2Putting health first
Improving treatment
11.From the evidence we have heard, it is clear that, for a variety of reasons, treatment for people with problematic drug use is currently inadequate. In the words of Professor Matthew Hickman, an epidemiologist at Bristol University specialising in drugs policy,
We need to call for a public health crisis to be declared around opioid-related deaths. They are the highest they have ever been and they are going up annually. The services are not working.14
12.Drug treatment takes a wide variety of forms. Clinical intervention often involves providing a substitute for the drug being used - for example methadone - and thereby reducing the harms associated with that drug use. Clinical intervention can also involve reducing the substitution and misused drug over time. Psychosocial interventions can support people through motivational interviewing or other psychological interventions. The social interventions can include supporting people with basic needs such as food and housing, and developing positive relationships with families and communities.15 We were also told that clear, evidence-based guidelines exist for managing drug dependency - Drug Misuse and dependence: UK guidelines on clinical management - or the ‘orange book’ as it is known to practitioners. However, we were told that in some places there can be a wide gap between what is set out as evidence-based best practice, and what is being delivered on the ground.16 There is no national oversight of commissioning practice, nor minimum national standards.
13.We heard of the frustrations when psychosocial interventions helping people change behaviour and integrate back into their locally communities were not consistently available.17 Residential rehabilitation and inpatient detox services–highlighted by two of our witnesses with lived experience as essential to their recovery–are in sharp decline. There are only a very small number of NHS inpatient centres remaining across England and even those are under threat of closure by 2020. Although people who are dependent on drugs are still able to access third sector and independent sector provision in some areas, in others there is no provision at all.18
14.And perhaps even more concerningly, we were also told that current provision of opiate substitution therapy–which is the core element of treatment for most heroin users with entrenched problems - is inadequate:
the reality of our provision is that a lot of the opiate substitution treatment we provide would be regarded as quite low quality on a number of measures … Most of the prescribing that we do is probably below the bottom end of the recommended dose window. There is a diminishing investment in helping to make sure that people get engaged with the treatment.19
15.Witnesses described users being on cycles in and out of treatment–and concern that particularly on release from prison, they are at considerable risk from overdose.20 This echoes the findings of a report on community-custody transitions, published by the Advisory Council on the Misuse of Drugs (ACMD), the Government’s advisory body on the misuse of drugs.21
16.We were also told that there is now an ageing cohort of patients whose physical and mental health is declining through from having lived with chronic conditions and risk factors for many years. The complexity of care that services are having to cope with has therefore escalated rapidly.22 Again, this repeats the recent findings of the Government’s advisory body on the misuse of drugs (the ACMD) in its report on ageing drug users.23
17.On our visit to Portugal we saw a system marked by a positive attitude to service users which recognised the impact that chaotic lifestyles could have on engagement with support and treatment. There was a striking ethos of holistic, non-judgemental treatment and access to services focused on the needs of individuals rather than the convenience of the system. English treatment providers share a similar ethos, but their capacity to deliver is compromised by inadequate funding and the policy framework.24
18.Many service users in England are living with drug addiction and underlying mental illness, and we were told that these people do not receive adequate mental health services.25 Witnesses suggested that this was due to changes in commissioning which mean that substance misuse services are now commissioned separately from mental health services; at the same time, the threshold for referral into community mental health services has become higher.26
19.We were also warned by witnesses of the increasing threat being posed by dependency both on prescribed medicines and on non-prescribed prescription medicines.27 The current US epidemic–there were 47,600 opioid-related deaths in 2017, equating to some 130 deaths a day28–is largely agreed to have been triggered by significant increases in medical prescribing of opioids in the 1990s; some commentators argue that this harmful overprescribing is still continuing in the US.29 Public Health England has recently published a review of dependence on prescription medicines in England, examining five different classes of medicines that can cause dependence. While the scale and nature of opioid prescribing is not equivalent to the current situation in the US, PHE concluded that the NHS needs to take action now to protect patients. The review found that 1 in 4 adults had been prescribed at least one potentially addictive medicine, and that long term prescribing of these medicines was widespread–half had been continuously prescribed it for at least the previous 12 months, and between 22% and 32% had received a prescription for at least the previous 3 years.30 It has also been reported that regulatory loopholes enable medicines to be obtained from online GP practices and pharmacies without adequate checks.31 PHE has made a series of recommendations, including improving training for clinicians to ensure their prescribing adheres to best practice, and the establishment of a national helpline for patients.
