Drug Misuse (Adults)

Introduction

Haringey has high levels of problematic drug use. The latest prevalence estimate of crack cocaine and opiate users in Haringey is 2424. The rate of 14.96 per 1000 population is higher than in London and England, 9.45 and 8.93 respectively (Hay et al, 2011). Those most vulnerable to problematic drug use, especially crack cocaine and heroin use, are more likely to live in deprived areas, suffer from mental ill health, live in poor housing and be involved in other criminal activity (National Treatment Agency, 2010). Injecting drug users are particularly susceptible to contracting blood borne viruses – including hepatitis B and C and HIV (Health Protection Agency, 2011). Drug misuse not only impacts on the individual drug user but it also contributes to other societal harm, including crime, poverty and family breakdown.

There is a high local demand for drug treatment which includes:

Support to reduce drug related harm, such as advice and information on drugs and their effects, needle exchange provision, outreach services to vulnerable groups, for example female sex workers, and hepatitis B/C screening and hepatitis B immunisation
Targeted work with specific communities, for example the Somali community and use of khat/incidence of tuberculosis
Intensive structured treatment where the aim is for people to become drug free, e.g. detoxification, counselling, residential rehabilitation, dual diagnosis, education, training and employment
Support for families and friends of drug users and children affected by parental substance misuse.

This JSNA chapter relates to illicit drug use across the adult population in Haringey, primarily crack cocaine and heroin use (referred to as ‘problematic drug use’).

See related topics: Deprivation, mental health, housing, employment, crime and safeguarding children.

Key issues and gaps

Haringey has higher rates of problematic drug use than the London and England averages
Testing for blood borne viruses and vaccinations for hepatitis B remains low whilst Haringey is classed as band C by the Health Protection Agency (high band) for numbers of drug users infected with hepatitis C
The current drug treatment system whilst effective could be further improved by integrating drug and alcohol provision in the borough and offering more recovery services, such as family therapy, social activities, self help groups and employment and training support.

Who is at risk and why

Whilst drug use can affect any section of the community, there is a strong correlation between economic disadvantage or deprivation and the development of more serious drug problems (Home Office, 2010). Many adult problem drug users will have had long histories of substance misuse which started before they reached 18. Research suggests that those most susceptible to developing problematic substance misuse problems are from ‘vulnerable groups’ such as children in care, persistent absentees or excludees from school, young offenders, the homeless and children affected by parental substance misuse (DfES, 2005; The NHS Information Centre, 2011). The majority of young people needing help for substance misuse also have other emotional or social problems, such as self-harming, offending and are not in education, employment or training (National Treatment Agency, Dec 2011). For more information go to substance misuse in children and young people section. Data from Haringey adult drug treatment services in 2011-12 indicates that our treatment population experience a range of social issues:

Housing problems reported by almost one third (32%, 196) of clients - 13 per cent (82) are homeless (with no fixed abode)
Nearly one in four (24%) came via the criminal justice system
One in four (25%; 160)were identified with dual diagnosis, a term which is used to describe co-existing mental health and substance misuse problems ^{(See footnote 1)}
Only 14% (20) of new clients had been in any paid work in the last four weeks prior to their treatment start date. ^{(See footnote 2)}

There is also considerable body of research which shows children who grow up in families where there is domestic violence and/or parental alcohol or drug misuse are at increased risk of significant harm (Cleaver et al, 1999; ACMD, 2003). The double stigma associated with being both a victim of domestic violence as well as having a substance use problem may compound the difficulties of help-seeking. Women drug users are also at risk of sexual exploitation through for example involvement in prostitution (Taylor and Kearney, 2005). For more information go to domestic violence section.

The level of need in the population

Prevalence of crack cocaine and opiate use

Glasgow University (Hay et al, 2009) estimates that there are around 2424 crack cocaine and opiate users aged 15-64 in Haringey (Confidence interval = 2,220-2,714). The rate 14.96 per 1000 population is significantly higher than in London and England (9.45 and 8.93 respectively). See figure 1. Combined use of crack and opiates is common.

The use of crack and opiates is in decline both nationally (National Treatment Agency, 2011) and locally. The young adult population aged 15-24 seeking drug treatment are increasingly less likely to use crack cocaine and opiates, alcohol and cannabis misuse is much more common. The prevalence of young opiate and crack users aged 15-24 with 12.35 per 1000 population is however higher in Haringey than the regional and national averages (8.51 and 6.87 respectively). See figure 2.

