‘Disinvestment in harm reduction is
As 2017 draws to a close we look back at a year of diminishing budgets and record drug-related deaths. While local authorities get to grips with cutting £85m from public health spending, the ACMD warned that slashing drug treatment budgets is a ‘catalyst for disaster’. Throughout the year we have heard many evidence-based arguments for harm reduction initiatives. The call for supervised injection facilities is gathering momentum again, and there is continued progress on naloxone roll-out. But what about those working in harm reduction who feel they are fighting a losing battle?
Disinvestment in harm reduction in the UK is deeply damaging. Not only are we dismissing the rights of people in desperate need of services – we are driving away those who work with passion in the most difficult environments. The result is a deskilling of this vital workforce, as we patch up services and miss out on a huge (and cost effective) opportunity to help clients engage with healthcare.
We opened a debate about commissioning in our last issue, following the ACMD’s call for longer retendering cycles. This month we look at the effect of this on shared care – a disturbing picture of GPs stretched to breaking point trying to make sure patients don’t drop out of treatment. So it’s not been an easy year, but there are clear goals to fight for. We have an amazing bank of evidence in this field – let’s make sure it reaches those who need to hear it.
Have a peaceful festive season and stay in touch with us as we gear up for a vigorous new year. We’ll be back in print on 5 February.
Almost 60 per cent of adults who drink are ‘doing so because it helps them to cope with the pressures of day-to-day life’, according to a YouGov survey commissioned by industry-funded charity Drinkaware. ‘Motivations for drinking are an important aspect of drinking behaviour and over half of all drinkers (58 per cent) report that they drink for at least one coping reason,’ says the report.
Almost 40 per cent of the 6,174 18-75 year-olds surveyed said they drank ‘to forget their problems at least some of the time’, while 47 per cent said they had done so to cheer themselves up. Of the 41 per cent who had drunk because they were ‘depressed or nervous’, meanwhile, 54 per cent were doing so ‘at increasing levels of risk’.
While 33 per cent of drinkers in social grades A and B drank to forget about their problems, among drinkers in social grades D and E this rose by 11 percentage points to 44 per cent. There was a similar 9 per cent difference among rates of drinking when feeling depressed or nervous.
‘What this thought-provoking survey shows is that a worrying number of people are drinking alcohol to help them cope with the pressures of day-to-day life,’ said Drinkaware chief executive Elaine Hindal. ‘Whilst people might think having a drink after a hard day can help them relax, in the long run it can contribute to feelings of depression and anxiety and make stress harder to deal with. This is because regular, heavy drinking interferes with the neurotransmitters in our brains that are needed for good mental health. The number of people who are drinking when they are already feeling depressed or nervous, and at levels which are harmful to both their physical and mental health, is also deeply concerning.’
Regular heavy drinking could also lower serotonin levels, she added, which could lead to depressive symptoms. ‘Alcohol and depression can feed off each other to create a vicious cycle,’ she stated.
Adults (18-75) in the UK who drink alcohol for coping reasons at www.drinkaware.co.uk
As you’ll know if you’ve been before… The DDN annual service user involvement conference is unmissable! You can book your place at the foot of this page.
This year’s theme is Get Connected.
This means you will experience…
A morning conference programme that looks at making the best relationship with the healthcare professionals and support services you need. Our presenters will speak from experience about taking your journey forward in a positive way. We will look at overcoming healthcare equalities and finding targeted support for your health, social welfare and personal development.
An afternoon session of ’roundtable’ discussions, where you will be able to experience three intimate 15-minute presenter-led sessions, with the experts of your choice. The perfect opportunity to connect with each partner in the treatment chain.
Our amazing exhibition, with information, expertise, peer-led support groups and healthcare advice. This year we are proud to present dedicated zones for health, training and employment, support and advice, and wellbeing. Within these zones, our experts will be able to give you specific advice, information and interventions, from health support to housing advice. (And you can work up to the delicious Balti lunch with a game of table tennis, or chill out with a massage!)
Naloxone training and kits from our expert, Philippe.
…plus the chance to influence the agenda on policy, commissioning and politics relating to service user involvement – we will be actively seeking your views.
So come along and experience the most useful and value-packed day ever – and our amazing annual networking opportunity. We’d love to meet you if you haven’t been before, and we’re looking forward to seeing familiar faces.
Welcome, setting the scene, making the most of your day. Introducing the ‘Get Connected’ theme and the DDN ‘Wider Health’ initiative.
Treating the whole person: Looking at linked conditions and better healthcare through a journey of hep C treatment.
Finding the right match: A look at screening, outreach and getting into treatment, whatever the health need.
