CIOS DAAT

Adult drug treatment plan 2013-14

Part 1: Strategic summary, needs assessment and key priorities

The strategic summary incorporating the findings of the needs assessment, together with local partnership ambition for effective engagement of drug users in treatment, and the funding and expenditure profile have been approved by the Partnership and represent our collective action plan.
Signature / Signature
Felicity Owen
Chair, CIOS DAAT / Sandra Miles
Chair, adult joint commissioning group

1. Drugs in Cornwall & Isles of Scilly

National estimates indicate that there are 2,285 opiate and / or crack users in Cornwall and the Isles of Scilly, equating to a rate of 6.8 per 1000 population. Collectively, they have a big impact on crime, unemployment, safeguarding children and welfare dependency.

Estimated prevalence of opiate and / or crack use is lower in Cornwall than the national average and this is particularly the case for crack use. The proportion of opiate and / or crack users estimated to inject, however, is slightly above the national average.

When engaged in treatment, people use fewer illegal drugs, commit less crime, improve their health, and manage their lives better, which also benefits the community. Preventing early drop out and keeping people in treatment long enough to benefit contributes to these improved outcomes. As people progress through treatment, the benefits to them, their families and their community start to accrue.

  • 1,184 opiate users engaged in effective treatment[1] in 2011/12, accounting for 55% of the prevalence estimate and close to the national average of 58%.
  • This indicates an unmet need of around 1,000 opiate and / or crack users.

The numbers of people engaged in treatment in Cornwall and the Isles of Scilly is dropping and for non-opiate users the fall is significantly above the national average.

Opiate users

In 2011/12 the number of opiate users dropped by 1% and the number of non-opiate users by 26%, representing a net overall drop of 8% in adults in treatment. Nationally over the same period, opiate users in treatment dropped by 3% and non-opiates by 1%. Trends in the year date indicate that the decline has slowed with the number of opiate users matching the national profile and the number of non-opiate users, although remaining significantly down on last year, may be starting to increase again.

1,184 opiate users were in effective treatment in 2011/12, a drop of 1% compared with 2010/11. The majority of people in treatment are aged 35 years of older.

385 opiate and / or crack users started new treatment journeys in 2011/12, an increase of 24% compared with 2010/11. Around three quarters of opiate users starting new treatment journeys in year had been in treatment previously and this compares with around 55% five years ago.

300 people went on to engage in effective treatment (78%). This equates to an average of 25 people entering effective treatment each month and we would have needed a minimum of 26 per month to achieve growth. The current trend continues to be relatively flat.

The Criminal Justice System (predominantly CARAT/Prison and Probation), GPs and substance misuse services are the main routes of referral into treatment for opiate users. The proportion of referrals coming through self, friends and family has not increased further to a rise last year and there are very few referrals through other routes, such as generic community or social care services.

Non-opiates

329 non-opiate users were in effective treatment in 2011/12 and this shows a significant drop of 26% since 2010/11, and is not in line with the fairly stable position nationally (a drop of only 1%).

213 non-opiate users started new treatment journeys in 2011/12 and the proportion that had been in treatment previously has remained fairly stable over the last five years at around 60%.

166 people went on to engage in effective treatment (78%). This equates to an average of 14 people entering effective treatment each month. Although the rate of new starts is similar to that in 2010/11, we would have needed a minimum of 23 per month to match the number of non-opiate users who had left treatment the previous year, leaving a substantial shortfall. The current trend continues to fall and causes some concern.

Self, friend and family referral is the main route into treatment for non-opiate users and they are much more likely to be treatment naïve.

2. How recovery orientated is our treatment system?

The greatest positive gains appear to be made in the segment for 6 months to 2 years – less housing need, increased opiate abstinence, less use of other drugs, less injecting, less offending. Self-reported health and wellbeing peak in this segment and drop noticeably as treatment progresses after 2 years.

As opiate use falls and the number of new users decreases, the treatment population will be increasingly older with more complex needs. They will have been into treatment, sometimes failing, sometimes leaving apparently drug free, several times previously and achieving recovery will be more challenging.

Those in treatment for less than 6 months are at highest risk across a range of factors, including housing, continued illicit drug use and offending. There is a higher representation of non-opiate users, non-injectors and under 35s.

The segment in treatment for 4 years or longer is predominantly opiate users with a history of injecting. Although this segment reports lower levels of opiate use, a higher proportion than other segments is using other drugs and drinking heavily. There is also a slightly higher proportion of current injecting in this segment than in the segment before.

3. Leaving treatment - who is doing well and who isn’t?

Around half of people leaving treatment in 2011/12 left in a planned way, and this sits in the middle range of the regional and national averages (52% and 48% respectively).

People who do not leave in a planned way are either referred on, drop out of treatment, go to prison or leave for another unplanned reason (such as declining treatment or treatment being withdrawn by the provider).

