Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Dr Deborah Judge (DP168)

At short notice I was made aware of the opportunity to feedback to the Select Committee.

I am Co-Chair of the Royal College of Psychiatrists—Special Interest Group for Child and Adolescent Substance Misuse. I am a National Health Service (NHS) Consultant Psychiatrist working with the Bristol Specialist Substance Misuse Service. I have been working with young people, substance misuse, mental health and youth offending over the last 10 years. I have briefly commented on the following items from the terms of reference. I am writing as an individual clinician as I have not been able to discuss these views with College colleagues, but many of my views are shared and regularly discussed within our group.

I have no idea how to submit thoughts to a Home Affairs Select Committee, so forgive me if I’ve stepped out of line!

Terms of Reference

The independence and quality of expert advice which is being given to the Government.

The relationship between drug and alcohol abuse.

The comparative harm and cost of legal and illegal drugs.

The impact of the transfer of functions of the National Treatment Agency (NTA) for Substance Misuse to Public Health England and how this will affect the provision of treatment.

The extent to which public health considerations should play a leading role in developing drugs policy.

The availability of “legal highs” and the challenges associated with adapting the legal framework to deal with new substances.

Young People and Substance Misuse—The Risks of Disinvestment in Child and Adolescent Treatment Services—2012

The independence and quality of expert advice which is being given to the government

The quality of advice being given regarding child and adolescent patterns of harmful substance misuse—could be greatly improved. The College Special Interest Group would welcome the opportunity to become more involved and deliver high quality evidence of treatment efficacy.

The Royal College Special Interest Group (SIG) have published a draft document to describe the mult-modal, systemic treatment to provide evidence-based interventions by specialist youth multi-agency teams. This document will help the NTA to significantly shift its position on young people’s treatment nationally and to develop specialist treatment services with improved health, social and re-offending outcomes. Thus the NTA will more productively blend the Department of Health (DoH), Ministry of Justice (MoJ) and Substance Misuse Treatment objectives within its new position in Public Health—these are the public health objectives for the next generation of working adults and parents.

The last three years have seen significant reductions in substance misuse services nationally for young people across all levels of treatment intervention; from residential detoxification and rehabilitation to community youth outreach workers.

Evidence

Closure of Middlegate Lodge—the only residential provision for young people in the UK, Lincolnshire.

Decommissioning or significant cuts in specialist treatment services eg Wiltshire, 2009, North Somerset 2009, Somerset, 2010.

Bath and North East Somerset—In-volve—provider of specialist treatment service for under 18s—company go into liquidation, November 2011.

Feedback nationally to Royal College Psychiatrist Special Interest Group—Child and Adolescent Addictions.

The opportunity arising from the move of the NTA Public Health

Because the NTA have followed definitions of Adult treatment models which have a linear model of causality—high risk is only ever recognised with dependent class A drug use. Cannabis use and Alcohol use disorders have been consistently marginalised and minimised as a treatment need for young people.

This rather simplistic model will inevitably give an impression that childhood substance misuse is low level, simple to treat and without serious consequences in adult life. This is a very dangerously misleading policy to follow.

By using the Adult definitions it has been possible for services to be cut back for young people, because the patterns of substance use in childhood, which are high risk, are very different.

The current collection of data, National Drug Treatment Monitoring System (NDTMS), which collects treatment data nationally (set up by the NTA) does not reflect young people’s treatment at all. It is currently, and has for the last 10 years been unfit for pupose. The latest figures published by the NTA which describe the decrease in young people in treatment for substance misuse problems, reflects the decrease in available services and youth workers and not any decrease in problematic substance misuse.

The patterns of substance misuse in childhood which lead to high risk behaviour and morbidty and mortality in adolescence are complex risk trajectories. This means that we should view these trajectories at any point in childhood with a developmental perspective.

For example, a nine year old boy, who has experienced family breakdown, disrupted early relationships, domestic violence, school failure, peer rejection and bullying and has started smoking tobacco and occasionally drinks alcohol and has been intoxicated on a couple of occasions, is on a high risk trajectory which is outside developmental norms.

For example, a 15 year old girl who has experienced parental domestic violence, separations and parental alcohol dependence, school truanting, sexual exploitation, pregnancy and pregnancy termination, who has been smoking cannabis daily for the last year, binge drinks at weekends and has been self-harming and depressed, is on a high risk trajectory which is outside developmental norms.

With current NTA definitions of treatment, neither of these high risk patterns of substance misuse in childhood would be recorded in NTA national data. These children would be unlikely to access Child and Family Mental Health Services, because these NHS Child and Adolescent Mental Health Services (CAMHS) have also been subject to financial budget constraints and rationing and children with conduct problems, who are out of school or in the care system tend to fall outside the high threshold for access (usually defined by mental illness and often excluding substance misuse).

Furthermore, because residential treatment is unavailable in England currently, young people are accessing residential facilities in Wales. These young people will not be recorded in NTA data, because this data is only collected in England.

The next fundamental difficulty in the NTA’s policy for young people’s treatment are the definitions for treatment outcomes.

Follow adult treatment outcomes, the major drive is for a model of abstinence for dependent drug and alcohol use. The only significant outcomes under scrutiny are those of reduced substance misuse.

This does not fit for young people’s treatment because most problematic/high risk use is not dependent use, as can be seen from the earlier examples. This misses a key opportunity for improved health and social outcomes.

We know that young people do not develop addiction problems in a vacuum. Young people develop patterns of substance misuse through childhood, especially when they come from high risk childhood backgrounds. The high risk trajectories are complex in health, mental health, social and offending risk. Treatment outcomes which reflect reduced risk must reflect the positive social (eg stable housing provision), health, mental health and reduction in re-offending outcomes as well as reduction in substance misuse. Multi-modal outcomes are currently not recorded at all.

How fortuitous then for the NTA to move into Public Health England to agree positive health, mental health and social oucomes for young people, and work systemically across government departments, knitting together enlightened cross-policy directives… instead of working with what could be described as a rather blinkered approach.

Patterns of Drug and Alcohol use

As exemplified in the two case vignettes, patterns of harmful use begin in childhood—and here is the opportunity to intervene most effectively!

Comparative harm and cost of drugs

In childhood alcohol is the cheapest, most widely available and most harmful drug impacting on child and adolescent health, mental health, morbidity and mortality.

Availability of legal highs

In clinical work we have seen a huge impact of the changing patterns of drug use in young people. Young people are evolving the new trends and tend to have a high level of experimentation with novel substances. There is a wealth of information from Youth services and professionals working with young people which has hitherto been ignored. Changing patterns of substance misuse should inform policy much more effectively—as this information indicates the future problems and risks in adult drug treatment services.

February 2012

Prepared 8th December 2012