Figure 1

Source: University of Glasgow prevalence estimates 2009-10

Figure 2

Source: University of Glasgow prevalence estimates

Profile of drug treatment population

Haringey residents who seek treatment are likely to come from the more deprived, diverse and densely populated east: the highest concentration of 2009-10 drug treatment population were found to be residing in areas around Seven Sisters, Bruce Grove and Northumberland Park. Accordingly, the main drug services are based around those areas. See figure 3.

Figure 3: Index map of drug treatment population by super output area (n=891) ^{(See footnote 3)}

Source: National Drug Treatment Monitoring System (NDTMS) - analysis by Haringey Council Business Intelligence (See footnote 4)

Women consistently make up a quarter of the drug treatment population (see figure 5 in the projection section), which is on par with national and regional averages
The largest group of all clients in treatment in 2011-12 were White British (34%; 425) followed by Other White and Black Caribbean and (18%; 246 and 14%; 191 respectively). See figure 4. These two ethnicity groups were over represented in treatment compared to overall Haringey population. .

Figure 4

Source: National Drug Treatment Monitoring System - Quarter 4 Adult Partnership report.
* Data suppressed for data protection

See related topics: deprivation and demographic context.

Current services in relation to need

Haringey has a long standing and evidence based drug treatment system which has been informed by local needs assessments, research and guidance by the National Treatment Agency (NTA) and National Institute for Clinical Excellence (NICE). Commissioning of drug treatment in Haringey is undertaken by the Drug and Alcohol Action Team (part of the public health team) on behalf of the Wellbeing Partnership Board and Safer Communities Executive Board.

There is a comprehensive range of services, from low level harm reduction services such as advice and information, needle exchange, outreach services to vulnerable groups such as sex workers, blood borne virus testing and immunisation through to structured drug treatment such as detoxification, counselling, community day and residential programs. The Drug Intervention Programme is commissioned to address drug related offending. Haringey DAAT also commissions services to support to friends and family of drug users and children affected by parental substance misuse.

There are also social reintegration programs which address the educational, employment and training needs of this group along with access to supported housing. The research in the drugs field (Cebulla et al, 2004), the drug strategy (Home Office, 2010) and the recent Marmot review into health inequalities (Marmot et al, 2010) recognise that access to meaningful employment is a key factor in addressing health inequalities. Being in employment itself has an intrinsic therapeutic value (South et al, 2001). These along with access to secure housing are the main long term indicators of a person’s ability to remain drug free. The importance of employment in users’ recovery was also borne out by a specific needs assessment undertaken by the DAAT in 2010.

Against the prevalence outlined earlier, a little over half (55%; 1427) of crack cocaine and opiate users in Haringey had accessed treatment services at some point prior to 31 March 2011, and half (50%; 1210) ^{(See footnote 5)} had been in ‘effective treatment’ as defined by the National Treatment Agency ^{(See footnote 6)}.

Haringey treatment services compare relatively well for other performance measures:

No one waits for more than 72 hours for an assessment and treatment starts within three weeks
The percentage of opiate (e.g heroin) users leaving treatment drug free as a proportion of all opiate users in treatment (13.2%), is currently higher than the national average
Reconviction rates are 41% lower for offenders who engage with the Drug Intervention Programme ^{(See footnote 7)}

Haringey Recovery Pride 2012

Haringey hosted Recovery Pride 2012 from 26 to 31 March. It was the first event of its kind in the capital to celebrate the achievements of those dealing effectively with drug and alcohol issues, and encourage others to follow their lead.

The week also tackled prejudice. People who use services locally exhibited artwork and other creative material expressing their thoughts on recovery at an exhibition in Wood Green Library. The borough will look at ways to replace addiction with positive activities and goals. The Recovery Pride Charter (external link) outlines the four key recovery pledges made by local services.

Drug and Alcohol Service Directory (PDF, 232KB) provides more information about the services available for Haringey residents.

Service users and carers opinion

The input of people affected by drug use is important in the development of services. Service users and their friends or families can influence how services are run and commissioned in a number of ways: by attending regular service user meetings at local services, attending meetings with commissioners, and being part of the Recovery Champions Group – a group set up to tackle the stigma associated with substance misuse and help build the ‘recovery capital’ of those in drug and alcohol treatment.