20.Witnesses were united in ascribing the falling standards of care to falling funding.32 Funding for drug treatment services fell by 27% between 2015–16 and 2018–19.33 Funding reductions are not evenly distributed between local authorities, with some local authorities having maintained budgets, and others having made large cuts. Cost pressures have been compounded by the rising prices of medicines, with one opiate substitute increasing in price by 600%.34 Mike Flanagan, Consultant Nurse and Clinical Lead for Drug and Alcohol Services at Surrey and Borders Partnership NHS Foundation Trust, told us:
One of the major challenges, which is the elephant in the room, is the cuts that drug treatment systems have had to endure for six or seven years or more. They have had an absolutely profound effect. The extent to which we can innovate, design and deliver very responsive services that respond to the changing patterns of drug consumption has been taken away from us. We are struggling to remain standing at the moment, with the cuts that we have taken …. All those things exist, but they are hanging on by the skin of their teeth at the moment.35
21.Concerns about cuts to funding for drug treatment were also raised by the police, including Hardyal Dhindsa, representing the Association of Police and Crime Commissioners:
If you are convicted and have a treatment order, how do local public health departments commission those services? The reality is that funding has been going down and down, and therefore the number of people getting drug rehabilitation has been going down, and there is a risk that it could go further if the ringfence for public health funding is removed in May 2020.36
22.The ACMD’s 2017 report on commissioning supports this view, referring to funding cuts as the most serious threat to the quality and coverage of drug treatment services.37 This followed its 2016 report on reducing opioid related deaths, which recommended maintaining investment in drug treatment services.38
23.We have heard that clear, evidence-based guidelines exist for drug treatment services, but that current practice does not deliver them. People on opiate substitution therapy are not consistently receiving optimal doses for the correct durations, placing their lives at risk. Psychosocial services and mental health services are not available to all those who need them, and inpatient services are also under threat.
24.Holistic, non-judgemental harm reduction approaches are needed which facilitate access to services. Following budget cuts of nearly 30% over the past three years, the Government must now direct significant investment into drug treatment services as a matter of urgency. This investment should be accompanied by centrally co-ordinated clinical audit to ensure that guidelines are being followed in the best interests of vulnerable patients.
Reducing harm
25.For most drug users, the ultimate goal is to recover fully from their addiction and be free of drug dependency. But this can be a long and difficult process and for those with highly entrenched problems, interventions can be put in place to protect them whilst they are still coping with addiction.
Needle and syringe programmes
26.Needle and syringe programmes are perhaps the best known and longest established of these practices, which aim to stop the transmission of viruses such as HIV and Hep C if people use contaminated equipment to inject drugs. Only 61% of people who inject drugs report that their access to clean needles and syringes is adequate, and 18% of people report needle sharing.39 We were also told that fewer needle and syringe exchanges are now offering testing for infections that can be spread through injecting drugs, including HIV and Hepatitis C.40
Naloxone
27.Naloxone is a life-saving drug which can be administered if someone is suffering from an opiate overdose, and can now be given to drug users for emergency use at home. However, our witnesses told us that provision is currently inadequate. Only half of prisons have a take-home naloxone programme to support prisoners with opiate problems through the high risk period following release from prison; and take home naloxone kits were only given on release to 12% of prisoners who need them.41 Witnesses suggested that this is because of disagreements over whether NHS England or local authorities should fund it, arguing that ‘it is not expensive, so this really should not happen’.42 Witnesses highlighted the advantages of national, centralised naloxone provision programmes, as have been established in Scotland and Wales.43 This was recommended by the ACMD report on community-custody transitions.44 In the absence of such programmes, our witnesses argued that more consistency was needed:
We need more central direction, good practice and monitoring from Public Health England to ensure that there is at least some consistency in naloxone provision across the country.45
Drug consumption rooms
28.To reduce harm even further, drug consumption rooms (DCRs) can be introduced–facilities where people can use drugs with sterile equipment in a clean environment, with medical supervision on hand in case of emergency. In common with needle and syringe exchanges, these facilities also give an opportunity for health professionals to offer other types of support to drug users, including screening tests and connection to other services. DCRs reduce drug use in public places and the unsafe discarding of needles that then pose a risk to others,46 therefore reducing harm to wider communities.
