Clinical & Policy Updates:
SMMGP Policy Update November 2010
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The ACMD published a report this month on the use of foil as a harm reduction intervention to promote the choice to smoke heroin as an option (rather than to inject it). The Council considered the evidence regarding the provision of foil as exempt under the Misuse of Drugs Act 1971, and having considered various options for the way forward, makes the recommendation that foil be exempt under Section 9A of the Act.
The Council concluded that current evidence does not show that there are harmful effects caused by the provision of foil; and that previous studies have concluded that the intervention does not encourage the use of illegal drugs. The ACMD found that there are benefits attached to the provision of foil to drug users. It noted that the recommendation of foil as a harm reduction intervention is different from that of other paraphernalia associated with injecting practice, and that the use of foil is designed to move individuals away from injecting practice and its associated risks.
It was found that the benefits could include: potential decrease in blood borne virus transmission, increased contact and engagement with drug service workers, reduced systemic infections, reduced soft tissue and vascular damage, a lower risk of overdose and reduced litter, e.g. needles. The findings of the report and recommendations were communicated to the Home Secretary, and the Minister of Health.
We wholeheartedly endorse the findings of the ACMD on the provision of foil as a useful harm reduction intervention. It is safe, simple and should be made readily available to drug users to empower them to exercise the choice to consider safer options in route of administration. Although smoking drugs off foil is not without risk it is so much safer than injecting particularly in relationship to HCV transmission. In ACMD's 2009 report The primary prevention of hepatitis C among injecting drug users they estimated that: "There are 120,000 to 300,000 (mid estimate 190,000) people that have been infected with HCV in England and Wales, and about 50,000 in Scotland. 85% became infected through injecting drug use." This report concluded that "ultimately we need to stop injecting to reduce the risk of HCV". We look forward to the response of the Government accepting the use of foil as a basic, yet far-reaching, harm reduction intervention.
Rebecca Daddow and Steve Broome, Royal Society for the encouragement of Arts (RSA). For full report visit the RSA website.
The RSA this month launched a comprehensive report of a major project which commenced with their 2007 investigation into Drugs Policy (Drugs - Facing Facts). Using a "bottom-up" approach, the RSA in partnership with West Sussex Drug and Alcohol Action Team, undertook research with over 200 former and current drug and alcohol users to formulate ideals of what users sought from treatment and concluded that services are too centralised, standardised and still too stigmatised to help the majority of problematic users.
The report firmly puts users at the centre of shaping effective treatment. It finds that whilst the concept of user-led services is not new, it is not part of any mainstream framework, and therefore remains patchy, and more so for drug and alcohol users.
The report also finds that the notion of having "recovery capital" in the shape of personal, community and social resources is vital in sustaining the commitment to address problem drug and alcohol use; and that recovery is "contagious" within a community where there are networks of people with a common goal of making changes in their lives towards recovering from drug and alcohol addiction. The report states that when GPs "get it right", they play a powerful and immensely significant role in improving their patients' lives in this area. It does contain some criticism of GPs by the user group, but is also clear from the findings that GP involvement is seen as being so important that one of the key local initiatives arising from this report will seek to provide GPs in the area with a user-led training kit to improve their practice.
With perfect timing for the new localism agenda, the report highlights the need for initiatives and services locally that are more personalised, better balanced between psychosocial and medical interventions and better able to draw on a whole community response to the problems associated with problematic drug and alcohol use.
It is heartening to see that GP involvement is seen as a key initiative, but saddening that this came out of negative experiences reported by users when they approached their GPs. We have to accept that stigmatisation and other barriers still exist in some general practices and SMMGP will continue to encourage increased awareness through knowledge and understanding.
On the back of this project, the RSA will launch a range of user-led innovations, which will include a training pack for local GPs. We look forward to reviewing it in due course.
See UK Drug Policy Commission website for more information.
The UK Drug Policy Commission is continuing its work on the problem of stigma, part of a major research undertaking to examine the extreme stigma attached to drug users. At a stakeholder workshop arranged by UKDPC this month, the organisation reported on the results of their media analysis research, which found that print media in particular was dominated by crime reporting in relation to drugs and that treatment and recovery are never mentioned "...unless someone famous is entering rehab".
At the workshop a presentation by Time to Change - a social movement to tackle discrimination against people who used mental health services reported that in terms of public attitudes there was often a difference between what people said and what they did - that in reality people were generally tolerant towards people who had mental health problems, despite what surveys showed. But drug users were seen differently - to be largely responsible for their condition and not blameless. Drug users and their families had shared "horrendous" stories of the attitudes of healthcare staff with UKDPC researchers. Drug users and their families experienced social isolation and rejection due to stigma, and took it on and accepted it as the general view.