It takes two – the unwritten contract of mutual respect: Communicating effectively with healthcare professionals to get the best from the therapeutic relationship.
What a team: A GP and patient explore the best kind of alliance.
11.15-11.45am – Refreshments
11.45-1.00pm – Session two
We’re listening to you: Time for thoughts from and questions to policy makers and The Faculty of Commissioners – important partners and enablers in the therapeutic alliance.
More than bricks and mortar: A personal journey showing how supported housing can open so many doors.
Mind, body and soul: Inspirational accounts of how our speakers brought the ‘oomph’ back into their lives.
1.00pm- 2.30pm – Lunch and networking. Enjoy the amazing DDN Exhibition, with information, expertise, and peer-led support groups. Special features include dedicated zones for health, training and employment, support and advice, and wellbeing; naloxone training and kits; and taster therapy sessions.
2.30-4.00pm – Roundtable Knowledge Exchange
An afternoon session of ’roundtable’ discussions, where you will be able to experience three 15-minute interactive sessions, with expert presenters. The perfect opportunity to learn, while connecting with different peers and partners in the treatment chain.
Themes include: Hepatitis C and BBV routes to treatment; inspirational alcohol projects; housing support; vocational training; how to run a service user group; routes to work; opportunities to influence commissioning.
Negative portrayals in the media and politics are reinforcing the perception that drug use is ‘immoral’ and people who use drugs are a threat to society, says a new report from the Global Commission on Drug Policy. This in turn increases stigma and discrimination and means that people who use drugs are seen as ‘sub-human, non-citizens, scapegoats for wider societal problems’ and undeserving of the right to health.
‘Public opinion and media portrayals reinforce one another, and they contribute to and perpetuate the stigma associated with drugs and drug use,’ says the document. ‘Commonly encountered terms such as “junkie”, “drug abuser” and “crackhead” are alienating, and designate people who use drugs as “others” – morally flawed and inferior individuals.’ When combined with the criminalisation of drug use, stigma and discrimination ‘are directly related to the violation of the human rights of people who use drugs in many countries’, it states.
Policy makers should aim to change perceptions of drugs and people who use them by providing reliable and consistent information, the report urges, while ‘opinion leaders’ in the media should promote the use of non-stigmatising language. Healthcare professionals also need to be vocal in promoting harm reduction and evidence-based interventions, while law enforcement should ‘stop acts of harassment based on negative perceptions of people who use drugs’.
‘“Addiction” remains extremely stigmatised in health care settings,’ said former executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Michel Kazatchkine. ‘Language matters. Research has shown that even trained mental health practitioners treat differently cases where patients are referred to as “substance abusers” than those alluded to as “people with a substance use problem’”.
‘In Switzerland’s direct democracy, drug policy reform promoting a health-centered approach focused on harm reduction and treatment has repeatedly triumphed at the ballot box,’ said Global Commission chair and former Swiss president, Ruth Dreifuss. ‘This is in large part because the public was well informed of the facts and positive outcomes.’
Levels of naloxone provision by local authorities are ‘chronically inadequate’ and ‘certainly not sufficient to prevent opioid deaths to any meaningful extent’, according to research carried out by Release. Although take-home naloxone is now provided by 90 per cent of local authorities (DDN, September, page 4), Freedom of Information requests revealed that just 12 take-home kits were being given out for every 100 people using opiates.
The charity surveyed more than 150 local authorities, of which 117 provided details of the number of kits they’d given out in 2016-17. Naloxone coverage was found to be between 1 and 20 per cent in more than 70 of the areas, while the best-performing local council, Somerset, still achieved less than 50 per cent coverage. Of those authorities providing naloxone, almost a third did not do so through needle and syringe programmes and almost a fourth did not provide take-home kits to people accessing OST or to family, friends and carers of those at risk of overdose.
Nearly one in five also required people to be referred and/or book an appointment in order to receive naloxone, while more than 20 per cent required them to be assessed first. ‘These requirements are a major barrier to naloxone access and are therefore contributing factors to overdose deaths,’ says Release.
‘There were nearly 1,900 opiate-related overdose deaths registered in England in 2016 – the highest number since records began, and over four times higher than the figure in 1993,’ said Release’s Zoe Carre, who conducted the research. ‘Many of these deaths could have been prevented if naloxone, a life-saving antidote to opioid overdose, was provided more widely for people to take home. The scale of the problem is a public health crisis, as such it requires a national and coordinated response, and government must not leave it to local authorities but must take action to prevent more people dying.’
