Clinical & Policy Updates:
SMMGP Policy Update January 2010
|Download the PDF version of this Update here! (PDF*, 90K)|
Martin Jelsma, Transnational Institute, Oct 2009.
This paper summarises good practices in legislative reforms world-wide, where there is an emphasis away from a zero-tolerance model towards a more evidence-based and humane drug policy. It provides examples of lessons learnt in practice about less punitive approaches. Evidence suggests that societies that have legislation that lessens criminalisation and shifts resources towards prevention, treatment and harm reduction are more effective in reducing drug-related problems. Fears that softening drug laws would lead to increases in drug use have proven to be unfounded.
The centre for these reforms has been Europe, and the European Monitoring Centre on Drugs and Addiction (EMCDDA) sums up the approach:
- a more powerful focus on treatment rather than on criminal punishment;
- a sense of disproportion between custodial sentences (and a criminal record) and illicit use of drugs; and
- a perception that cannabis is less dangerous to health compared to other drugs.
Other countries where similar reforms have taken place are Australia, Canada and within several US States. Increasingly Latin America is becoming a centre for advancing this type of reform. The report examines decriminalisation of drug users, alternatives to incarceration, proportionality of sentences, harm reduction and drug law reform, and reclassification of substances.
The conclusions include that criminalising users drives them away from health services due to fear of arrest and "into the shadows" and locks them up in "schools of crime" and argues that this cycle derails lives even more than drug dependence itself and tellingly - diminishing chances of recovery.
Current trends in drug reform around the world pose a challenge to the zerotolerance model of the UN conventions and the "war on drugs" approach.
A sane response must surely be to view drug use as primarily a health issue, supported by policies that reduce the harms caused by drug use.
Sadly, there are still too many countries where it is treated as a criminal condition so here's hoping that this trend continues.
The NTA has published the findings of an Ipsos MORI poll they commissioned on public attitudes to treatment for drug users. The poll revealed that there is overwhelming public support (82% of respondents) for the benefits that NHS treatment for drug addiction provides to communities and society. There has been a significant increase in the numbers of people accessing drug treatment offered on the NHS in England in recent years, improving the lives of the individual drug user and having a positive impact on the communities affected by drug addiction, including the reduction of crime.
The NTA poll, which was undertaken to coincide with the release by the Home Office of the Drug Treatment Outcomes Research Study (DTORS) to evaluate the long-term effectiveness of drug treatment, revealed that communities have faith in the UK drug treatment system, which has a harm reduction approach, and a belief in its benefits, which include the reduction of crime.
Joseph Rowntree Foundation, Dec 2009, www.poverty.org.uk
This is the 12th report in a series on indicators of poverty and social exclusion in the United Kingdom. Key points include:
- The number of unemployed or people who want work is the highest since 1997 and the unemployment rate in the 16 to 24 age group is higher than since the series began in 1993. These increases predate the recession.
- The number of people living in lowincome households has risen by 1.3 million in the last three years.
- The number of children in lowincome households is at 2.1 million - the highest it has ever been.
Despite this, the overall picture is not all negative:
- The number of 16 year olds getting fewer GCSEs is now lower than at any point in the last ten years.
- The rate of premature death (before age 65) has come down for men and women by one sixth over the last ten years (although rate for men is still 50% higher than the rate for women).
- There are striking reductions in levels of anxiety about being the victim of burglary or violent crime.
Social exclusion indicators over the last decade (including the recession) that have been impacted on are low incomes, child well-being, adult wellbeing and community activity. Whilst this study reflects the impact of the recession, it is significant that some of the underlying problems became negative trends much earlier - in 2004 and 2005. Child poverty targets, which have long been a high priority for the government, are falling behind other social exclusion indicators where there are improvements.
The NTA estimates (from NDTMS figures) that at least 120,000 children are living with adult drug users in England's total treatment population.
We therefore welcome the recent announcement by the Department for Schools and Families of Child Poverty Family Intervention Projects which will provide additional investment, including in training - and more intensive family support - for children of parents with drug and alcohol problems; children whose parents are in prison (which affects more children each year than divorce); and children who are carers.
In the Child Poverty Bill debate which took place in the House of Lords this month the Opposition asked for an amendment to the Bill to make the link between Child Poverty and (parental) substance misuse.
For more details and graphs visit the NTA website.
The NTA released its figures for young people accessing specialist substance misuse services in England during 2008-09, which show that more teenagers are receiving help for drug and alcohol problems than ever before - due to the increased availability of services. Most under 18s are receiving help for problems with the misuse of cannabis and/or alcohol, but the number of young people accessing services for cocaine has increased.
The analysis of trends in interventions offered to this group over the last four years shows a steady decline in the reported incidence of problems with "hard drugs" such as heroin. The NTA report suggests that the pattern echoes a generational shift away from drugs such as heroin and crack among young adults in the 18-24 age group in treatment.
With the NTA report on young people's statistics showing that there is a decrease in the number of young people presenting with problem crack and heroin drug use, it may well be that there are emerging trends in new drugs of misuse which are not yet evident in users presenting for treatment. Although the numbers using heroin are reduced, they are still significant and the availability of YP prescribing services are patchy around the country.
Dr Harry Sumnall and Olivia Wooding, Centre for Public Health, Liverpool John Moores University, Dec 2009.
