South Gloucestershire Substance Misuse Needs Assessment by ...

South Gloucestershire Substance Misuse Needs Assessment to Inform 2015/2016 Treatment Plan

Nasrul Ismail Performance & Commissioning Officer South Gloucestershire Drug & Alcohol Action Team (DAAT) South Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

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TABLE OF CONTENT Strategic Summary Key Recommendations Horizon Scanning South Gloucestershire Area Profile South Gloucestershire Prevalence Estimates Engagement Local Treatment Services Service Users’ Demographics Treatment Outcome Profile Treatment Outcomes Harm Reduction Service Users’ Support Residential Rehabilitation Local Alcohol Treatment System Drug-related Deaths Safeguarding Children Innovative Pilot Projects Crime Substance Misuse Impacts on the Communities Appendices

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South Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

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1 Strategic Summary Aims The aim of the Substance Misuse Needs Assessment is to inform the annual Substance Misuse Treatment Plan of South Gloucestershire. It will ensure that we are working towards meeting the needs of service users, their families and communities. Embracing a recovery-focused treatment system has been a running theme throughout the Needs Assessment.

The Needs Assessment will be used as a guiding document to ensure evidence-based service planning and delivery for the Drug & Alcohol Action Team (DAAT). It is also anticipated that the Needs Assessment will have the following interfaces with the following local strategies, crosscutting among Public Health, Criminal Justice and Social Care:

• South Gloucestershire Local Plan1 • Joint Strategic Needs Assessment (JSNA) 2015/2016 • South Gloucestershire Joint Strategic Assessment for Crime and Disorder 2014/2015 • Priority Neighbourhoods Action Plans • Children & Young People’s Plan 2012 – 2016 • Alcohol Harm Reduction Strategy 2014 – 2017 • Reducing Re – offending Strategy • HMP Eastwood Park & HMP Leyhill Substance Misuse Treatment Plans 2015/2016 • Health and Wellbeing Strategy 2013 – 2017 • Public Health Outcomes Framework • South Gloucestershire Clinical Commissioning Group (CCG) Priorities 2015/2016 • Sustainable Community Strategy 2026 • South Gloucestershire Child Poverty Strategy 2015 The Local Plan consists of the Core Strategy 2006 – 2027, the West of England Joint Waste Core Strategy, the South Gloucestershire Local Plan 2006, and the Minerals and Waste Local Plan 2002. 1


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Prevention of drug-related crime 16,761 avoided cases, equating to benefit of £3,400,226.

Why Invest in Substance Misuse Treatment? The substance misuse services are aimed to reduce addiction and assist service users in re-integrating into the community and sustaining long-term abstinence through recovery oriented services. We know that addressing the needs of our clients can be effective in tackling health inequalities, addressing social determinants of health, preventing wider damage to the community and instilling community confidence in South Gloucestershire as a great area in which to live and work.

According to the Value for Money calculation (Public Health England, 2013), £1 spent on substance misuse in South Gloucestershire will derive £8.34 of benefit in terms of crime reduction and increased health and wellbeing. The benefit is four times above the national average of £2. Figure 1 below shows the prevented crime activities and health and wellbeing benefits accrued by the substance misuse system in South Gloucestershire: The estimated harm in South Gloucestershire area if no opiate and/or crack cocaine users were treated for their addiction is £12.8m. The services will provide not only treatment to drug and alcohol users but also addresses other underlying problems such as homelessness, unemployment and poor physical health which can de-stabilise a drug and alcohol user while they work towards freeing themselves of their problematic use. By doing so, we are able to address health inequalities by tackling structural determinants of health through a system approach.

Increase in health & wellbeing of the local area of £1,578,691.

£4,978,917

Appendix 1 shows a map of service users who were in South Gloucestershire treatment in 2013/2014.

