Monday, 23 February 2015

Bite-sized Briefing - Take-home naloxone for opioid overdose in people who use drugs

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 January.

Case Study of steps to take to introduce
a take-home naloxone scheme
Public Health England have produced a document giving advice to local authorities and others on promoting the wider availability of the overdose medicine naloxone.

The paper sets out the current position on supplying naloxone saying that it can be prescribed to anyone who is: currently using illicit opiates (such as heroin); receiving an opioid substitution therapy; leaving prison with a history of drug use; those who have previously taken opiates (in order to prevent relapse).  Equally importantly, if the person who has been supplied naloxone agrees then it can also be supplied to family members, carers, peers and friends.  They do warn that:
Regardless of how naloxone is provided locally, information on the risks of overdose and how to respond in an emergency should be available to all those at risk, their carers and families, and staff.
Freedom of Information requests by Release and the National Needle Exchange Forum show that one in three local authorities are currently providing take-home naloxone.

Changes to the regulations which will make it even easier to make naloxone more widely available are being drafted by the Medicines and Healthcare products Regulatory Agency (MHRA) and will come into force in October 2015.  PHE suggest that the new regulations will mean “naloxone is made exempt from prescription only medicine requirements when it is supplied by a drug service commissioned by a local authority or NHS.”

The paper includes steps that local authorities or others interested in making naloxone more widely available may wish to take, based on the experience of Birmingham which has had a take-home scheme since 2012.  There is also: an outline of the issues that need to be covered in training in overdose prevention; advice on recording how naloxone is supplied; and a reminder that naloxone is just one way to reduce drug related deaths.

Download the paper here.

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

Friday, 20 February 2015

What does a good life mean to you?

It might mean having a safe and secure home; forming respectful and trusting relationships; or experiencing new places and activities. In fact, I'd be surprised if at least one of those didn't feature in your answer.

Recently researchers from Revolving Doors Agency asked members of their national service user forum – all of whom have experience of multiple needs, including drug and alcohol misuse – to think about this question.

They produced collages (right, and below) that represented their ideas of a good life, and then talked through them. A report describing the process was published yesterday, and makes for a fascinating read. Looking through it, a few things occurred to me.

Firstly, those basic components of the good life I mentioned earlier are as important to people facing complex situations such as drug dependency as anyone else – and arguably more so.

This should be obvious, but often our public debate treats people with serious problems as if they can only be defined in terms of what's gone wrong. Ask people what they want to achieve, though, and you get a very different response. For instance, one participant said:
“That’s just … what I would like, to be able to, sleeping easy at night, not worrying, security, not worrying, just to be able to feel safe in my own house, not having the door banging in or, yeah bailiffs, no police, no dealers, no owing money, just … happy place."
Secondly, work is a hugely important part of this picture. One person, talking about their job, said: “I respect myself, I feel good cos I’m one of the workers coming home from work and life’s normal.”

This echoes the findings of our project with Making Every Adult Matter, Voices from the Frontline. Many people with experience of multiple needs see meaningful work as a central goal - even if they're some distance from full-time employment.

Finally, it made me think about the role of treatment services. Some people involved in the study felt that an important step towards the life they wanted was ceasing to be dependent on services. However, others recognised the value of the strong, positive relationships that they formed through accessing them.

The recovery movement rightly acknowledges the importance of creating a supportive community within which people can resolve their challenges. Sometimes, though, this comes with strong expectations about the manner in which people need to change their lives, and at what speed.

The report concludes (and for what it's worth, I agree) that as far as possible, someone seeking help must decide for themselves what a better life looks like. That requires a support system that can reconcile professionals' views on what’s most important – reducing drug use, getting a home, getting a job – with people's own personal goals.

(Importantly, it also provides reason to think that coercing people into accessing treatment, as has recently been proposed, is unlikely to help people achieve lasting change.)

It follows from this that the system mustn't put barriers in the way of success. Through our work on Voices from the Frontline, we've seen how the unintended consequences of government policy can hold people back from realising the kind of life they want to lead. This valuable research helps strengthen the case for why that has to change.

Sam Thomas is the programme manager for Voices from the Frontline. Follow him on Twitter @iamsamthomas

Tuesday, 17 February 2015

Education Select Committee calls for PHSE to be made statutory

Life Lessons, photo by Flickr user niXerKG
DrugScope welcomes the Education Select Committee’s recommendation to make Personal Health Social and Economic education a statutory part of the national curriculum.