This is an early briefing given that there is little scientific evidence available on mephedrone at this time. Mephedrone, which is also known as 4-MMC, Meow, M-Cat) has attracted media attention recently because it is considered a "legal high" and is easy available on the internet as tablets or powder. There have also been unsubstantiated speculations around whether or not it has contributed to deaths. The ACMD is currently reviewing what evidence there is and is expected to advise government this year about the classification of this drug.
Mephedrone (not to be confused with methedrone - a different compound) and other similar drugs have no licensed medicinal use. Reports are that it produces a similar effect to ecstasy (MDMA) which last for 2 to 3 hours when taken orally. Its negative effects too are similar to ecstasy/MDMA and include a desire to re-dose, insomnia, changes in body temperature, heart palpitations, impaired short term memory, tightened jaw muscles and teeth grinding. There are currently no guidelines for the treatment of adverse reactions related to mephedrone.
There are some signs that young people seem to be moving away from using drugs favoured by preceding generations, and the treatment field too has to "move with the times". However, the principles of working with users in an empathic, motivationally enhancing framework will be a core part of drug treatment regardless of the drug of misuse.
An article in the SCANbites' Winter issue examines new drug trends based on information from the internet in a Web Mapping Project http://tinyurl.com/SCANbites-Winter
SMMGP recently attended a K-Day arranged by a group of researchers - a dialogue and information sharing event with ketamine users, where mephedrone was mentioned frequently by people who anecdotally reported using it as well as ketamine. Soon, it may be classified as an illegal drug with all the associated harms attached to criminalisation. One to watch.
Jez Buffin, Yaser Mir and Imran Mirza, Dec 2009
The National Drugs and Race Equality Coalition (NDAREC) recently published a report on the findings from community engagement forums on the use of khat. It summarises discussions held with Somali, Ethiopian, Eritrean and Yemeni communities in boroughs with high concentrations of these population groups to explore the impact of khat. It makes a series of recommendations which it is hoped will influence national policy makers and decisions made by commissioners.
Key themes identified by the report includes the finding that GPs and mainstream drug services fail to ask about, or are ignoring the signs of khat use, possibly because of being unaware of khat use and cultural patterns of use. Users too are reluctant to mention khat use during a GP consultation as they anticipate that GPs do not know enough about it. In addition there are no khat-specific services for GPs to refer users to. High levels of use result in both physical and mental health problems, including intestinal damage, insomnia and depression. Dental health is a major issue for users.
The report suggests that differing patterns of khat chewing in the UK and in countries of origin exist, for example in the UK vulnerable people who have nothing to do and many hours to spend may use in far greater quantities than they would have done in their countries of origin where cultural norms would have imposed boundaries for excessive use. Khat use amongst men usually takes place in mafreshi (unlicensed khat houses in the UK) in communities with populations from the countries mentioned earlier. Khat use is also common amongst women in these communities, but they are more likely to use at home and not go to a mafreshi.
The report suggests that there is a requirement to respond better to the needs of khat-using communities and identifies training needs for mainstream health and social care providers.
Whilst khat use is not a new phenomenon in the UK, and there have been other reports on it in the past few years, in the increasingly diverse society we live in, where we offer "health care to all" it reminds us of the importance of being culturally aware when talking to patients.
For more details please visit the NTA website.
This new guide from the NTA for adult treatment drug partnerships and their commissioning staff quotes an extract from the 2008 national drug strategy which states that "the goal for drug users is to achieve abstinence from their drug or drugs of dependency".
The foreword continues by talking about the need for partnerships to express and make clear the vision for drug treatment in their area for those currently in treatment, and for newcomers to treatment. This requires that the ambitions of service users and their families in terms of their drug treatment be met - by paying heed to service users' own aspirations and maximising opportunities for individuals to recover from problematic drug use.
It necessitates working with users, and integration with their care plans, as well as consideration of the housing and employment needs they express in order to support them in their recovery.
Commissioners may want to harness local job opportunities, build links to local mutual aid groups and will need to pay close attention to how service users exit treatment, ensuring planned exits from treatment (either through structured day services, communitybased abstinence services or rehabilitation) and establishing pathways to mutual aid groups. In order to assist in delivery, the NTA promises to work with drug partnerships to ensure that that drug treatment staff are competent with good clinical governance and provide "value for money". It will also work in partnership to ensure that there are tangible and sustained benefits to families, children, and wider communities where someone's drug use is having a negative impact.
Rightly so, most of us are embracing the recovery agenda. As commissioners and drug partnerships are urged to get on the road to recovery, those of us working in primary care recognise that recovery needs to be person defined and is evident in the person achieving stability on a methadone script, and in the person who is happily sober in AA. The challenge now, not least with the election this year, is how we share our wealth of knowledge and rich experience of recovery with those who develop strategy.
The Department of Health (DH) is to devolve the funding known as the Pharmacy Global Sum to PCTs from 1 April 2010. This is in line with DH policy to devolve central NHS funding to PCTs wherever possible.
There will also be changes to the basis for re-charge for costs of pharmacy service provision. At present, these costs are charged to the PCT of the dispenser, but the new arrangements will move these costs for the most part to the PCT of the prescriber.
This move may have implications for FP10 prescription costs incurred by drug services.
DH is holding a series of events to explain the implications of the changes for 2010/11. For more information see the Primary Care Commissioning website.