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DrugScope Comment

Updated: 2016-10-20T20:34:59.960+01:00


"I might go back to knitting after all" (or: Why innovation isn't always the answer)


As you may have read, earlier this week DrugScope announced its closure after fifteen years serving the substance misuse sector, and working on behalf of people facing drug and alcohol problems.This has been a terrifically difficult time for all the staff here, but we have been overwhelmed by the response to the news - both from partners and friends that we know well, but also from many others who have appreciated DrugScope's work over its long history.We've collected a small sample of these messages, and offer them for what they say about the continuing and vital importance of effective drug and alcohol services and sensible, evidence based drug policy.From everyone at DrugScope, thank you for your support over the last 15 years, and your good wishes at this sad time. They are much appreciated. src="//" width="100%" height="750" frameborder="no" allowtransparency="true">No such provocation from Wilson, who – in a detailed if unremarkable speech – set out his stall. What the third sector needs, he argued, is support for innovative organisations to grow (more on that in a second); better opportunities for charities and social enterprises to bid for public sector contracts; and more action to encourage public and corporate giving.Shadow Minister Lisa Nandy and others picked up on Wilson’s reference to a ‘bigger society’ – but this didn’t strike me as much more than a rhetorical flourish. What was more noticeable was his – and the other panellists – repeated stress on ‘innovation’. I’m never exactly sure what people mean by this, but here I took it be “finding new ways of solving old problems”.On the face of it, it’s difficult to argue with that – particularly when some of the old ways aren’t that sustainable. Over recent years, the Cabinet Office has introduced initiatives like the Social Action Fund, a joint venture with NESTA, designed to support new ideas that can grow bigger, or ‘scale’.There’s no doubt that this money is welcome to those receiving it, but where does such a focus leave those charities that don’t particularly want to tear up their existing model, or grow beyond the area they already work in? Many highly effective organisations – especially in the drug and alcohol sector – have a long track record and are highly attuned to local need.When I asked the Minister about this, he replied that the Social Value Act – currently under review – ought to help smaller organisations to win public sector commissions. (The review is welcome: I took part in a round-table for it organised by NCVO last November, and my impression was that there’s little evidence of the Act playing this role so far.)He also said, though, that successful charities should be expected to scale to help more people. This was challenged by the other panellists – Andrew Barnett from the Calouste Gulbenkian Foundation and Danny Kruger from Only connect – who argued that staying small should be a viable option. Wilson clarified he didn’t expect all charities to grow beyond their local area, but his slightly rattled tone suggested tension.It’s easy to understand why politicians and policymakers – not to mention many leaders in the sector – want new ideas and big ambitions: they’re facing real challenges and lack money to throw at them. But venture out of Westminster and many small charities aren’t interested in getting bigger: they want to secure the funding they already have (and fear they may lose).Last week, at DrugScope’s regular forum of CEOs and senior managers from drug and alcohol services, many expressed concern about the pressures on their organisations to expand rapidly or merge in order to remain competitive. In particular, there’s growing evidence that smaller substance misuse organisations are disappearing without trace, as their contracts are taken over by larger providers.Of course, not all small providers are effective, and often charities grow or merge because it makes sens[...]

Putting numbers to faces: a new map of substance misuse, homelessness and offending in England