Stigma of drug use and its knock-on effects of social exclusion, poverty, unemployment, and lack of housing is potentially more damaging than the use itself and are a daily reality for many people and their families affected by drugs. People who use drugs are often blamed for a whole range of social ills which pave the way for the development of some policies which would never be tolerated for other disadvantaged groups. It is therefore important to be continually vigilant in carrying a consistent message when dealing with the press, in public, but especially within treatment services that people who use drugs and alcohol are not denied the right to basic human rights including respect and access to treatment.
With recovery likely to be central to the Government's new drug strategy, and rightly so, it is vital that we address stigma on many levels - including our own, that of our organisations and institutional stigma. We need to take care with language and not reduce people to one activity. We believe that the new RCGP Certificate in Harm Reduction, Health and Wellbeing for Substance Misusers will contribute to the education of front line workers not necessarily working in the field, and who may come in contact with people who use drugs and alcohol in the course of their work.
See www.scotland.gov.uk for more information and access to the full document.
This recently published report by the Scottish Government, undertook a review of the international literature in relation to what is known about "recovery" in the addictions field and an evidence-based appraisal of "what works" in this area. It includes a review of the recently published literature examining three areas: recovery focused research; treatment effectiveness; and treatment outcomes.
The main points made in this large-scale review of the evidence for recovery models and which is part of the Scottish Government's paradigm shift towards a recovery-oriented treatment system are:
- The existing literature is largely on alcohol and is North American dominated.
- The report acknowledges that there are some serious shortcomings within this literature.
- Lots of people recover. More social/cultural capital produces better recovery outcomes in general and we should therefore encourage the development of "recovery capital" by, for example, supporting clients and patients to access support from local recovery networks or other resources including finding a safe place to live, developing meaningful activities and inclusion in their local community.
- Barriers to recovery do exist and include psychological problems (mental illnesses and the absence of strengths, such as self-esteem and self-efficacy), significant physical morbidities (including blood borne viruses), social isolation (including stigma) and ongoing chaotic substance use.
The publication of this report and its contribution to the current body of knowledge around the subject is timely and useful. We are advised to work from the evidence base, but as Gerry Stimson said in the inaugural Alison Chesney and Eddie Killoran Memorial Lecture this month: "if evidence was all we needed we would be well ahead". (See Gerry Stimson lecture here)
The Drugs Strategy is going to be based on a framework that embraces recovery in all its facets and we hope that we aren't in for a period of "policy-based evidence making" (quoting Gerry again) and will aim to try to understand the good reasons behind the decisions of current policy makers. But it is reassuring to note that the definitions of recovery that are becoming more consensual do not necessarily require abstinence and embrace the whole spectrum of harm reduction. SMMGP supports personally determined goals of recovery.
See www.government-news.co.uk for more information
The Government last month announced plans for a "pathfinder" scheme for "early adopters" - GP practices who want to press ahead with commissioning care for patients. These pathfinder pilot schemes will take on budgets a year before PCTs are scrapped in April 2013, and in effect will test different design concepts of GP Consortia and identify issues or areas of learning early on.
The Pathfinders Consortia will contribute their experience to help shape the way that the GP Consortia scheme set out in the NHS White Paper will work in the future. In support one million pounds has been set aside from central funding to back regional learning programmes across England and GP practices keen to participate can put themselves forward from this month to their Primary Care Trust and Strategic Health Authority. A series of resources in the shape of commissioning packs (e.g. the first one is for cardiac rehabilitation) is already being rolled out.
Several commentators - including the RCGP and King's Fund - have called for a more measured way of implementing GP commissioning, rather than imposing it nationally in 2013.
Whilst recognising that GP commissioning presents opportunities for GPs and the NHS, there have been concerns about how the scale of the change can be managed. It is therefore encouraging that the Government has responded positively to criticism by providing this initiative for GP practices keen to progress the new commissioning structures.
Let's hope the final product considers feedback from these pioneer groups carefully - and favours the continuance of the NHS.
Commissioning for drug and alcohol services is set to be ring fenced within public health which will now be managed by local authorities and not the GP consortia. What is not clear is how the relationship between the public health commissioners and the GP commissioners will play out, and how much influence one will have on the other.
The much anticipated changes in the drug treatment system will be clearer with the publication in December of the new Drugs Strategy with its ambition for recovery for drug users. Payment by results are at the centre of the criminal justice system's "rehabilitation revolution" and a handful of pilot sites to introduce this concept into substance misuse are planned for 2011, but it may not come to a drug service near you for some time.
The Public Health White Paper entitled "Healthy Lives, Healthy People" published on the last day of November, sets out its vision for the new public health service: Public Health England (PHE).