While the government’s latest drug strategy recommends that all local authority areas should have appropriate provision in place, the approach of some is ‘far from adequate and may be contributing to avoidable overdose deaths’, she continued. ‘A national take-home naloxone programme is needed in England as a matter of urgency to coordinate and monitor take-home naloxone provision across local authorities. This has been successfully implemented in Scotland, and England should follow suit. Government must act now to prevent more of its vulnerable and marginalised citizens from dying.’
The treatment sector’s ability to absorb funding cuts through efficiency savings and service redesign has been ‘exhausted’, according to the latest State of the sector report.
There has already been ‘substantial service redesign and some hard decisions made’ and the system is starting to buckle under the pressure, says the document, which is based on stakeholder interviews and published by Adfam on behalf of the Recovery Partnership. While there had so far been no serious compromise in service quality or safety standards, the capacity of the sector to respond to further cuts ‘has been seriously eroded’ on the provider side and increasingly in terms of commissioning capacity as well, it warns.
‘The sector has passed the point at which efficiencies and service remodelling can continually compensate for the loss of funding, and moved into a period where choices about service configuration have become much harder,’ it states.
A high turnover of commissioners is causing concerns about loss of expertise, and there are ongoing worries about rising caseloads and erosion of service capacity, it warns, with some areas ‘losing valuable one-to-one support’ and many services using volunteers out of necessity. The previous State of the sector document – the third – had already found that almost 60 per cent of residential services and 40 per cent of community services were reporting deceases in funding (DDN, April 2016, page 5). Only central government intervention can now protect the sector from further cuts, the latest report states, as there ‘appears to be high variation locally in priorities and ways of working’.
The report had uncovered ‘worrying signs that potentially serious damage’ has been done to the treatment system, said Adfam chief executive Vivienne Evans. ‘These findings echo those of the Advisory Council on the Misuse of Drugs in their powerful commissioning report released in the autumn’ (DDN, October, page 4). While there were ‘many wonderfully talented and dedicated people’ working in the sector, funding pressures meant they were ‘unable to deliver to the gold-standard we’d all like to see’, she stated, leaving ‘some vulnerable people with substance misuse problems not able to get the help they need’.
Disinvestment in harm reduction is hurting services and failing clients, say those struggling to maintain life-saving provision. DDN reports.
‘A couple of weeks ago I had a call from the BBC, asking if I could speak on their breakfast show about issues faced by a pharmacist in Staffordshire,’ says Philippe Bonnet, chair of the National Needle Exchange Forum (NNEF). ‘The pharmacist said he was thinking of stopping needle and syringe programmes (NSP) because of safety reasons – his staff were being abused regularly. He mentioned a couple of incidents where a service user threatened a member of staff with a used syringe, demanding they give him needles. On another occasion someone came into the dispensary with a knife, demanding their methadone and threatening to kill.’
Bonnet pleaded with the pharmacist to reconsider, asking him ‘not to punish everyone because of the actions of a couple of individuals’. He mentioned that NSPs were the reason that HIV prevalence was low in the UK, compared to Europe, and that giving out equipment is so much cheaper than the treatment for blood-borne viruses. He did not get an answer from the pharmacist when he asked him if he was going to stop dispensing methadone.
To the casual listener, the conversation on the radio may sound like discussing sensible precautions on staff protection. But for those working in harm reduction it is another red flag in a public health emergency.
The ease with which people who need these services are being dismissed is being compounded by a crisis in funding and staff morale. ‘In some services, NSPs are being forgotten about,’ says Bonnet.
Mark (not his real name) works in the harm reduction team of a large treatment agency, and says there has been ‘a steady erosion of knowledge about harm reduction approaches since 2010’. Large cuts to funding have meant ‘caseloads of increasing complexity’ and evidence-based practice being replaced by ‘a mush of dubious interventions’, including an over-reliance on urine testing.
‘Significant numbers of drug-related deaths this year, including several believed to be linked to fentanyl’ have not prompted a relevant response. ‘The focus appears to be more on data requirements rather than interventions around reducing risk,’ he says. ‘There has been no information about fentanyl circulated by the manager or the organisation, in stark contrast to the constant emails related to data needs.’
Furthermore, he sees a slide towards a deskilled workforce. Within increasingly complex caseloads, ‘much of this work is done by recovery workers who are relatively new to the field but have received little or no training other than shadowing colleagues’.
Amy (who also asked for her name to be changed, because she feels she is in a ‘speak out at your own risk working environment’) manages a needle exchange and has worked in drug treatment services for the last five years. During this time she has seen ‘the steady erosion of vital aspects of harm reduction’.