New research released todayStatistics can be a limited and limiting way to understand social issues. When we focus on how many people are affected by a problem, or how much the government spends on tackling it, we start to see numbers instead of people. The opposite is also true, though: without statistical evidence, it’s hard to understand the scale of a problem.For instance, we know that a small but significant number of people facing serious problems in their lives bounce between different kinds of support – drug and alcohol treatment, supported housing, mental health services, and sometimes prison.However, because these services don’t share information at a national level, it’s hard to know where these individuals’ issues overlap and interact. DrugScope is one of four members of the Making Every Adult Matter coalition, which is committed to understanding and improving their lives, not least through Voices from the Frontline, the project I’m leading. What we’ve lacked, though, is solid data on the national picture – until now.Pioneering new research from Heriot-Watt University, supported by the LankellyChase Foundation, has found that over 250,000 people in England experience problems with homelessness, substance misuse and offending in some combination. A smaller subset, estimated at 58,000 people, experience all three at the same time.The research team spent several years analysing multiple official datasets – including the National Drug Treatment Monitoring System (NDTMS) – and building a composite picture. Their report out today, Hard Edges, provides the most detailed data we have yet on the extent and nature of severe and multiple disadvantage in England.One thing is clearer than ever before from their findings: substance misuse features in a majority of people’s experiences of complex needs. Their analysis indicates that at least 190,000 people with a substance misuse issue also have problems with homelessness and/or offending: this is almost exactly the same number who have a substance misuse problem without these complicating factors.This diagram estimates the number of people in England experiencing each kind of need, and how they overlapIt’s worth noting that these figures only cover those in treatment – the authors’ estimate including who are receiving no support for a drug or alcohol issues is even higher.What’s more, the research cements what we already know about the strong link between substance misuse and mental health problems. People with a drug or alcohol problem who are not also homeless or offenders have the highest prevalence (58%) of mental health problems in the study.  And those who are homeless and/or offenders are much more likely to have a mental health problem if they also misuse drugs or alcohol.The report also provides a useful corrective to commonplace assumptions. Often, when we think of the most vulnerable in society, we focus on single, homeless men with no family connections. However, through an analysis of NDTMS data, the researchers show that of those with the most complex needs – the 58,000 people who have experience of homelessness, substance misuse and offending together – over 60% either live with children or have ongoing contact with them.This echoes what we've heard from our Voices from the Frontline: for many people with complex needs, particularly women, the fear of losing access to children looms large. These findings also give us cause to revisit the Advisory Committee on the Misuse of Drugs’ 2003 recommendations, which set out the benefits to children of their parents receiving effective drug treatment.More widely, what should the substance misuse sector take from this important research? First and foremost, the challenge it poses cannot be tackled by the substance misuse sector working alone. Better mental health, access to housing and effective offender rehabilitation must all figure in our response to complex needs.All the same, any response must continue to include high-quality treatment for people[...]

Drugs and Prison - Statistics from the last year


This weekend there were reports in the media about the increased number of drugs being found in prisons. This echoes findings in DrugScope's Street Drug Survey, published last week, where we reported that many respondents were finding that synthetic cannabinoids were readily available in prisons and many people referred into services from jails came out with dangerous levels of use of the drugs.One drug worker said that inmates at a Liverpool prison had become so used to emergency services being called out when people collapsed after taking Black Mamba that ambulances are now known as ‘the Mambalance’.The last annual report from the HMI for prisons found that around 26% of new arrivals at prison had substance misuse and 19% had alcohol misuse needs. The report makes a number of useful points about substance misuse services in prison:Prisons continued to focus on recovery working, which was appropriate, usually with active peer support and service user engagement. A quarter of inspected prisons were not focused enough on the needs of prisoners with alcohol problems.In a minority of services, recovery working was undermined by enforced reduction or inflexible prescribing, which did not adhere to best practice guidelines. Prison substance misuse services offered psychosocial support to prisoners and clinical management of opiate substitution therapy. However, full psychosocial support was not available in a quarter of services and prisoners’ needs were not met. Clinical management in most prisons was flexible and catered to individual need. However, some options were limited by the refusal of the prison or SMS provider to prescribe buprenorphine, which was contrary to national guidance.DrugScope will have more to say about prison drug and alcohol services as part of our State of the Sector work.The following slides are compilation of the statistics that we've seen over the last year which helps describe some of what is going on about drugs and prisons.  src="//" width="595" height="485" frameborder="0" marginwidth="0" marginheight="0" scrolling="no" style="border:1px solid #CCC; border-width:1px; margin-bottom:5px; max-width: 100%;" allowfullscreen> Update - Channel 4 have uncovered some new information through social media accounts of current prisoners: [...]