Compared with the regional and national exit profiles, locally we see a much lower proportion of onward referrals and a much higher drop out rate.

In 2011/12 30% of people leaving treatment dropped out, compared with 19% in the South West and 21% nationally. This also includes higher than average numbers of people dropping out within 12 weeks of starting treatment, which has already been highlighted in this assessment.

This is a persistent problem for Cornwall and there has been no improvement over the last 18 months.

Treatment discharge outcomes were reviewed across a wide range of factors to ascertain the degree of impact each may have had on the outcome.

  • Gender is the only factor reviewed that does not notably impact in either a positive or negative way.
  • The impact of ethnicity / nationality is difficult to assess due to the low numbers of people in non-white / non-UK national groups. There appears to be a slightly higher rate of successful completions amongst non-UK nationals leaving treatment but the difference may not be significant.

4. Re-presentations to treatment

Re-presentation refers to the situation where a person leaves treatment apparently free of dependency but then subsequently represents to the system for further treatment. Representation rates are a key measure of whether our treatment system delivers recovery successfully.

The proportion of people re-presenting to treatment in Cornwall has been unacceptably high compared with similar areas nationally.

Over the first six months of 2012/13 re-presentation rates for opiate users showed some improvement, dropping to 3 in 20 individuals at the half year point, but have recently increased again; our current performance indicates that 1 in 5 opiate users re-present to the treatment system. The best performing treatment systems in our cluster are showing between zero and 13% (around 2 in 15 people).

Examination of our local data provided a cohort of 120 service users who had been in contact with treatment at some point in the last 18 months and had a history of 5 or more previous treatment journeys. 72 of them are currently in treatment (i.e. have an open modality). They are nearly all opiate users with a history of injecting. 35% of this group have previously been in tier 4 treatment and completed successfully.

5. Implementing effective practice and system design: what do we need to do?

Service users, as part of the last 2 years’ needs assessments, have consistently said that they require more face to face time with treatment services to develop sustained recovery and help with a wider range of needs.

  • People with complex drug problems are accessing treatment but cite that their mental health issues remain unaddressed.
  • There are significant numbers of people requiring support in managing intractable pain.
  • There are significant levels of homelessness affecting opportunities to recover
  • Some work is required with adult ADHD clients if they are to be able to stop using illicit drugs to self medicate.

Psychosocial interventions that involve families and support networks are available

  • Some historical excellent practice in engaging pregnant women and parents in particular
  • A dedicated specialist has been assigned to the Multi-Agency Referral Unit (MAFU) to improve the understanding of drugs and alcohol amongst children’s and families services and provide specialist support
  • Locally agreed protocols are in place for working with children and families affected by alcohol and drugs
  • The ‘Breaking the Cycle’ programme delivers psychosocial interventions specifically for families
  • Families and “Affected Other” groups have been available in 5 locations across Cornwall, (Bude, Liskeard, Bodmin, Truro and Penzance) but there is demand for additional groups.

Recovery Support

  • Recovery is muchmore ‘visible’ now in Cornwall, with ex-service users working in apprenticeships, as peer mentors, volunteers, delivering the Mutual Aid Programme (MAP) and Recovery Cafes as well as NA and AA.
  • Where caseload sizes allow, staff are referring into Intuitive Recovery classes and facilitating access to Breaking Free Online
  • People in recovery have set up UFO in Penzance as a Recovery Support and User Voice organisation
  • Post treatment support options have developed considerably over the past year across Cornwall and Isles of Scilly, but service users are not always aware of their existence, how to access or whether they are eligible.
  • The exits from treatment are not always clear or well managed. People still cite support as stopping when they go for detoxification or are discharged from treatment.

Medications in Recovery

In 2010, the NTA asked Professor John Strang to chair an expert group to provide guidance to the drug treatment field on the proper use of medications to aid recovery, this included the need for the following:

  • Evidence-based pharmacotherapy, including supervised consumption and optimal dosing
  • Comprehensive assessment and care planning
  • Clear pathways or ‘phases’ of treatment (are there interventions for the beginning, middle and end of a journey)
  • Different ‘intensities’ of treatment to be made available
  • The treatment system can respond to complex need (appropriate clinical expertise, pathways and partnerships)

The Cornwall & Isles of Scilly Prescribing for Substance Misuse Manual clearly evidences good practice, but it is timely to review local guidance and practice against this updated evidence.