Case example 1 - the ‘Frankfurt Way’
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The Frankfurt Way was developed in the early 1990s in response to the open drug scene near Frankfurt’s central station, coupled with very high numbers of drug-related deaths in Frankfurt and high rates of acquisitive crime. A 4-pillar approach was designed–incorporating prevention, crisis and survival, drug free programs, and law enforcement. There was an official commitment, as part of a ‘public health approach,’ that a person with a drug addiction would be not taken into the criminal justice system until they had had a medical examination. We heard from the police about the cultural change that took place in thinking about drug addiction not as a crime but as an illness. Funding was provided by the European Central Bank, which had recently moved its HQ to the area with high rates of drug use. We heard from the police that robberies have more than halved since institution of these changes. Drug death rates have fallen dramatically in Frankfurt since the early 1990s, as have broader drug-related health problems and drug-related street crime. Drugs death rates in the wider Hesse region are 44% lower than in neighbouring Bavaria, which has maintained a traditional policy approach. Frankfurt has a number of well-established drug consumption rooms. Drug users bring their own drugs to consume, and are provided with health care (with doctors on site at specified times), prevention of infection, first aid in case of overdose, needle and syringe substitution, connection to other services, detoxication, opioid substitution treatment, drug counselling, therapy, medical treatment and rehab. Heroin Assisted Treatment is available for people with the most problematic addiction to heroin. As well as health advantages, we heard that DCRs offer advantages for the police: there is a central contact for police matters; and there is less of a concentration of drug users in public places–which we heard has been associated with reductions in violence and drug-related crime. However, with three quarters of DCRs located in areas with flats, shops and offices, complaints do arise from residents. We also saw that drug use is more concentrated (even in the street) in the area of the DCR. As in England, public budget cuts are putting a strain on services. The approach to harm reduction and treatment varies between different states in Germany: we heard that Hesse has a much more expansive offer than neighbouring Bavaria, which has a higher rate of drug related deaths. We were told that drug users travel from Bavaria to Hesse (predominantly Frankfurt) to access drug services. |
29.Jason Harwin, Deputy Chief Constable of the National Police Chief Council, gave the following helpful explanation of DCRs:
Drug consumption rooms have an evidence base showing that they work, but again it has to be part of a wider whole-system approach and a public health response. It has to be done with an understanding of what you are trying to achieve from a drug consumption room. It is not just about allowing people to take illicit drugs: it is about safety; it is about stopping drug overdoses; and, importantly, it is about the wraparound of other services to try, ultimately, to take the person away from illicit drugs, to manage their need for drugs and put them into other services … I always argue that drug consumption rooms exist, without the title, in some people’s houses, realistically, and people are dying there.47
Heroin-assisted treatment (HAT)
30.Heroin-assisted treatment is an evidence-based intervention where people who have not responded successfully to any other type of treatment can be prescribed heroin to use in a supervised clinical setting. These are individuals who are at particularly high risk. Despite trials showing evidence of clinical effectiveness and cost effectiveness, services at the three pilot sites at which HAT has been introduced as part of a clinical trial have been terminated, although a new service has just started in the North East.48
Drug checking services
31.We also heard from witnesses about the benefits of different drug checking services now being introduced, including at festivals, and a postal service offered in Wales.49 At these services, people who use drugs can submit a small sample for testing, and are then sent results about what the substance actually contains. Witnesses told us that these ‘are already having an impact, and there is a lot of international evidence that it works’.50 We head that as well as having a health benefit to the individual–if people get information about adulterance to the drug, they may be less likely to take it - such testing can also provide an effective early warning for the public health system about particular batches of drugs and the dangers they might pose, enabling public health messages to be put out to reduce wider harm.51
International approaches to harm reduction
32.International evidence shows that harm reduction interventions are both effective and cost effective.52 The 2015 Lancet Commission on drugs policy, coinciding with a UN summit on this subject, concluded that:
Scaling up of health services for people who use drugs can demonstrate the value to society of responding with support rather than punishment to people who commit minor drug infractions … In Switzerland and Vancouver, Canada, substantial improvements in access to comprehensive harm-reduction services, including supervised injection sites and heroin-assisted therapy (ie, prescription of heroin for therapeutic purposes under controlled conditions), have transformed the health picture for people who inject drugs.53
33.Recent systematic reviews of the effectiveness of take-home naloxone programmes have found evidence that its provision in combination with educational and training interventions reduces overdose-related mortality.54 In 2018, community-based take-home naloxone programmes were operating in 10 European countries. These programmes are commonly run by drugs and health services, with the exception of Italy, where naloxone is an over-the-counter medication, and service providers are able to distribute it to bystanders.55 Denmark, Germany, and the Netherlands all provide heroin assisted treatment.56 In the European Union and Norway, Drug Consumption Rooms operate in 51 cities, with a total of 72 facilities in operation.57
Summary
34.Witnesses were clear that both treatment services and harm reduction initiatives are needed, but that there has not been sufficient investment or focus in either.