10 Interesting Things about Alcohol and Other Drugs (January 2015)


We scour the data on alcohol and other drugs and here are 10 things we found in the last month that might interest you, including:
  • The number of high risk drug users, 
  • Police estimates of the cost and purity of drugs, 
  • Trends in property crime, and how drug services may have contributed to it's decline
  • Numbers in treatment in Wales, 
  • Benefit claimants with drug problems in Scotland (and alcohol problems across the UK), 
  • Detection of drugs in prison, and 
  • The support needs of single homeless people

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As always any misinterpretation of the data you spot are down to me (and please do let me know so that I can fix them).

Briefing - Mental health and substance misuse


DrugScope has produced this briefing ahead of a debate on mental health being held in the House of Lords today.There is a close relationship between mental ill health and problems with drugs and alcohol.Where these issues co-exist (often referred to as ‘dual diagnosis’) people experience poorer outcomes – including high rates of relapse, hospitalisation and completed suicide.A 2002 study found that:75% of users of drug and 85% of alcohol services experienced mental health problemsConversely, 44% of mental health service users reported drug use or harmful alcohol use38% of drug users with a psychiatric disorder were receiving no treatment for itThe Department of Health issued guidance that year establishing that mental health services should lead on providing integrated care, working closely with substance misuse services to establish appropriate processes and training. Progress to date has been limited and inconsistent.Through its member organisations on the frontline, DrugScope has learned that:People are frequently denied access to mental health services on the grounds that their substance use is the cause of their mental ill health or will make treatment impossibleRaised thresholds for statutory mental health services often mean that people are unable to access mental health care and support until they are close to or actually in crisisPeople experiencing a mental health crisis while intoxicated are often excluded from health-based ‘places of safety’, which may result in being placed in a police cellPeople with drug and alcohol problems have struggled to get appropriate support through the Improving Access to Psychological Therapy (IAPT) programmeDrug/alcohol treatment providers have repeatedly voiced concern about their clients’ access to appropriate mental health support, and see this as worseningThis is of concern given that a number of international studies suggest that substance misuse can account for the increased risk of violence amongst those accessing mental health services.What’s more, a recent investigation by the Lancet highlighted concern about adequate funding and training for addiction psychiatrists.There are specific issues in the prison population, where 70% of prisoners suffer from two or more psychiatric disorders with 75% experiencing dual diagnosis. Lord Bradley’s 2009 report found services are organised in a way that ‘positively disadvantages’ this group. These concerns were again highlighted in Lord Patel's report on drug related crime and offender rehabilitation.Reviews of the use of Section 135 and 136 of the Mental Health Act have highlighted the problem of intoxication in assessing the mental health of those believed to need a 'place of safety'. In a survey carried out by the Care Quality Commission about half of the providers said that people who were intoxicated would be excluded from the places of safety in their local area. Similar findings are reported by the Centre for Mental Health who say:This issue of intoxication was a problem for most areas, and some emergency departments (EDs) and most 136 suites would reportedly not accept a person whom they deemed too incapacitated to assess.Recently, there have been some positive developments:The Department of Health is currently engaging with this issue, which is, for example, highlighted in the 'Mental Health Crisis Care Concordat'. This work includes the development of tools and resources to support practitioners and a review of the 2002 guidance on dual diagnosisThe introduction of Health and Wellbeing Boards provides an opportunity to join up mental health and substance misuse care (which are currently commissioned separately)The continued roll-out of the Liaison and Diversion schemes will place mental health professionals in police stations and courts, covering half the population from April 2015. These have been particularly championed by Lord Bradley, who observes in his report that “no approach to diverti[...]

6 things we've learnt about young people in substance misuse services in England in 2013/14


Public Health England have published their annual report on young people who accessed specialist substance misuse services in England in 2013-14.