As we said in our evidence to the committee, despite sustained and important falls in both the prevalence and problems that young people face as a result of their drug and alcohol use, young people in England are amongst the mostly likely to have been drunk before the age of 13 years old. 

Addressing these risks in a developmental way is an important component of an effective preventative response and so we are pleased to support the call for PSHE to be a mandated part of the school curriculum.

This year Public Health England report that more than a quarter of all those under 18 who entered drug treatment were identified and referred to specialist services by schools, colleges and pupil referral units; over half were engaged in mainstream education and a further one in five were in alternative education.

PSHE education can help support pupils in developing the values they bring to health decisions, and in developing the resilience that will allow them to bounce back when mistakes are made.

Earlier this year the new psychoactive substances expert panel made a similar recommendation, for PSHE to be given statutory status, DrugScope hopes that the government will now listen to the evidence collected by the Education Select Committee.

Monday, 16 February 2015

Sick and sanctioned

How do we best engage people with drug and alcohol problems but who seem unwilling to enter treatment?  The debate has been re-ignited again this weekend by a proposal by the Conservatives that, should they win the next election, Dame Carol Black will be asked to look at whether those on sickness benefits with drug, alcohol and obesity issues should have those benefits reduced if they refuse treatment.

A recent Freedom of Information request to the DWP indicates that there are about ninety thousand people claiming sickness benefits where drug and alcohol problems are their most significant issue; but it isn't clear how many of those are not engaged in treatment already.

As the Guardian in their coverage of the proposals makes clear, this isn't the first time these sorts of ideas have entered the political debate.  Last year saw similar ideas proposed in relation to those claimants with mental health problems though those have not resurfaced in this proposal.

The Guardian's report points out that DrugScope has been critical of previous moves to introduce benefit sanctions on people with drug and alcohol problems, both under this government and the previous one.

Indeed it has been pointed out to us that this government explicitly ruled out the approach they are now proposing, with Lord Freud telling the House of Lords:
First, it mandates claimants to do something, such as being tested for drugs, that is not directly about helping people to approach the labour market. That does not mean that entering treatment is not the right approach to help many claimants who are substance dependent to address their barriers to work, but-and this leads to my second reason-claimants enter treatment for a series of complex reasons, and whether or not they succeed also depends on a series of complex reasons. Forcing claimants to answer, for example, questions about possible drug use, requiring them to attend substance-related assessments about drug use and insisting that claimants enter a mandatory rehabilitation plan if they decline to enter treatment voluntarily would be asking them to do something a large proportion of them would not want to do. If we took the approach of the previous Government, we would create a high risk of those claimants immediately failing these requirements and having to be sanctioned.

Wednesday, 4 February 2015

10 Interesting Things about Alcohol and Other Drugs (February 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:
  • Deaths amongst opioid users (especially those which are not overdose related); 
  • Children in need and care and substance use problems; 
  • Multiple and complex needs; 
  • Trends in police recorded drug offences; 
  • Gang membership, dependency and mental health problems; 
  • Seizures of synthetic cannabinoids in prison; 
  • Public perceptions of the safety of drug taking 

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).

Friday, 30 January 2015

PHE's Duncan Selbie gives evidence to the Public Accounts Commitee

By Richard Clifton

Almost two years ago, Public Health England (PHE) began operating with a mission to improve wellbeing and reduce health inequalities across the country. £2.7 billion of ring-fenced grants were given to local authorities in 2013/14 to improve public health, including the provision of drug and alcohol treatment and related interventions. The National Audit Office (NAO) produced a report in December 2014 evaluating whether intended outcomes and value for money were likely to be achieved. 

On the 20th January, the chief executive of PHE, Duncan Selbie, and three others (Dr Felicity Harvey from the Department of Health, Michael Brodie from PHE and Dr Janet Atherton from the Association of Directors of Public Health - ADPH) were called to give evidence to the Public Accounts Committee. DrugScope provided a short briefing to the Committee ahead of the evidence session, focusing on key findings from the forthcoming State of the Sector 2014-15 report and emphasising the breadth and depth of the contribution made to improved public health by the drug/alcohol treatment sector.