Increase community confidence and enable access to services for marginalised and socially disadvantaged groups. Embracing the Recovery Agenda of the National Government The Government 2010 Drug Strategy, ‘Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug-free Life’, has been a drive to respond to emerging drug threats and to tackle drug dependence. In particular, the strategy makes references to ‘dependence on all drugs, including prescription medicines’ and ‘local responses to drug misuse and dependence.’ Figure 1: Outcomes of the Drug and Alcohol Treatment in South Gloucestershire

This also runs parallel to Building Recovery in Communities 2011, which enshrines the value of working with people who wish to take proactive steps in tackling their dependency on substance misuse, and offers an exit strategy through recovery. Effective clinical governance policies and practices are at the core of our services and we plan to continue to develop and maintain the areas of work that comply NICE guidance, the 2007 Guidelines on the Clinical Management of Substance Misuse, Building Recovery in Communities Framework, Medications in Recovery, Drug Misuse and Dependence: UK Guidelines on Clinical Management, and any other relevant national guidance.

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Sources of Data Unless stated otherwise, the following data sources have been used to produce the Needs Assessment report: • JSNA Support Pack for Substance Misuse – Provided by the Public Health England (PHE), the support pack provides the structured treatment data for planning for effective substance misuse prevention, through the provision of key performance and recovery outcomes information. The data is based on the performance of the local area in 2013/2014. The previous Needs Assessments were produced based on the PHE’s Needs Assessment pack, which was a different set of planning documents. Because of the unavailability of such data following the National Drug Treatment Monitoring System (NDTMS) suspension, a decision was made at the local level to use the JSNA Support Pack instead, to ensure that the progress of the Needs Assessment is not interrupted. • Local Data – Local service providers, such as Developing Health & Independence (DHI), Avon & Wiltshire Mental Health Partnership NHS Trust (AWP), which is an umbrella organisation of both South Gloucestershire Specialist Drug and Alcohol Service (SGSDAS) and the Criminal Justice Intervention Team (CJIT), and Battle Against Tranquilisers (BAT) have submitted the data that they collect locally, to provide a holistic picture of the non-structured treatment system in South Gloucestershire. Through this provision, it has been possible to establish contact with drug users who are not known to structured treatment services. As the data has been collected for the last two years, the data will be based on the trends between 2013/2014 and Q3 2014/2015, which gives a more complete picture of the non-structured interventions delivered in the local area. In addition, residential rehabilitation data, which has been collected locally, is also used for the analysis.

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Substance Misuse Treatment System in South Gloucestershire 2013/2014 WAITING TIME

COMMUNITY CONFIDENCE -50% feel that drinking in public is a problem - 50% feel that substance misuse is a problem in their area - 3 in 10 respondents do not know whether they are satisfied or dissatisfied with the way in which the council is tackling substance misuse

- 96% drug users and 98% alcohol users waited less than three weeks to access treatment

RESIDENTIAL REHABILITATION - 21 drug referrals - 13 alcohol referrals

SAFEGUARDING CHILDREN - 1139 - 1708 children affected by parental drug misuse - 12529 children living with hazardous drinkers - 3417 children living with dependent drinkers

- 55% OCUs penetration versus Avon & Somerset average of 46% - 97% opiate and non-opiate users effectively engaged in the treatment system - 78% alcohol users were drinking at higher risk levels in 28 days before entering treatment

ENGAGEMENT -7 out of 10 users were male -The majority of the drug users were aged 25 – 34 -3 out of 10 service users either previously or currently injecting -3 Drug-related deaths crime

DRUG USERS - Those who were not on benefits are 2 x as likely to complete their drug treatment successfully - 2 out of 10 drug users had a housing issue - 1 out of 10 alcohol users had a housing issue

ALCOHOL USERS

EMPLOYMENT AND HOUSING SUCCESSFUL COMPLETIONS - 11% locally for opiate users compared to 8% nationally - 31% locally for non-OCUs compared to 41% nationally - 41% locally for alcohol users compared to 38% nationally

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REFERRALS - 15% increase in referrals -Self-referrals recorded the highest number of referrals - 6 out of 10 were treatment naïve at presentation

- 50:50 male/female split - The majority were aged 30 – 39 - 2 out of 10 service users also cited a drug problem - 1 in 10 service users is currently receiving care from mental health services for dual diagnosis


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also receive care from mental health services, a referral pathway from such services may be worth exploring further by the local alcohol services. • With the Jobcentre Plus,

if they require stabilisation on the prescription first before challenging the behaviour of these service users and providing them with mutual aid or peer support groups to remain abstinent and recover from addiction.