Localism will be at the heart of the new public health system, each local authority will have a Department of Public Health and Directors of Public Health (DsPH) will be the strategic leaders for public health in local communities. Each local authority will have a health and wellbeing board, which will have a membership of elected members including GP consortia. PHE will be responsible for funding and ensuring the provision of services including recovery from drug dependency, alcohol prevention, sexual health etc.
What is clear is that all areas will be directly affected by a shift towards outcome-based commissioning. The NTA are finalising work on The draft recovery framework document - to replace Models of Care 2006 Update - and which will be out for consultation on 13 December.
There is likely to be more pathfinding ahead as we find out soon what the new Drug Strategy brings. We look forward with anticipation to the NTA consultation document on the new national framework - the revised Models of Care - and will keep members informed on our website. One thing we do know is there will be no more tiers! In the midst of all the jargon DrugScope have an accessible and useful "Bitesized Briefing" on "Payments by Results" and how it will affect the drugs field, available in the Other Resources section.
The recent statistics released by the NTA are more than just an annual snapshot for one year, and took into account NDTMS figures for the past 5 years, as well as recent research from Glasgow University. The report on statistics published last month by the NTA shows changing patterns of drug use and dependency, including a conclusion drawn from the stats that for the first time the number of adults seeking treatment for addiction to cocaine (for both powder and crack) has fallen, particularly amongst 18-24 year olds.
For heroin users in treatment, this year's statistics build on last year's report findings which revealed a declining pattern in the number of adults seeking treatment for this drug. This year's figures confirm that this decline is continuing, particularly in younger adults (from 18 up to age 29). The NTA report draws the conclusion that there is an older (1980s) generation being treated for heroin dependency but that fewer young people are risking becoming addicted to this drug. A significant trend revealed by the analysis was that more adults aged 18 to 24 are seeking treatment for problems with cannabis.
NTA statistics indicate that there are fewer adults seeking treatment for heroin use, but we need to be careful not to celebrate too soon and consider the direct link between the level of welfare provided by a country and its drug user population (for example refer Alex Stevens article "Needle Syndrome" in the current Druglink,available on subscription). Welfare cuts will make it much harder for the people who suffer most from inequality to avoid and recover from dependent drug use and the government would do well to heed this.
Key messages include:
- Needle and syringe sharing has declined in recent years, but almost one-fifth of injecting drug users continue to share. The level of needle and syringe sharing reported in England, Wales and Northern Ireland has declined from 31% in 2000 to 19% in 2009.
- Infections are common among injecting drug users. Around one-half of injecting drug users have been infected with hepatitis C, one-sixth with hepatitis B, and about one-third reported a symptom of a bacterial infection (such as a sore or abscess) at an injecting site in the past year.
- The prevalence of HIV among those who have injected drugs remains low and is estimated to be 1.5% overall in the UK and the uptake of HIV testing is improving, with three-quarters of injecting drug users now reporting having been tested; however, almost a third of injecting drug users with HIV remain unaware of their infection.
- Hepatitis C: In 2009, 11,005 hepatitis C infections were diagnosed in the UK, and around 90% of these infections will have been acquired from injecting drug use.
- Current levels of hepatitis C transmission among IDUs probably remain higher than a decade ago, as 24% of recent initiates. participating in the UAM survey were infected in 2009 compared with 12% in 2000.
- Uptake of voluntary confidential testing for hepatitis C has increased among IDUs with the proportion reporting ever having been tested in England, Wales and Northern Ireland rising from 49% in 2000 to 81% in 2009.
- Hepatitis B: The transmission of hepatitis B continues among IDUs, but may have declined in recent years as the proportion of participants in the UAM survey ever infected has fallen from 28% in 2000 to 17% in 2009.
Not forgetting anthrax - a very rare infection caused by a bacterium that produces spores. These spores can survive in the environment for a long time and so can contaminate heroin during production or distribution. The first confirmed case of Anthrax among a drug user in the UK was reported in December 2009. Up to 30 September 2010 there had been a total of 51 cases reported in the UK (47 in Scotland and four in England); of which 16 had died. During this period, two cases were also reported in Germany. There were no reports from elsewhere in Europe.
Although the sharing of needles appears to be declining, infections, particularly Hepatitis B and C, among injecting drug users remain a grave concern and we recognise this and started work last this year on developing a new RCGP Certificate in the Detection, Diagnosis and Management of Hepatitis B and C in Primary Care. NB Early notice: watch out details of the training the trainers day and pilot course for the above certificate in February 2011 on our website soon!
The NTA this month launched the Substance Misuse Skills Consortium. The Skills Hub offers easy access to hundreds of resources to help front line drug and alcohol workers improve services and achieve better results for those in their care and provides examples of good practice. This new resource gives everyone in the field the chance to share good practice and work together.
SMMGP are members of the Skills Consortium and will in turn keep our members updated of new developments in this welcome new iniative.