The committee voiced concerns about the allocation of public health resources. The committee cited a survey conducted by the British Medical Association (BMA) which suggested that some public health funding had been diverted to support services – not necessarily public health services as usually understood - that would otherwise have faced cuts due to reductions in local authority revenue funding. Margaret Hodge argued that this could potentially lead to a lost opportunity to improve public health.
 Duncan Selbie insisted that the grants were not substitutes for general revenue funding, but that local authorities had flexibility to spend money where it was most required and the allocations were best decided at a local level. Importance was placed on authorities using public health grants to achieve beneficial outcomes at a local level and assessed against local need. There is a mandate for an equitable service, but services should be prioritised based on the needs of individual areas.

Witnesses were asked to explain PHE’s position in relation to NHS England, local authorities and the Department of Health. The committee focussed on a number of different aspects throughout the session: how PHE can work to influence local decisions; how it can influence national allocations, and around the role of mandation in ensuring the effective and universal delivery of services and interventions.

The committee also raised the matter of the ring fence around the public health grant. Having already expressed concerns about its porosity, members were keen to seek views on the future of the ring fence, given that is currently only guaranteed to be in place until the end of 2015-16. Although Selbie has previously called for the ring fence to remain in place beyond 2015-16, on this occasion the consensus among witnesses was that it was a matter for an incoming government.

Selbie argued that health and wellbeing should not be solely conflated with the NHS; and that public health must be considered within the wider context of both economic and environmental issues. In his view, economic prosperity was the biggest health driver and Margaret Hodge agreed that employment, education and housing are all important. However, the committee was keen to focus on areas PHE directly control and witnesses were asked about PHE’s influence at both a local and national level.

Drug and alcohol misuse initiatives receive a third of the public health budget, and so were discussed in a number of contexts during the select committee. While not being included as prescribed functions for local authorities, there are grant conditions in place for substance misuse – a matter that was of some interest to David Burrowes MP, who co-chairs the APPG on Complex Needs and Dual Diagnosis with Lord (Victor) Adebowale of Turning Point. Selbie stated that treatment for substance misuse was not included as a prescribed function due to the variation in need across different authorities and that prioritisation must therefore be local. Referring again to the NAO report, Margaret Hodge observed that when less funding is allocated to drug and alcohol misuse, outcomes are worse.

There was discussion about using the health premium to reward local authorities producing successful results in public health, for which drug treatment is the only national indicator. Like the grant condition, the health premium is new in 2015-16  and is seen as one of the key mechanisms to incentivise and maintain investment in treatment.. The committee expressed concern that the health premium, limited to £5m nationally, might offer only a modest incentive to improve outcomes. Dr Harvey agreed with the importance of an incentive programme and stated the premiums available would increase after a spending review.

Selbie was especially passionate about plain packaging for cigarettes and minimum-unit pricing for alcohol, discussing his desire for a tobacco-free country in the future. He stated that PHE fully support measures to reduce demand for and harm from the two substances due to compelling evidence, and it is down to parliament to pass laws and garner support for harm reduction measures.

As 2013/14 was the first full year of PHE, it was too early to identify if public health outcomes were improving, subsequent years should yield more meaningful data to compare against the baseline. The Public Health Outcomes Framework was acknowledged as a key development in this area. Other examples of effective interventions were provided: PHE’s emergency MMR catch-up vaccinations led to a reduction in the number of measles cases from 673 in the first quarter of 2013 to 70 in the same period of 2014. The ‘Stoptober’ smoking cessation campaign, designed and supported by PHE was successful as well, with a University College evaluation finding it to be cost effective and that it had saved 10,000 years of life.

Wednesday, 28 January 2015

Half the picture – beyond drug overdose as a cause of death in opioid using people

The big rise in heroin and other opioid drug poisonings that the ONS reported last year has been real focus of concern amongst service providers, policy makers and anyone who cares about the lives of vulnerable people.

But new research from the University of Manchester suggests that while overdoses in opioid users remains the largest cause of death (43%) there are other causes which providers, commissioners and policy makers need to be conscious of particularly amongst older drug users.

Dr Tim Millar who led the research says,
It is apparent that older users of opioids are one of the most vulnerable groups in society.
Looking at the paper it’s easy to see why.