• Utilise on the role of the previous service us°° Create a new referral pathway for alers as recovery mentors to ensure that recovcohol clients via the Jobcentre Plus, as ery is visible throughout the treatment jourthose who claim jobseeker allowance ney. and employment support allowance were overrepresented in the alcohol treatment • Use random drug testing and ascertain the system compared to the national profile, accuracy of self-reported abstinence, to consignifying that there is a hidden cohort of firm treatment compliance. Such information substance misusers with those accessing can be used further to mark the users’ progthe Jobcentre Plus ress in treatment.

2 Key Recommendations The following recommendations have been put forward for further consideration: Engagement • Improve the engagement with injecting cohorts, which include steroid users, to ensure that the treatment uptake from this group is in line with the national average, and assist with the reporting of the non-OCUs in the local area.

the surgeries and the treatment system. °° Raising awareness of those who visit the GP surgeries (potential service users and family members or carers impacted by drug use) through promotional posters and leaflets.

• Focus on engaging with new alcohol service • For referral routes of drug users, increase the users, through creative routes such as tarvisibility of the treatment system at the GP geting large employers such as the Ministry surgeries via the following activities: of Defence, Airbus, Rolls Royce, and the student population at the University of the West °° Engagement with GP-focused activities of England (UWE) and South Gloucester(such as the Royal College of General shire & Stroud College. Practitioners (RCGP) trainings) • Target younger cohorts for engagement of °° Promotion of Single Point of Contact those using amphetamines and cannabis through the CCG newsletters by the Drug substances. Collaboration with the Young and Alcohol GP leads People Drug and Alcohol Service (YPDAS) may be beneficial as they primarily focus °° Engagement with the practice managers. on these two substances for young people, °° Substance misuse pilot workers, such as which would ensure a better transition from the GP Alcohol Liaison Nurses and Subthe young people’s service into the adult substitute Prescribing workers to act as the stance misuse treatment system. ambassadors of the local treatment system by brokering the relationship between • As we have a proportion of alcohol users who

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°° Ensure that the information on service users benefiting from the Jobcentre Plus protocols (TPR1 and TPR2) is collected in the next financial year, to ensure seamless exchange of information of the service users with the Jobcentre.

• Ensure that the service users receive the range and intensity of interventions that will provide them with the best chance of recovery, which may include optimising doses of appropriate medications, split dosing regimens, supervised consumption, and active keyworking by the drug workers.

°° Work with the Criminality Champions of the Jobcentre Plus to ensure that the bar- • Consider the use of contingency manageriers for those who have criminal records ment, for example incentives, for a segment who want to go to work are challenged. of service users to motivate them towards recovery. Successful Completions Employment • In line with the recovery agenda, a proportion of the opiate service users who have been • Consider channel-shifting a proportion of the in treatment for more than two years should service users to volunteering first before embe segmented and that their needs are identiployment. This may help to address the isfied, to ensure that they are able to complete sues of low self-confidence and self-esteem their treatment successfully. before they apply for part-time and full-time roles. • Ensure that the length of treatment for alcohol is in line with the national performance, • Consider partnership working with Adult where nearly seven out of ten service usLearning Team of South Gloucestershire ers completed their treatment in less than Council to increase the literacy of the service six months nationally compared to six in ten users to prepare them for employment. service users who completed the treatment Housing during the same period of time locally. • Continue to work with the Empty Properties Dual Diagnosis Department of South Gloucestershire Coun• Employ better data recording on service uscil to bring empty properties back to use by ers with dual diagnosis status to aid better the service users. understanding on the scale and complexities of the service users in the treatment system. • Reduction in Substance Misuse and Abstinence • Identify service users who are still using on top of their prescribed medications. Determine South Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

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Harm Reduction

Residential Rehabilitation

• Continue to prompt the GPs to return the data on the commencement and completion of Hepatitis B Virus (HBV) courses through the CCG newsletters, and direct engagement with the GPs and Practice Managers.