‘The stuff we know works – assertive outreach, consistent and persistent support for treatment-resistant individuals – has taken a back seat in favour of assessment, TOPS [information that needs to be supplied for the Treatment Outcomes Profile] and group work,’ she says. ‘There is so much pressure on “positive outcomes” that ultimately very little energy is spent nailing the basics. Ultimately the pressure and expectations we have to impose on our clients is mammoth. The system feels designed for the chaotic to fail – and why wouldn’t it be? Fewer chaotic clients in treatment means fewer drop-outs, fewer representations, and all of a sudden your positive outcomes and numbers are on the up.’
While Amy acknowledges some good initiatives – ‘naloxone has been a game-changer, as long as you turn up to a service to pick it up’ – ultimately, she says, ‘we know that there are so many of our most vulnerable – in the car parks, out camping behind Tesco, sleeping in the underpass – that cannot or will not come into treatment to access such potentially life-saving interventions. What about them? We are not going to get to them, that’s for certain. There’s no time, no strategy, and barely enough staff to keep the hubs running. Yet again, these folks fall through the cracks.’
As well as not receiving the immediate help they need, clients are missing out on a much bigger opportunity to engage with healthcare.
‘NSPs for many people represent the first, and possibly only, engagement with a “professional” agency,’ says Kevin Flemen of KFx training. ‘This toe-hold in a service opens up routes to so many other interventions – overdose prevention and naloxone, vaccines and BBV testing, wound care and treatment. It can be the first tentative step on a longer treatment journey.’ For many it will also offer the right environment to discuss OST and life-changing options for stabilisation – steps that not only transform the individual’s prospects, but also reduce the harm to their families and ultimately to society.
As a trainer he has a fair idea of the level of staff knowledge, and also of the level of priority that harm reduction is getting within services. At the moment he sees that we are devaluing it ‘by failing to provide space, time, privacy and resources to make needle exchange excellent. All too often, staff with no training dole out equipment with no discussion or further engagement.’ He sees that ‘some areas have no trained staff or dedicated space for NSP’. As injectors turn to using lower-threshold pharmacy services, this is seen as a further reason to keep downgrading this essential service.
Amy’s colleagues in another service from the same provider have told her about the ‘no bin, no pin’ policy there to encourage returns, getting rid of pre-injection swabs ‘for good old soap and water – great! Unless of course you don’t have access to such facilities!’, and ceasing the distribution of water ampoules because of unfathomable ‘concerns around legalities’.
According to Amy, a little investment in her needle exchange would go a long way. There are the material items that could be bought with more money – the BBV testing kits and homeless packs; and the specific services they could provide, like access to a nutritionist, wound care specialist or dentist. But what the service really craves is ‘to reduce pressure on staff, invest in quality training and nurture specialisms’.
‘One of the heartbreaking things to watch over the last few years is how so many of my colleagues with a love and speciality for harm reduction have moved into other areas of the care sector, or even out of it entirely. Why? Because it’s not worth the heartache,’ she says. ‘You either have to leave because it’s too much, or suck up your pride and principles and get on with the work at hand.’
‘Most importantly,’ she says, ‘we need to really take a step back and reduce the threshold for those accessing support – it can’t be that we turn away the chaotic, dependent injecting drug user because they are ten minutes late for their appointment. We need to be present, consistently – not just from nine to five in an office, but at 6am in the car parks and at 10pm out with the working girls.’
Amy thinks that introducing key performance indicators (KPIs) for harm reduction might be the way to regain energy and focus, and redress the attitude that ‘no one really cares about what we do or don’t do on the front end’. Having ‘60 clients on your caseload and a mountain of admin on your desk’ translates to telling the client ‘take your script and I will see you in two weeks’, instead of giving them the time and energy required for a meaningful working relationship.
‘We underestimate the power that just sitting down and having a cuppa and a chat, with no expectations, can have. We need time and we need patience, and unfortunately there is no pot of funding for that,’ she says, adding: ‘I regularly sit in team meetings in which discharge stats are sniffed out like dogs with a bone. These are people’s lives!’
Mark is also weary of the attitude that ‘NSP cover is something that can be delivered by anyone, often admin staff’. He believes that the initiative must be taken by treatment providers, in the same way that naloxone distribution has (eventually) been embraced. Just three years ago he remembers that a senior manager in one of the larger organisations was instructing members of staff that they ‘must not talk about naloxone as we are not a campaigning organisation’.
Many organisations are still silent about issues such as drug consumption rooms (DCRs) and heroin-assisted therapy, perhaps taking their lead from the government’s drug strategy, which (while acknowledging that we should protect society’s most vulnerable) only fleetingly mentions harm reduction and ignores the importance of outreach.