Here are six things I took from the report:

  1. The numbers in treatment (19 thousand in 2013-14) have been falling since 2008-09, but are still higher than a decade ago.
  2. Most were over 15 years old, but 1 in 5 were younger.
  3. Almost half of referrals come from two sources - Youth Offending Teams and mainstream schools.
  4. Cannabis and alcohol remain the two most important substances treated for this age group, but fewer and fewer are presenting with alcohol problems.
  5. Most young people got a psychosocial intervention and three quarters were in treatment for less than 26 weeks.
  6. Substance misuse was likely to be one of a range of problems for the people who accessed these services.

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Atul Gawande's Reith lectures: building a system that cares


On my wintry walks to work these last few weeks, I’ve been enjoying the 2014 Reith lectures. Each year, the BBC invites a distinguished guest to give a series of talks on an issue of public interest. This time, surgeon and writer Dr. Atul Gawande has been discussing medicine and public health. I’m grateful to my colleague George Garrad, who suggested they might be up my street. Dr. Atul Gawande (photo: CfAP, Creative Commons)Firstly, if you have any interest in health (and which of us doesn’t?) I really recommend listening to the four lectures. In them, Gawande makes a passionate yet highly methodical case for how we can improve the health care that people receive throughout their lives, across the world.He blends stories from his professional and personal life, which are often very moving, with political argument in a way that’s entirely absorbing (I occasionally came close to walking into lampposts). And although his focus is on medicine, I think the issues he discusses are of vital importance for the drug and alcohol sector – and especially its approach to complex needs, which is of particular interest to me through my work at DrugScope with the Making Every Adult Matter coalition.Why the system mattersGawande’s basic argument, as I understood it, is this: over the last century, we’ve made huge advances in knowledge about the body and how it works. We’ve also developed technology – surgical techniques, medicines – that can help us treat ever more conditions. However, what we haven’t worked out is how to apply this knowledge consistently across every hospital, country and continent. This helps fuel the dramatic health inequalities we see at all of these levels.In his second lecture, therefore, he focuses on problems with ‘the system’: the interactions between people and organisations that deliver healthcare. As a surgeon, he uses the example of avoidable deaths in the operating theatre and describes work that he and colleagues are doing to introduce simple checklists for basic tasks. A tiny detail like washing your hands takes on huge importance when it’s one of hundreds of tasks that contribute to a successful operation. Often, Gawande explains, surgeons and other medical professionals resist the idea of following a checklist – until they see the evidence that it saves lives (you can read more about this in a fascinating 2007 New Yorker article that he draws on in his talk). However, where his argument gets really interesting is in the final lecture, where he discusses the limitations of this approach:“But just because you have a roadmap does not mean anyone is going to follow it. There are barriers to overcome to execute even the simplest step, and those barriers differ from place to place. In one health centre, staff may not wash hands because they don’t know it’s important; in another, because they don’t have sinks or running water in the delivery rooms; and in another, because they simply have not made it their habit and no one cares."That last phrase I think is the critical one: if no one cares when someone takes the trouble to do things right, nothing changes. And the overwhelming message to the people who work at the frontlines of care around the world is that no one notices excellence and no one cares. That is the biggest source of burnout and discouragement for health care workers everywhere.”What this means for drug and alcohol servicesI think this insight is crucial to how drug and alcohol services approach treatment for those with the most complex needs. We often hear calls for ‘system change’ – the demand that services should be re-designed to work better together. That’s clearly a valuable goal – but it’s also vitally important that we take into account the human beings on whom services depend, who are often forgotten in the rush to reform and restructure.At DrugScope’s conference in N[...]

Bite-sized Briefing - Public Health England’s grant to local authorities


As part of the support we offer our members DrugScope's policy team send out a monthly round-up and précis of reports which we believe are of interest to the field.  The following is offered as an example of the content of our Bite-sized Briefing for December.

(image) The National Audit Office have produced an assessment of whether the new public health grant to local authorities is likely to lead to intended outcomes and achieve value for money.