• As data collection at the service providers’ level remains an issue, it will be proposed that all residential rehabilitation providers should provide their NDTMS monthly upload data to the DAAT, to ensure that what is reported through the NDTMS reflects the practice.

• Consider sustainable ways of improving the data collection on vaccinations through de- Alcohol livering the interventions as part of the local • Following the identification of violent crime treatment services rather than ‘outsourcing’ hotspots in Kingswood, Yate, and Chipping them entirely to the GP surgeries. Sodbury as a result of alcohol misuse, ensure • Engagement with the gyms, to ensure that that engagement processes are focused on they are aware of the issues around injectthese three areas, particularly on the Nighting, with a view of delivering safer injecting time Economy establishments. interventions and appropriate on-site needle Safeguarding Children disposals. • Education establishments such as prima• Engagement with the GPs, to ensure that ry and secondary schools can be targeted they are aware of the issues around injectto reach out to the hidden cohort of service ing and signpost the potential users through users of drug and alcohol who may require the Single Point of Contact for the local subtreatment interventions. Activities may instance misuse services. clude: • Engagement with the pharmacies, to gather °° Drug and alcohol awareness evening with soft intelligence around steroid use in South parents Gloucestershire. °° Training school staff to identify students • Encourage the injectors to consider BBV inwho may live with parents who have drug terventions and debunk the myths around and alcohol addiction such interventions as part of the health protection programme. °° Linking with the Children & Young People Services Team of South Gloucestershire Mutual Aid Council as they attend Multi-agency Dis• Continue to encourage service users to atciplinary (MAD) meetings to discuss stutend the SMART Recovery Group to assist dents’ issues that include parental subthem with the recovery journey, particularly in stance misuse. challenging behaviours such as using on top Crime of script and relapse. • Continue to work closely with Domestic • Consider volunteering as part of the peer & Sexual Violence Services, particularly support group activities. This will prepare the through MARAC, to support drug and alcohol service users to attempt at applying for emclients experiencing these issues. ployment and training. • Ensure that the referral pathways for the Support for Families and Carers criminal justice offenders with drug and al• Continue to explore whether family sessions cohol misuse problems are strengthened. and facilitative training sessions remain relIn particular, ensure that the Single Point evant for the FAM Service, and if so, ensure of Contact works closely with AIRS service. a higher uptake of such sessions by parents Swanswell has been commissioned to delivand carers. er Arrest, Intervention, and Referral Service (AIRS) to deal with offenders with substance • Consider new ways of bringing in grandparmisuse issues across Avon & Somerset and ents who are affected by substance misuse the opening of the Patchway Custody Suite. of their family members. 12


In this instance, South Gloucestershire is in the best place to ensure that the transition from the custody to the community treatment system is seamless. Community Confidence • Find creative ways in increase publicity on the council’s effort at tackling drug and alcohol addiction problems and assess its effectiveness. This will address the lack of awareness of the work that the council and the commissioned services are doing to improve the drug and alcohol problem in the local area, as identified through the Viewpoint Residential Survey 2014.


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Smarter Use of Data

Support for Young Adults

Following extensive work with the service providers, we can be proud that we have robust local data compared to other DAATs in the South West region.

