Drug Misuse (Adults)
- Key issues and gaps
- Who is at risk and why
- The level of need in the population
- Current services in relation to need
- Service users and carers opinion
- Projected service use
- Expert opinion and evidence base
- Unmet needs and service gaps
- Recommendations for consideration by commissioners
- Recommendations for further needs assessments
- Key contact
- Print-friendly version of this section (PDF, 216KB)
Around one in 100 people in Haringey use crack and/or opiates. 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, Oct 2011). The same is also true of Haringey. Injecting drug users are particularly susceptible to contracting blood borne viruses – 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 by, for example, needle exchange, outreach services to vulnerable groups such as female sex workers, and hepatitis B/C screening and hepatitis B immunisation
- Intensive structured treatment where the aim is for people to become drug free, e.g. detoxification, counselling, residential rehabilitation
- Support for wider issues including mental health and education, training and employment
- Support for families and friends of drug users and children affected by parental substance misuse.
Haringey’s service provision is focussed on full recovery, in line with the current drug strategy (HM Government, 2010) and the recent influential publication by the experts in the field ‘Medications in Recovery’ (Strang, 2012) which has at its core a vision that problem drug users can have a life free from addiction.
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’).
- Haringey has higher rates of crack and opiate use than London and England averages
- Whilst successful drug treatment completion rates for opiate users are better than in England overall, the rate for non opiate users is below the England average. (See footnote 1)
- Haringey is classed as band C by the Health Protection Agency (high band) for numbers of drug users infected with hepatitis C
- Treatment provision needs to be accessible to a range of different populations affected by substance misuse who may have differing needs, including lesbian, gay, bisexual, gay and transgender populations. In addition, monitoring of all protected characteristics should be consistent across all treatment agencies
- The current drug treatment system has been further improved by integrating services following a re-tender. The provision will offer a recovery focused support such as family therapy, social activities, self help groups and employment and training support. The new service provision will be in place by January 2014
Whilst illegal 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 (HM Government, 2010). Many adult problem drug users have long histories of substance misuse which often starts before the age of 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. For more information go to substance misuse in children and young people section). Data from Haringey adult drug treatment services in 2012-13 (See footnote 1) indicates that our treatment population experience a range of social issues:
- Housing problems were reported by almost one in three (30%) new clients - over one in ten (12%) had no fixed abode
- One in seven (14%) drug treatment clients came via the criminal justice system
- Nearly one in three (31%) had a dual diagnosis, a term which is used to describe a co-existing mental health and substance misuse problem
- Only one in seven (14%) clients were in employment at the start of their treatment
- A local needs assessment on lesbian, gay, bisexual and transgender populations - 2013 (PDF, 677KB) found evidence of higher prevalence of ‘party’ drugs among these groups (albeit evidence for the transgender population is lacking). This relates partly to social settings where drug taking and alcohol consumption is more prominent but the issues also stem from discrimination and homophobia (UK Drug Policy Commission, 2012; EMCDDA, 2012; Chakraborty , 2011)
- A local needs assessment completed in 2013 for opiate users in opioid substitution treatment (OST) found that crack use, housing issues and unemployment have the most significant adverse impact on treatment outcomes. For example, the odds for clients in employment or studying to complete treatment drug free is almost two and a half times higher than (Odds ratio: 2.49) for those who are unemployed
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.
Prevalence of crack cocaine and opiate use
Glasgow University estimates that there are around 1866 crack cocaine and opiate users aged 15-64 in Haringey (Confidence interval = 1,530 - 2,192). The rate of 10.03 per 1000 population is higher than England and London (See footnote 2). Combined use of crack and opiates is common.
The use of crack and opiates is in decline both nationally (National Treatment Agency, Oct 2011) and in Haringey. The young adult population (aged 15-24) seeking drug treatment is increasingly less likely to use crack cocaine and opiates. Alcohol and cannabis misuse is much more common in this age group. (National Treatment Agency, Dec 2011)
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 1.
Figure 1: Index map of drug treatment population by super output area (n=891) (See footnote 3)
Source: Haringey Council Business Intelligence
- Women consistently make up a quarter (25%) of the drug treatment population which is on par with national and regional averages
- The largest group of all clients in treatment in 2012/13 were white British (33%; 434) followed by other white and black Caribbean and (23%; 308 and 12%; 154 respectively), the breakdown of which is very similar to Haringey population
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 Health and Wellbeing Partnership Board and Community Safety Partnership 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 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 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.