‘The providers of treatment really need to start to use the language of harm reduction and be clear about a commitment to those approaches, rather than continuing with a culture of harm reduction by stealth,’ says Mark. ‘If they don’t believe that they should do everything possible to campaign for initiatives and interventions that can reduce the numbers of deaths among their service users, then we are in an impossible situation.’
This article has been produced with support from Camurus, which has not influenced the content in any way.
Buckinghamshire County Council (BCC) is redesigning the children and young people substance misuse support system in Buckinghamshire. The new service will be a combined tier 2 and tier 3 that will work across the whole of the county. The new service will commence on the 1st October 2018 and will include innovative harm reduction, brief advice and information, drop in facility, structured support, links with Early Help and Safeguarding, Hidden Harm support
BCC will be running a tender process during this year and the resulting contract will be awarded for an initial period of four years with the option to extend it further by up to two years. Extension options will be dependent on performance and subject to ongoing available funding. The value of the contract will be circa three hundred thousand pounds per annum.
The Council is of the opinion that Transfer of Undertakings (Protection of Employment) Regulations 2006 (TUPE) may apply to this contract.
The Council is holding a Provider Information Event in relation to this tender on:
Tuesday 30th January 2018 10am – 1pm
BCC, Exhibition Suite Room 1, Market Square, Aylesbury
We would like to invite interested parties to attend the event which will include:
Information about the substance misuse needs of children and young people in Buckinghamshire
Information on the new service model
Information on the strategic direction for children and young people substance misuse prevention work
An opportunity to meet commissioners
Information on the procurement process including key dates
To book a place at the Provider Information Event please email firstname.lastname@example.org. Please note that due to limited space we can only accommodate two people per organisation Forany general questions regarding the event contact Becky Carlile on 01296 387061.
Attendance at the Provider Event will not give any advantage to potential bidders nor will your organisation be disadvantaged by not attending the event. All information provided at the Provider Event will be published on the Buckinghamshire Business Portal (the Portal) at www.supplybucksbusiness.org.uk
The Council uses the Portal to advertise tender opportunities and run its tender processes. To access the tender documents you will need to register on the Portal at www.supplybucksbusiness.org.uk. We anticipate that the tender documents will be published on the Buckinghamshire Business Portal in February 2018
The International Criminal Court (ICC) must ‘urgently’ open an investigation into crimes against humanity committed during Philippine President Rodrigo Duterte’s ‘war on drugs’, says Amnesty International.
As many as 60 children have been killed in anti-drug operations since Duterte came to power last year and ‘yet not a single police officer has been held to account’, the human rights NGO states. Family members have told Amnesty how they saw police ‘shoot children dead at point-blank range as they were begging for mercy’, it says, while an Amnesty research term has also witnessed ‘large numbers’ of children suspected of drugs offences being held in overcrowded and unsanitary conditions. ‘Some said they had been beaten and tortured by police on their arrest, and claimed police had framed them by forcing them to pose in photographs with drugs that had been planted,’ it adds.
‘It is time for international justice mechanisms to step in and end the carnage on
Philippine streets by bringing the perpetrators to justice,’ said Amnesty’s regional director for Southeast Asia and the Pacific, James Gomez. ‘The country’s judiciary and police have proven themselves both unwilling and unable to hold the killers in the “war on drugs” to account. It is time for international justice mechanisms to step in and end the carnage.’
The ICC should ‘cast its net widely’, he added, as responsibility was ‘not just limited to those pulling the trigger, but also those who order or encourage murders and other crimes against humanity’. Duterte and other high-level officials had ‘openly advocated’ for the killings, he said, which ‘could amount to criminal responsibility under international law’.
Duterte recently removed his police force from the violent crackdown on drugs following widespread protests after an unarmed 17-year old student was shot dead (DDN, November, page 4). However the Philippine government has now announced that the police will ‘resume providing active support to the Philippine Drug Enforcement Agency (PDEA) in the conduct of anti-illegal drug operations’, claiming that there had been a ‘notable resurgence’ in drug-related activity and crime since the police and other agencies were directed to leave to the PDEA in charge.
This latest decision would consign the poorest and most marginalised people in the country to ‘another catastrophic wave of violence, misery and bloodshed,’ said Gomez. ‘Since the police were withdrawn from anti-drug operations in October, there has been a marked decline in the number of deaths resulting from these operations. We can only expect that to reverse, as the police have the opportunity to pick up where they left off and resume their indiscriminate killing with impunity.’