3 Horizon Scanning

The following emerging trends are predicted in the local substance misuse field in 2015/2016: Novel Psychoactive Substances (NPS) An increase in the use of NPS, also known as legal highs, is proving hard to deal with because of the delay in criminalising individual formulations as they are created, and the problem of re-criminalising formulations as they are changed slightly to avoid the law.

at least one side effect as a result of their injecting behaviour, such as water retention, aggression, acne, erectile dysfunction, and high blood pressure.

Young adults are considered as an emerging theme in South Gloucestershire, as there are two higher and further education establishments in our patch – the UWE and South Gloucestershire and Stroud College – which remain to be With such a wealth of data, there is a danger of tapped into. Discussions with YPDAS are conbecoming a data hoarder entity – data rich but tinuing to ensure that there is continuing support insights poor. It will therefore be recommended for those who are in transition from young people that the local data can be layered using a conto young adults. sumer intelligence tool, such as ACORN, to facilitate better use of data in service delivery, par- Alcohol Use ticularly in reaching out to service users who are There is evidence to link substance misuse, esyet to present to the treatment system. pecially alcohol, to multiple other issues includWith the data collection, comes the data sharing ing domestic abuse, hate crime, violence and exercise with broader stakeholders. The data on health problems. Use of alcohol is higher in our substance misuse can be shared with Family in deprived neighbourhoods (and therefore has a Focus, Great Western Ambulance Service Trust negative effect on our most vulnerable communiand Avon Fire & Rescue as part of the multi-agen- ties) and alcohol misuse in general represents a cy approach in tackling drug and alcohol misuse. population-wide health issue. Changes to licensing laws have made it harder to carry out operData sharing with Family in Focus in particular, ations like test purchasing to find premises that will enable signposting the troubled families who are selling alcohol to underage customers; nevhave parental substance misuse into non-strucertheless efforts need to continue to challenge tured and structured drug and alcohol treatment. premises who sell alcohol illegally. This will increase the chances of the Families in Focus Team to claim successes under the Gov- It is also anticipated that there will be a potenernment’s Payment by Results Scheme for the tial spike in alcohol-related disorder when Troubled Families Agenda, particularly when the new UWE stadium is open to the members the drug and alcohol treatment enables £13,374 of the public, particularly through the Accident cost savings as a result of drug and alcohol inter- & Emergency (A&E) Department at Southmead vention for every troubled family. Hospital.

Avon & Somerset Arrest, Intervention, and Referral Service (AIRS)

AIRS have been delivered in South GloucesterWe need to better understand and address the shire since 1st April 2014. Based on activities use of legal highs, including looking at ways to undertaken by Swanswell, 35 contacts with ofprevent use that do not just rely on legal prose- fenders were made in both April and May. Subcutions. This includes trying to maximise our use sequently, the Staple Hill custody unit was closed of the reducing licensing powers that we do still down, leaving a gap in the reporting of the Arrest have. Referral Scheme for South Gloucestershire temporarily. Steroid Use Subsequently, the new custody suite in PatchThere is an emerging trend of increasing steroid way was opened on 23rd September 2014, and use in the local area. There were 77 service usrecorded 238 contacts with the offenders by the ers accessing the service by the end of October end of January 2015. The trend will be moni2014. The majority of these users have an avertored for the next 12 months to ensure that more age age of 28 years old, are using more than one offenders are referred and retained within the substance at a time, are injecting twice a week, treatment services, before successfully complethave not had a Hepatitis B vaccination, and had ing their treatment.

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Cross-border Clients

Domestic Abuse

To recognise the inevitable challenge of cross-border clients, South Gloucestershire DAAT had entered into a Memorandum of Understanding (MoU) with Bristol Substance Misuse Team (SMT) on the Maternity Drug Service and Specialist Prescribing (Shared Care) Services, by 31st March 2015. This will ensure that the service users from Bristol and South Gloucestershire have access to appropriate antenatal substance misuse treatment programmes and substitute prescribing service, with psychosocial support for service users who are registered with Bristol and South Gloucestershire GP surgeries.