People who use drug and alcohol services worked together to develop a logo and strap line for the Recovery Pride which took place in March 2012. The logo and strapline are based on a quote by Indian civil rights campaigner, Gandhi, 'Be the change you want to see' representing recovery and the journey to becoming a more productive member of society. Together with treatment services Haringey service users have also produced a Recovery Charter (external link).

Families and friends of drug users have set up a group with the help of the DAAT and service providers. Chrysalis, as it is known, has its own newsletter. There is also an annual service user survey. The key findings from the 2011-12 survey which was completed by 194 service users were as follows:

Peer led services are considered to be an important element of treatment. Service users prefer peers to be trained in areas such as housing and benefits
Over a third of respondents would like their key worker to be an ex-user
Although only a few were prepared to involve their family in their treatment programme, a vast majority of respondents whose partners misused substances thought that services did not do enough for couples
The majority felt that services were well balanced between providing harm reduction and moving forward into recovery/abstinence. The pace of treatment was found to be appropriate
The idea of drug and alcohol services being housed in the same building was supported by a vast majority of the respondents.

At the time of writing, proposed changes to service provision from December 2013 is out to consultation.

Projected service use

In Haringey the total number of drug users in treatment peaked at 2008-9 (1485). Projected yearly figure for 2013-14 is 1200 which represents a 19% decrease since 2008-9. (See figure 5). It is not possible, however, to accurately predict trends or the demand for drug treatment. For example the impact of the economic downturn on the level of drug use is unknown. New drugs coming in to the market (e.g. legal highs) and the availability of drugs also has an impact - which in turn depends on police activity, not only in the UK but in the source countries.

Figure 5

Source: National Drug Treatment Monitoring System report: Generated by NDEC, University of Manchester, 07/12/2011. Projection by Haringey Council Business Intelligence.

Expert opinion and evidence base

The effectiveness of the specific harm reduction interventions (See footnote 8 ) and drug treatment (See footnote 9 ) outlined in the Models of Care (National Treatment Agency, 2006) and various NICE guidelines is well established. Treatment effectiveness is monitored through the National Drug Treatment Monitoring System (NDTMS) and evidenced in other national research projects (Davies et al, 2009; Jones et al, 2010; Millar et al, 2008; Barnard et al, 2009). Research studies on the overall cost of illicit drug use to society suggests that drug treatment provides value for money (Davies et al, 2009; Godfrey et al, 2002). Cost benefit estimates by the National Treatment Agency show that our local treatment provision provides good value for money: in Haringey every pound spent on drug treatment saves £5.02 in crime and health costs. The estimated net benefit is £46.1 million in total for the 2010 spending review period (See footnote 1 0 ).

Studies have highlighted a relatively high prevalence of mild and moderate mental health problems in drug treatment population (Strathdee et al, 2002 cited in National Treatment Agency 2010; Daddow and Broome, 2010). Accordingly those who received help for particular mental health issues as part of their drug treatment strengthened their chances for recovery (Daddow and Broome: 2010).

The recently published ‘Medications in recovery’: re-orientating drug dependence treatment’ (Strang, 2012) and The National Treatment Agency guidance (2010) highlights the need to focus on full recovery with a balanced treatment system that seeks to reduce the associated harm by stabilising the drug use, helps people to become drug free and achieves better social reintegration. Given the broad range of problems drug users face (i.e. physical and mental ill health, family dysfunction, offending) such a process can take a long time or require several attempts. National guidelines, including clinical guidelines from NICE, that are implemented locally are available from the National Treatment Agency (external link).

Unmet needs and service gaps

Services for children affected by parental substance misuse are not adequately resourced storing up potential for intergenerational substance misuse.
Care pathways into drug (and alcohol) treatment need to be simplified (see recommendations).
Further and ongoing work with the Somali community regarding khat use and TB.
Social exclusion factors/stigma which prevent people with former histories of drug and alcohol use from accessing meaningful employment and stable housing.
Further development of recovery services including mutual aid, peer support and user led services.
Wider coverage of blood borne virus screening and immunisation services.
Parenting support for drug using parents.