Dual diagnosis

The term ‘dual diagnosis’ covers a broad spectrum of mental health and substance misuse problems that an individual might experience concurrently. The nature of the relationship between these two conditions is complex and includes:

  • A primary psychiatric illness precipitating or leading to substance misuse
  • Substance misuse worsening or altering the course of a psychiatric illness
  • Intoxication and/or substance dependence leading to psychological symptoms
  • Substance misuse and/or withdrawal leading to psychiatric symptoms or illnesses (DH, 2002, p7)

Poor mental health is commonplace in people who are dependent on or have problems with drugs and alcohol. And, for many people, mental ill health and substance misuse combine with a range of other needs including poor physical health, insecure housing and offending.[2]

In Cornwall, 26% of people in treatment[3] were recorded as having a dual diagnosis (25% of opiate users and 30% of non-opiate users) – a total of 266 people.

The proportion of dual diagnosis in new drug treatment presentations for the period April to December 2012 is 24% (91 people), above the South West and England average (16%).

The recently published Community Mental Health Profiles 2013[4] highlight that the proportion of adults in Cornwall suffering with depression (13%) is significantly higher than the England average. It also indicates that people in Cornwall are at greater risk than the England average of developing a disease, injury or mental health problem due to higher levels of statutory homelessness and percentage of the population with limiting long term illness (worst quartile nationally).

While the need for integrated support for people with concurrent mental health and drug or alcohol problems is widely understood, the reality is often very different.

Successful outcomes for both problems need early intervention and effective joint working between drug and alcohol treatment and mental health services in integrated, recovery-oriented local systems.

For the larger number of individuals with less severe mental health conditions alongside substance misuse problems, provision is even less developed and they may be particularly at risk from any fragmentation of service provision arising from the different commissioning arrangements for mental health and substance misuse services under the current reforms. It is important that the differing needs of both these groups are considered as the reform process develops.

Improving Access to Psychological Therapies programme (IAPT)

IAPT has produced a ‘Positive practice guide for working with people who use drugs and alcohol’ (2012) and recommends:

  • People with a history of drug and alcohol problems, and receiving treatment, do not necessarily pose any special challenges for IAPT services but there are often substantial clinical gains to be made in working with them.
  • Substance misuse clients with mental health problems should have access to NICE-recommended psychological interventions, including CBT for depression and anxiety and there is no evidence that substance misuse per se makes the usual psychological therapies ineffective (NICE, 2007).
  • Between 70 and 80 per cent of clients in drug and alcohol services have common mental health problems, largely anxiety, depression and trauma (Weaver, 2003). The same study also found high levels of drug use and hazardous and harmful drinking in the populations using mental health services.
  • The study concluded that ‘substance misuse services should work more collaboratively with local psychotherapy services and GPs to improve management of co-morbid patients who do not meet the criteria for access to community mental health services’.

Priorities for 2013/14 therefore include the need to develop and implement a local dual diagnosis strategy. Key elements to include an agreed system of pathways, contracts with providers, workforce development (including training for healthcare professionals in substance misuse workers), alignment of Payment by Results systems and a service user and families/carers feedback framework.

We also need to develop a specific IAPT pathway to describe the access to psychological therapies for people in alcohol and drug treatment and those receiving psychological therapies who require assistance with alcohol and drug problems.

6. Harm Reduction

Preventing the spread of blood borne viruses, drug related deaths and hospital admission are key health priority outcomes to be delivered in drug treatment.

Blood borne viruses

People who inject drugs are vulnerable to a wide range of viral and bacterial infections. These infections can result in high levels of illness and in death.

  • The latest figures from national research estimate that there are between 398 and 1,312 injecting opiate and / or crack users in Cornwall and the Isles of Scilly, with a mid-point estimate of 858.

Immunisation against Hepatitis B and testing for Hepatitis C form part of the treatment plan for drug users with a history of injecting behaviour.

In 2012/13 Dry Blood Spot Testing was introduced to increase the opportunities for screening people with histories of injecting in the treatment population. Rates of vaccination for hepatitis B and testing for hepatitis C have improved significantly over the last two years and are well above the national average, but still fall short of national targets to reach 90%.

  • 63% of adults new to treatment eligible for a Hepatitis B vaccination have accepted one, compared with the national average of 48%
  • 82% of previous or current injectors eligible for a Hepatitis C test have received one, compared with the national average of 70%.

Unsafe injecting

The DAAT and Cornwall Council’s Community Safety Team receive sporadic reports of needle finds and other evidence that public places, such as toilets, are being used for injecting. Recently, for example, we have received two reports concerning Bodmin.

In the review of drug related deaths last year, public toilets were identified as being key venues for drug related litter and overdose and the DAAT and Cornwall Council took positive action to minimise the risk.

Needle exchange services

599 clients accessed Freshfield harm reduction services in 2011/12 accruing just under 2,800 visits over the course of the year, an increase of 7% compared with last year. 89% of visits were to static sites and the remainder were home visits and / or postal service. Almost 282,300 syringes were issued, of which 98% were known to be disposed of safely.

Freshfield report that users of Performance and Image Enhancing Drugs (PIED) now constitute the majority of their service users, seeing rapid growth over the last few years.