Alcohol is frequently seen as an aggravating factor in domestic abuse cases, and alcohol-related domestic abuse referrals to MARAC have increased. 15% of victims (n=41) and 60% (n=169) of perpetrators were identified as having a current substance misuse problem; with data indicating an increase in the use of alcohol rather than drugs for victims and drugs rather than alcohol for perpetrators.2 South Gloucestershire Child Poverty Strategy

A child is said to be living in poverty if their household income is less than 60% of the averThe service users’ choice of substitute prescribage wage. In South Gloucestershire, there are ing service was often not based on the nearest more than 6,000 children living in poverty. Child GP surgeries where they live. Appendix 2 shows poverty is a major source of inequalities which a mapping exercise of South Gloucestershire can persist throughout life. Children who grow up service users receiving the service in Bristol, in poverty are four times as likely to become poor and that there are nearer GP surgeries where adults becoming the parents of the next generathey live compared to where they are currently tion of children living in poverty. accessing the service. A South Gloucestershire Child Poverty Needs Therefore, the MoU specifically refers to the Assessment is currently being produced as reneed to allow service users to make an informed quired by the Child Poverty Act 2010. The scope choice, by giving them the necessary information of the Needs Assessment will cover the key drivregarding the availability of treatment in South ers of child poverty as outlined in the national Gloucestershire. In doing so, the DAAT and the Child Poverty Strategy 2014 – 2017. The two Bristol SMT will continue to promote each other’s main drivers of child poverty are worklessness services to future clients to ensure that they are and low pay. Parental drug and alcohol misuse aware of the right service and referral pathways has been identified as a barrier to work and a into the local treatment system and promote the section on this will therefore be included in the best use of resources in an efficient and effective Child Poverty Needs Assessment. way. Priority Neighbourhoods All Priority Neighbourhood area forums in South Gloucestershire (Kingswood, Yate and Doddington, Filton, Staple Hill, Cadbury Heath, and Patchway) have listed drug and alcohol issues as an area of concern. Kingswood in particular, is one of the top areas for referrals of high risk domestic abuse victims into the MARAC (Multi-agency Risk Assessment Conference) process. At present, there is a lack of local level analysis to aid the Priority Neighbourhood forums in understanding the scale of substance misuse in their local areas. It will be recommended that such analyses are made available in the future.

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South Gloucestershire MARAC Annual Report 2013/2014


Mental Health Needs Assessment Strategy

Local Outcome Comparators (LOCs)

A Mental Health Needs Assessment was undertaken to obtain local mental health data to inform the Mental Health and Wellbeing Strategy. It identified groups with the highest risk of mental ill health in South Gloucestershire and the following emerging local priorities:

To aid meaningful comparisons between South Gloucestershire and other comparative areas, PHE devised Local Outcome Comparators’ (LOCs) to improve comparisons between local performance and that of other areas. This method supersedes the previous opiate and non-opiate clusters.

• Joint working with other key agendas (drug and alcohol, and employment services) • Development of sub-threshold preventative and community-based interventions • Consistency of GP care for people with mental illness • Increasing the capacity of secondary mental health services • Care co-ordination for individual service users

Each local area, including South Gloucestershire, will be compared to the 32 areas that are most similar in terms of the complexity of the clients in the substance misuse treatment – see Appendix 3. According to the new method, the performance of the local area is determined by the probability of individuals achieving successful completions, and no representation within six months after completion. This is different from the previous methods, which looked into broader similarities among the general populations of the local authorities.

• Availability of consistent and joined up support after mental health crises or discharge Based on the current performance level, South Gloucestershire either better off or in line with from hospital other similar authorities within the same LOC • Continued promotion of service user involve- group. The benchmark between the local and ment in designing and commissioning ser- other LOC areas is reflected within the perforvices mance suites of the DAAT. • Tackling stigma and promoting whole population mental health awareness • Mental health training for specialist and non-specialist staff.