At the time of writing, the main treatment services have been re-tendered. The new provision will be in place by January 2014. The new treatment system will be simpler to access and will have multiple entry points. It will work more closely with the alcohol service for those who use both drugs and alcohol. There will be a new recovery service where service users can access both therapeutic interventions like counselling and also learn social reintegration skills like managing finances or job preparation training. There will be a stronger emphasis on mutual aid (NA/AA/CA) and peer support (SMART) and self-empowerment through the piloting of more personalised care.
Against the prevalence outlined earlier, in 2012/13 nearly half (48%, 902) of crack cocaine and opiate users were in ‘effective treatment’ as defined by the National Treatment Agency (See footnote 4)
Haringey treatment services compare relatively well for other performance measures:
- No one waits for more than three weeks for their treatment
- The percentage of opiate (e.g. heroin) users leaving treatment drug free as a proportion of all opiate users in treatment (12%), is currently higher than the national average (8%). Although for non-opiate users the proportion fares (31%) worse against the national average (40%)
- Re-offending rates for drug using offenders are lower than London and England (See footnote 5)
The input of people affected by drug use is important in the development of services. In the recent re-tendering of services service users were involved in all elements of the process from completing surveys, attending focus groups to selecting the winning providers. On an ongoing basis service users and their friends or families can influence how services are run and commissioned in a number of ways: filling in the annual service user survey, by attending regular service user meetings at local services, the borough wide forum, meetings with commissioners, and by 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.
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.
In Haringey the total number of drug users in treatment peaked in 2008-9 (1485). In the latest financial year the number in treatment was (1254) which represents a 15% decrease since 2008-9. On the basis of recent national and local trends it is expected that the treatment demand will remain at similar levels or decrease slightly for crack and opiate users. The impact of economic downturn appears not to have increased the demand as expected. New drugs coming onto the market (e.g. new psychoactive substances known as ‘legal highs’ not covered by current misuse of drugs laws) and the availability of drugs have an impact – as does police activity, not only in the UK but in the source countries.
The effectiveness of the specific harm reduction interventions and drug treatment 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) now part of Public Health England 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 suggest 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 6).
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).
‘Medications in recovery’: re-orientating drug dependence treatment’ (Strang, 2012) and The National Treatment Agency guidance (2010) highlight 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 Public Health England.
- 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
- There is a need to keep up to date with changes in trends and the drugs law e.g. proposals to classify khat as a class C drug which will have implications for the local Somali Community
- 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
- Promote the newly developed club drug clinic which is tailored to drug users who have issues with substances such as cocaine, ketamine, MDMA as well as GHB, and the ever changing psychoactive substances available from the internet
- 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
The key recommendations from the needs assessment for opiate users in 2013 are:
- Expand on psychosocial interventions, improve engagement with Narcotics Anonymous (NA) and other mutual aid groups and facilitate peer support and recovery communities with a coherent commissioning strategy
- Integrate the recovery service into the specialist drug service
- At the time of writing the service for children and families affected by parental substance misuse is being jointly re-tendered with the existing young peoples substance misuse service. The new service will be in place in April 2014
Main recommendations from the LGBT needs assessment, 2013, were to:
- Establish routine analysis of LGBT status data and commission training for treatment staff in working with LGBT community
- Assess the feasibility of Drug Club Clinic support via satellites in other community health organisations, away from traditional drug treatment
- Establish referral pathways between substance misuse and sexual health services
Our future needs assessments will respond to changes in the drug trends and the increased national emphasis on recovery. We therefore plan to:
- Explore the use of over the counter medication and prescription drugs
- Monitor the success of recovery activities and the evaluate the effectiveness of the new service provision
- Identify the general health needs of rough sleepers and hostel dwellers in Haringey many of whom will have drug, alcohol and/or mental health problems
- Sarah Hart - Senior Public Health Commissioner
Public Health Directorate
- Email: firstname.lastname@example.org
- Tel: 020 8489 1480
- 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 11MB). 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. Home Office Research Study 249. London: Home Office.
- Hay et. al. (2011) Estimates of the prevalence of opiate use and/or crack cocaine use, 2009/10: Sweep 6 report. Glasgow: The Centre for Drug Misuse Research
- 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 (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. 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. London: NTA (Last accessed 10 February 2012)
- National Treatment Agency (Oct 2011) Drug treatment and recovery in 2010-11. 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 851KB). London. NTA (Last accessed 10 February 2012)
- National Treatment Agency (Dec 2011) Substance misuse among young people 2010-11. 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 (external link, PDF, 852KB). 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) T - The Drug Treatment Outcomes Research Study (DTORS): final outcomes report (external link). London: Home Office (Last accessed 20 January 2012)
2. Source: Health Profile: Haringey 2013 (external link). Public Health England.
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.
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.
4. “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 Public Health England (external link).
6. 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.
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