic properties, can cause water retention and in extreme cases can cause electrolyte imbalance and swelling of the brain. This can be life threatening. Advice remains to drink around a pint of water or an isotonic drink, sipped over the course of an hour, which helps maintain hydration but minimises risks of hyponatraemia.
Self-care: MDMA use can lead to significant depletion of serotonin after use and can cause quite serious low mood and depression. Stress the importance of taking long breaks after use, eating well and avoiding other substance use.
Kevin Flemen runs the drugs education and training initiative, KFx.
Visit www.kfx.org.uk for free-to-download leaflets on ecstasy – Fest-E (about the wisdom of doing ecstasy for the first time at a festival) and First-E (guidance for first-time users). Both were produced by KFx in 2014 and illustrated by a 17-year-old, in response to growing concern about ecstasy.