Recommendations for commissioning

Re-tender existing substance misuse provision to create an integrated, recovery focused substance misuse treatment system by December 2013.
Embed the Integrated Offender Management Model into the new treatment system.
Respond to changing trends in drug misuse, non class A drug use and needs of particular communities e.g. lesbian, bisexual, gay and transgender (LGBT), Somali community for khat use etc.
Continue to ensure fast access to a wide range of prevention and treatment services to meet changing drug trends, along with services for carers and families and children affected by parental substance misuse.
Ensure wider coverage and better uptake of blood borne viruses screening and immunisation.
Continue to tackle the wider determinants of health inequalities in this group such as access to housing and employment by working with colleagues elsewhere within the council and through national government initiatives such as the Work Programme, Supporting People programme and locally commissioned education, training and support services.

Recommendations for further needs assessments

Our future needs assessments will respond to changes in the drug trends and the increased national emphasis on recovery. We therefore plan to:

Evaluate recovery amongst opiate users who are in substitute prescribing
Understand the needs of those who drop out of treatment early or who are not progressing in treatment
Improve knowledge about the impact of powder cocaine, legal highs and cannabis use on local health services
Monitor the success of recovery activities
Conduct a needs assessment on drug misuse needs amongst Lesbian, Bisexual, Gay and Transgender (LGBT) community.

Key Contact

Marion Morris
Drug and Alcohol Strategy Manager
Public Health Directorate
marion.morris@haringey.gov.uk
telephone: 0208 489 6909

References

ACMD (2003) Hidden Harm: responding to the needs of children of drugs users. The report of an inquiry by the Advisory Council on the Misuse of Drugs London: Home Office.
Cebulla et al. (2004) Returning to normality: Substance users’ work Histories and perceptions of work in Br J Soc Work.2004; 34: 1045-1054
Cleaver, H., Unell, I. & Aldgate J. (1999) Children’s needs – Parenting capacity: The impact of parental mental illness, problematic, alcohol and drug use and domestic violence on children’s development. The Stationary Office: London
Daddow, R, Broome, S. (2010) Whole person recovery: A user-centred systems approach to problem drug use (external link). London: RSA (Last accessed 20 January 2012)
Davies L, Jones A. et al. (2009) The Drug Treatment Outcomes Research study (DTORS): Cost-effectiveness analysis (external link, PDF 1.28MB). 2nd Ed. Home Office Research Report. London: Home Office. (Last accessed 20 January 2012)
DfES (2005) Every Child Matters: Change for children, young people and drugs. Department for Education and Skills. ISBN No: 1-84478-446-0
Godfrey, C., Eaton, G., McDougall, C. and Culyer, A. (2002) The economic and social costs of Class A drug use in England and Wales, 2000 (external link, PDF 175KB). Home Office Research Study 249. London: Home Office. (Last accessed 20 January 2012)
Hay et. al. (2010) Estimates of the prevalence of opiate use and/or crack cocaine use, 2009/10: Sweep 6 report (external link, PDF 651KB).Glasgow: The Centre for Drug Misuse Research (Last accessed 20 January 2012)
Health Protection Agency (2011) Shooting up: Infections among injecting drug users in the United Kingdom (external link, PDF 323KB). London: Health Protection Agency (Last accessed 10 February 2012)
HM Government (2010) Drug Strategy 2010: Reducing demand, restricting supply, building recovery: supporting people to live a drug free life (external link). London: H M Government (Last accessed 20 January 2012)
Jones, A., Donmall, M. et al (2010) The Drug Treatment Outcomes Research Study (DTORS): Final outcomes report (external link). 3rd Ed. London: Home Office (Last accessed 20 January 2012)
Marmot M. et. al. ( 2010) Fair Society, Healthy Lives - Strategic review of health inequalities in England post-2010: The Marmot review (external link). London. DoH (Last accessed 10 February 2012)
Millar, T., Jones, A., Donmall, M. and Roxburgh, M. (2008) Changes in offending following prescribing treatment for drug misuse (external link, PDF 302.01KB). London. NTA (Last accessed 10 February 2012)
National Treatment Agency (2010) Commissioning for Recovery. Drug treatment, reintegration and recovery in the community and prisons: a guide for drug partnerships (external link, PDF 280KB). London: NTA (Last accessed 10 February 2012)
National Treatment Agency (Oct 2011) Drug treatment and recovery in 2010-11 (external link, PDF 320KB). NTA: London (Last accessed 10 February 2012)
National Treatment Agency (2006) Models of care for treatment of adult drug misusers: Update 2006 (external link, PDF 881KB). London. NTA (Last accessed 10 February 2012)
National Treatment Agency (Dec 2011) Substance misuse among young people 2010-11 (external link, PDF 1.01MB). NTA: London (Last accessed 20 January 2012)
The NHS Information Centre (2011) Smoking, drinking and drug use among young people in England in 2010 (external link). London: NHS Information Centre for Health and Social Care (Last accessed 10 February 2012)
South, N., Akhtar, S., Nightingale, R. and Stewart, M. (2001), ‘Idle hands’ [Thematic review on drug treatment and unemployment], Drug and Alcohol Findings, 1(6), 24–30.
Strang J. (2012) Medications in recovery: Re-orientating drug dependence treatment. London: National Treatment Agency for Substance Misuse.
Taylor, J. and Kearney, J. (2005) Researching hard to reach populations: Privileged access interviewers and drug using parents (external link). Sociological Research on line: Volume 10, Issue 2. (Last accessed 10 February 2012)
Barnard, M., Webster, S., O’Connor, W., Jones, A. and Donmall, M. (2009) The Drug Treatment Outcomes Research Study: Qualitative study (external link). London: Home Office (Last accessed 20 January 2012)