Fundamentally, you have to have proper investment in the spine of opioid agonist treatment and all of the other add-ons—take-home Naloxone and needle and syringe programmes—at an adequate level that will make a difference to the population. We have not had that focus or that investment.58
35.The potential value of these interventions is well established, with the Government’s own advisory body recommending their introduction over three years ago. The ACMD’s 2016 report on reducing opioid related deaths recommended the scale-up of naloxone provision, central funding of heroin assisted treatment, and consideration of the establishment of safer drug consumption rooms in areas with high concentrations of injecting drug use.59
36.We have heard that existing good practice in harm reduction such as needle and syringe exchanges is now being eroded; Heroin Assisted Treatment is proven to be both clinically- and cost-effective as a treatment for a small number of people but is not available. Giving at-risk drug users take-home naloxone to protect them from overdose is a simple and life-saving intervention that again is not available to all those who could benefit. We saw first-hand the benefits of Drug Consumption Rooms in Frankfurt. Police representatives told us that these facilities should not be viewed simply as allowing people to take illicit drugs–they are about safety, stopping drug overdoses, and very importantly, providing access to a wraparound of other services to eventually stop that person’s drug use. Harm reduction approaches such as DCRs reduce the wider harms to local communities as well as for those using drugs.
37.Sufficient funding should be made available to ensure that HAT, Naloxone, and needle and syringe exchanges are accessible to all those who could benefit from them. We also support the introduction of on-site drug checking services at festivals and in night time economies. Drug Consumption Rooms should be introduced on a pilot basis in areas of high need, accompanied by robust evaluation of their outcomes. If changes to current legislation are required to facilitate the piloting of DCRs, they should be made at the earliest opportunity and the Government must set out where the barriers exist to these evidence-based approaches being taken forward.
Commissioning and the workforce
Commissioning
38.Since 2013, drug treatment services have been commissioned by local authorities as part of their public health responsibilities. Public Health England point out that the Public Health Grant (£3.2 billion in 2018–19) funds core public health services commissioned by local government. Between 2015–16 and 2020–21, the public health grant will have decreased by 23% in real terms (by 7.5% in cash terms).60
39.The LGA argue that local authorities are well-placed to lead the treatment and recovery agenda, as the role of local authorities in supporting social reintegration, addressing social inequalities and developing local initiatives across public health is well known.61 The Association of Directors of Public Health provides further detail on the importance of a multi-agency approach, drawing together drug treatment services with the wider prevention agenda, encompassing other local authority led services including education, social services and housing:
Drug users are likely to have complex needs that should be met through co-ordinated, whole system approaches and commissioning that addresses health inequalities. It is important that local authorities take a whole life course, multi-agency approach working closely with the criminal justice system as well as partners in social services, education, housing and the NHS. Shared learning between those who have contact with the vulnerable is key for preventing and addressing drug misuse.62
40.The role of education and prevention is discussed in more detail in the following chapter.
41.Whilst our witnesses working in drug treatment services reported pockets of good commissioning practice, and some recent improvements, on the whole the providers we heard from felt that there were major problems with the commissioning of drug services.63 They cited the difficulties caused by frequent retendering, and competing for funding against other local priorities, in the context of ever-shrinking local authority budgets.64 Some witnesses described the positive impact of a centralised agency and argued for the return to more centralised oversight of commissioning, as in the days of the National Treatment Agency.65 Others called for commissioning to be returned to the NHS.66
42.While these are in some ways similar issues and arguments to those that we considered during our recent inquiry into sexual health,67 witnesses pointed out that drug treatment differs from sexual health provision. Sexual health services deliver more episodic service focused on the treatment of infectious diseases. While drug treatment services do deliver some short-term advice and guidance for individuals using non-opiates, they tend to see more complex opiate users with multiple needs who require longer-term interventions.68
43.The centralised agency model was frequently mentioned during our trip to Portugal as a critical factor in the success of that country’s drug policy. SICAD (Serviço de Intervenção nos Comportamentos Aditivos e nas Dependências; General-Directorate for Intervention on Addictive Behaviours and Dependencies) is a central agency with responsibility for all aspects of drug policy which has an umbrella structure encompassing 1) campaigning, 2) housing, 3) NGOs and 4) treatment. Having one central organisation responsible for bringing everything together—including both funding and leadership on drug policy—was seen as particularly helpful.