The report makes clear that despite increases in the overall budget allocated for public health (up by 5.5% in 2013-14) allocations within the overall envelope are changing slowly as local authorities exercise their judgement on local priorities.

They report that in 2013-14 local authorities had budgeted 54.3% of spending on sexual health, drugs and alcohol services; in 2014-15 this proportion had reduced to 52.8%.  They also found:
“between 2010-11 and 2012-13 alcohol-related admissions to hospital increased by more than 6% in 26 local authorities. These 26 local authorities spent on average 6% of their public health spending on alcohol services for adults. This was significantly less than the 9% spent by the 26 local authorities where alcohol-related admissions reduced the most.” 
 Other key messages from the report are:
  • A survey of stakeholders found that three-quarters of respondents have a good working relationship with PHE, although it is generally too early to tell whether public health outcomes are improving. That said, the report points out that PHE prioritised 54 local authority areas for intensive diagnostic and support work to improve recovery and reduce relapse rates leading to a 1.3% increase in recovery rates.
  • The Department of Health has not decided how long the ring-fence for the public health grant will remain in place.
  • There have been limitations in the quality of data, for example, 81 local authorities initially reported not spending anything against 1 or more of the 6 prescribed public health functions, and there are lags of at least 18 months for publishing much of the public health outcomes data.
  • Some stakeholders think PHE should display stronger system leadership.  However, the formal levers available to PHE for securing better public health outcomes are limited and the autonomy of local authorities gives no guarantee that PHE can secure improvements in outcomes (and at £5 million, the health premium risks being too small to bring about significant change).
Download the full report here.

If you would like to join DrugScope you can do so here.

10 (more) things - late December edition


A final set of slides for the year with 10 more things I saw about alcohol and other drugs and which I thought were interesting.

This time including: data on drug deaths as a proportion of all deaths of adults 15 - 43; the use of naloxone by ambulance crews in the East Midlands; substances people said they were dependent on amongst people in police cells in London; seizures of drugs and mobile phones in HMP Durham; victims of criminal exploitation; number of people using residential rehab; cultivation or illegal drugs in Scotland; number of possession and possession with intent to supply offences recorded in Scotland; global narcotic seizures by the Royal Navy; and % changes to the ABV of alcohol between 2011 and 2013.

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As always any misinterpretation of the data you spot are down to me (and please do let me know so that I can fix them).

StreetLink celebrates its second anniversary


Many happy returns, StreetLinkPrior to joining DrugScope in 2012, much of my working life had been spent in homelessness services of one sort or another. Between the mid-90s and 2010, I worked in hostels, supported housing, outreach and floating support, before spending two years at Homeless Link, the membership organisation for the sector. Despite getting to know the homelessness sector pretty well during that time, I was sometimes perplexed when faced with rough sleeper outside of work. Identifying the relevant outreach team (having first established that there was an outreach team – many areas don’t have one), finding a contact number or email address and then actually getting through (outreach teams generally work highly unsocial hours) could be time consuming and complex. If I was away from my adopted home turf of London, these difficulties were compounded. I thought at the time that if it was a difficult and time consuming process for me, for someone unfamiliar with the way the system works, what services work with whom, what they might be called and so on, it would be even more daunting, if not impossible.In December 2012, life was made considerably easier for anyone worried about someone sleeping rough, including rough sleepers themselves. Building on the work of the No Second Night Out London hotline, StreetLink was rolled out across England. Developed and run by Homeless Link and Broadway (now St Mungo’s Broadway) and funded by the Department for Communities and Local Government (DCLG), StreetLink provides a single portal for rough sleepers themselves, members of the public, and members of emergency, health and support services to get connected to outreach teams.What StreetLink does is in some respects quite simple – it takes referrals (and self-referrals) from anywhere in England and passes that information on to the relevant outreach team or local authority. Instead of having to go through the process of researching provision in any particular locality, StreetLink provides a single phone number, mobile app and website and even offers to let people know – in a general sense – what happened to their referral. In contemporary terms, it ‘hides the wiring’ of what remains a complex patchwork of services and provision spanning around 150 local authorities.About rough sleeping and homelessnessThe relevance for drug and alcohol services is in the number of people they support who have housing problems of one sort or another. Around 10% of people starting new drug treatment journeys in 2013-14 had no fixed abode, with a further 14% having other housing problems. The corresponding figures for those starting new alcohol treatment journeys are 4% and 10% respectively. As those figures have been pretty constant for some years, it seems plausible that over 10,000 people in contact with drug and alcohol services are actually homeless, with around 40,000 having some other sort of housing problem. Looking at it from the other side, we also know that ‘tri-morbidity’ is commonplace – rough sleepers often have coexisting poor physical health, poor mental health and problems involving substance misuse.Nationally, over 2,400 people sleep rough on a typical night. This number is based on the street counts conducted in winter and reported by DCLG and represents a continuation of an upward trend visible since 2010, when the street count guidance was changed. In London, the CHAIN database used by all the main outreach teams suggests a corresponding significant increase, with new contacts increasing from 1672 in 2007-08 to 4363 in 2013-14.These numbers are substantial. Figures recently releasedby StreetLink show that in the two years it has been operating, almost 9,000 people have used the service and been connected with support, just over a quarter of them self referrals [...]