Footnotes

1. Source: National Drug Treatment Monitoring System - Quarterly partnership report and Diagnostic Outcome Monitoring Executive Summary reports, quarter 4, 2011-12

2. Source: National Drug Treatment Monitoring System - Treatment outcome report, quarter 4, 2011-12. The cohort includes only new starters.

3. The analysis includes only known values hence the sample is smaller than the total number in treatment in 2009-10. It includes Haringey residents in drug treatment in 2009-10 aged 18 who had their full postcode recorded, representing 66% of the total treatment population. It was not possible to retrieve this data from CRI and residential agencies outside the borough. The representativeness of the sample was tested: there were no differences of more than 3% percentage points in the demographic profiles between the sample and the total treatment population.

4. The index map shows a score for each of the boroughs 144 Lower Super Output Areas (LSOA). An index value of 100 indicates a score that is proportionate to the borough average rate (3.95 clients per thousand residents [891 known clients/225.529 residents] based on ONS MYE 2009 population figs).The client rate for each LSOA is calculated: (no of clients/LSOA residents) x 1000 and then the rate is divided by the overall borough rate and multiplied by 100 to create the index score i.e. (LSO rate/borough rate) x100. A score exceeding 100 indicates that an area is above average. Thematic mapping requires class ranges for each area (or LSOA) - absolute numbers do not work - so the borough average is represented as a range defined as 20% less than 3.95 to 20% greater than 3.95. This translates to an index class range for the borough average of 80 – 120.

5. Source: NDTMS needs assessment data. These figures include clients in treatment 31/03/2011, in treatment in the year prior to 31/3/11 and clients known to treatment, but not treated in 2010-11.

6. “In effective treatment” includes individuals in contact with Tier 3 or 4 structured treatment services, during the period in question, who are recorded as having begun a drug treatment intervention and who fulfil either of the following criteria:

they were retained in treatment for 12 or more weeks from their triage date
they were subject to a planned discharge following a planned exit from their treatment within 12 weeks of their triage date (for opiate and crack users, planned discharge means that they finished treatment drug free)

Definitions for the National Drug Treatment Monitoring System data and reports are available from the National Treatment Agency (external link)

7. Figures accurate as at 29 of October 2012. Drug Interventions Programme data is based on analysis of clients drug tested positive April – September 2011 and a 41% (n=34) decrease in number of convictions of offenders who engage with DIP following a positive drug test. This compares to 10% (n=16) reduction in convictions of offenders who test positive at arrest but do not engage;

8. eg needle exchange, hepatitis C & B testing, advice and information

9. eg substitute prescribing, residential rehabilitation, counselling

10. Spending review period refers to period from 2011-12 to 2014-15 financial year. These estimates include both, the cashable cost benefit for the public sector in crime and health savings, as well as non cashable natural benefits, e.g. quality of life years (QALYs). The cost of and spend on the drug treatment system is shown in real terms, during the spending review period, and is discounted and adjusted for market forces. The baseline data is from 2010-11 financial year but the estimates for the 2010 spending review period are based on a number of assumptions, for example, the reductions in offending (evidenced in other studies) were assumed to be caused by the treatment itself and not by other factors associated with treatment entry. Therefore the figures should be treated as indicative only. Source: National Drug Treatment Monitoring System - Value for Money Tool.

Page Last Updated: 27 March 2013

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