44.As our inquiry has been cut short, we were regretfully not able to hear from commissioners of services, nor from their representative bodies - the LGA or the ADPH - or Public Health England. It is therefore not possible for us to make conclusions or recommendations on this point. However, it is clear that these concerns warrant further consideration by the Government.
45.In 2017, the ACMD considered issues related to the commissioning of drug treatment services. Its report concluded that ‘reductions in local funding are the single biggest threat to drug misuse treatment recovery outcomes being achieved in local areas’ and that the ‘quality and effectiveness of drug misuse treatment is being compromised by under-resourcing’. It recommended how the Government could protect investment in treatment services by mandating local authorities to provide them or by moving commissioning of these services back into the NHS. The ACMD also recommended increasing the transparency of drug treatment funding, and its coordination with other health services, as well as a review of the drug treatment workforce.69
Workforce
46.There are serious concerns about the drug treatment service workforce, with a 24% reduction in consultant addiction psychiatrists in drug treatment services.70 Mike Flanagan, Consultant Nurse and Clinical Lead for Drug and Alcohol Services at Surrey and Borders Partnership NHS Foundation Trust, explained the reasons:
The drug treatment sector has become a less attractive option for a whole variety of reasons. First, its reprocurement cycles make it an unattractive option. The increasing involvement of the third sector has been positive for the field in its ability to deliver good, evidence-based psychosocial interventions and being rooted in communities, but newly qualified doctors and nurses often do not want to work for third sector providers; they prefer to work for the NHS, where they get pensions, CPD and so on.71
47.In his view, the current workforce shortages not only made it harder to deliver a good service, but also posed a grave threat to the future of drug treatment services, as fewer and fewer clinicians were available to train and develop the next generation.72
48.Drug treatment services are commissioned by local authorities, which are arguably well placed to do so, given their links with other relevant services including housing, social services and education. However, the way this localised model of commissioning is currently working is a cause of concern to many providers of drug treatment services. We recommend that the Government conduct a review of the commissioning of drug treatment services to consider how they should be strengthened to enable them to co-ordinate and deliver the much-needed improvements to drug treatment services as effectively as possible. The review should consider whether improvements should be made to the current localised model, or whether, alternatively, a national agency to oversee commissioning should be established, to provide and ensure adherence to a minimum set of national standards. The review should also explicitly consider and address the clear and present crisis in the drug treatment workforce.
21 ACMD, Custody-community transitions, June 2019
23 ACMD, Ageing cohort of drug users, June 2019
28 CNN, Opioid crisis fast facts, October 2019
29 BMJ Editorial, What we must learn from the US opioid crisis, October 2017
30 Public Health England, Dependence on prescription medicines linked to deprivation, September 2019
31 BBC News, Safety concerns over websites selling prescription drugs, August 2018
32 Q126, Matthew Hickman, Yusef Azad; Q174, Dr Arun Dhandayudham; Q101, Adrian Crossley; Q80, Mike Flanagan
37 ACMD, Commissioning impact on drug treatment, September 2017
38 ACMD, Reducing opioid related deaths in the UK, December 2016
44 ACMD, Custody-community transitions, June 2019
46 European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Drug consumption rooms: an overview of provision and evidence, June 2018
52 David Wilson et al, The cost effectiveness of harm reduction, International Journal of Drug Policy, February 2015
53 The Lancet Commission on Public health and international drug policy, the Lancet, March 2016
54 EMCDDA, European Drug Report - trends and developments, 2019
55 EMCDDA, European Drug Report - trends and developments, 2019
59 ACMD, Reducing opioid related deaths in the UK, December 2016
63 Q126, Q136, Yusef Azad; Q139, Professor Matthew Hickman; Q173, Q184, Qq191–193, Professor Sir John Strang; Q79, Karen Biggs; Qq176–177, Danny Hames
67 Health and Social Care Committee, Sexual Health Services, June 2019
69 ACMD, Commissioning impact on drug treatment, September 2017
Published: 23 October 2019