Owen Bowden-Jones: If I had my way the government would...


T(image) his is a guest blog from Owen Bowden-Jones. 

Owen is the founder of the Club Drug Clinic, the current Chair of the Faculty of Addictions at the Royal College of Psychiatrists (2010-2014), a Consultant in Addiction Psychiatry, overseeing alcohol and drug services in the borough of Kensington and Chelsea and an Honorary Senior Lecturer at Imperial College in the Division of Brain Science.  Owen is also a Trustee of DrugScope.

Invest where the evidence is most robust.

Develop an inspectorate for scrutiny and oversight of commissioning.

Move commissioning of drug and alcohol specialist services from local authorities to Clinical Commissioning Groups.

For both drug and alcohol problems, increase the focus on young people at early stages of harmful use. Early intervention is well established for most illness management and should become a priority for harmful/dependent drug and alcohol use.

Invest in technology to support recovery. Relapse prevention, motivational enhancement and peer support can all be enhanced with online/mobile telephone interventions.

Review the workforce to ensure that necessary skills are retained within the sector. We are facing a brain drain, particularly for addiction psychiatry, which is bad news for the whole sector.

Jan King: If I had my way the government would...


This is a guest blog from Jan King, the Chief Executive of the Angelus Foundation.

We need the government to take positive steps to ensure young people are better informed of the risks to their mental and physical well-being from new psychoactive substances, the so called ‘legal-highs’.

We already have a poor commitment to drugs education in this country and the government needs to ensure that all schools cover some key messages. There has been an understandable trend to schools setting more of their own teaching agenda but this cannot be at the expense of our young people’s future health and well-being.

Compulsory PSHE (Personal Social and Health Education) would be a welcome start and much more proactive means of getting messages to young people. We need well thought out approaches delivered in a range of ways but ideally with young people centre stage saying what works for them.

The emphasis needs to be on equipping them to withstand the myriad of pressures they may face and not rather pointless enforcement messages around potential penalties.

At Angelus we have been visiting schools, universities and festivals showing films of what can happen when people experiment with untested substances with little idea of what they are taking let alone what might be a safe dose, assuming such a thing is possible. When they see the outcomes they are often angry they have not been informed by anyone before that there are new forces at play trying to take advantage of their potential vulnerabilities.

While we are committed to working with young people and their parents so that young people can take informed decisions we need the Government to be taking a much clearer stand on what schools should be doing to stem this pernicious trend.

The Government’s review into NPS goes some way in the right direction but the new Administration will need to ensure that its recommendations are pursued vigorously if we are really to keep our young people safe.

There will be no time to rest on any laurels as we know the industry that knocks out these substances will already be cooking up new ways to get around any changes in the law.