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4 South Gloucestershire Area Profile South Gloucestershire covers 53,665 hectares. It is one of the largest unified local authorities in the UK. The population is estimated to be 269,107 at the mid-year point of 2013. Trends indicate that the population could reach 295,600 by the year 2025. The area is dominated by middle income families. It has areas of relative affluence and areas of deprivation. Alongside areas of relative prosperity, there are areas defined as priority neighbourhoods. These are Kingswood, Staple Hill, Cadbury Heath, Filton, Patchway and West Yate/Dodington. There are pockets within the local area that face rural isolation, with access to services and transport of particular note.

closely aligned with the England average; 18.6% are children, 63.5% are aged 16-64 and 17.9% are aged 65 or over. According to the last Census, 5% of the population were of Black and Minority Ethnic (BME) origin3. Despite the economic recession, South Gloucestershire continues to have one of the highest employment rates in the UK and unemployment remains below the national average. The latest Viewpoint citizen’s panel survey indicates that 77% of residents are fairly or very satisfied with their local area as a place to live.

The age structure of the district’s population is

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Excluding ‘White Other’ category


Figure 2: South Gloucestershire Map South Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

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5 South Gloucestershire Prevalence Estimates

6 Engagement

South Gloucestershire’s treatment system has a good track record for engaging with OCUs. Collectively, this cohort of service users has a significant impact on crime, unemployment, safeguarding children, and long-term benefit reliance for the local area.

The engagement with the local treatment ensures that the service users use less or abstain from using drugs, commit fewer crimes, and improve their health and quality of life. For drugs, in 2013/2014, the numbers of both opiate and non-opiate users in treatment have surged by 8% and 24% respectively. Overall, 97% of both opiate and non-opiate users are effectively engaged in the treatment system, compared to 95% engagement in 2012/2013, reflecting a good track record for engaging with service users.

On the other hand, engagement with both crack and injecting cohorts are lower than the national average. For engagement with crack users, the local area recorded 42% (n=291) treatment uptake compared to 39% nationally, whilst the local area recorded 47% (n=93) of engagement with injecting cohort, compared to 54% nationally.

In 2013/2014, it is estimated that there are 896 users in the local area, which is equivalent to one Recommendations in 189 people. 55% of the estimated number of • Improve the engagement with injecting coOCUs in South Gloucestershire were engaged horts, which include steroid users, to ensure in structured treatment (n=493), which is notathat the treatment uptake from this group is bly higher than the Avon & Somerset average of in line with the national average, and assist 46%. with the reporting of the non-opiate and crack For engagement with opiate clients, our local users (non-OCUs) in the local area. treatment outperforms the national average of 60%, by recording a 62% engagement rate (n=476).

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higher for men and 1.3 times higher for women, compared to a normal drinker). Looking at the combination of alcohol with other substances used, the use of alcohol in conjunction with opiates and crack is in line with the national average (4%). On the other hand, the use of alcohol with cannabis and other drugs in South Gloucestershire is higher than the national average (11% locally as opposed to 10% nationally for crack and 12% locally as opposed to 10% nationally for other drugs respectively).

In 2013/2014, 78% of the service users (n=169) Recommendations were drinking at higher risk levels in the 28 days prior to entering treatment. This represents a • Segment the clients who are using drugs in 19% increase compared to 2012/2013. This coconjunction with alcohol, and target this cohort faces an increasing alcohol-related risk such hort as a holistic recovery approach. as liver disease (13 times higher than a normal drinker) and coronary heart disease (1.7 times


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Referral Routes of Alcohol Users 2013/2014 42%

36%

19% 17%

10%

Routes into Treatment

7%

A total of 299 drug referrals were received during 2013/2014 in comparison to 254 in 2012/2012, representing an increase of 15% in the number of referrals. Figure 3 below shows the proportion of referral routes into the local treatment system in 2013/2014:

Self-referral

GP Local

Criminal Justice

Regional

Referral Routes of Drug Users 2013/2014

Figure 4: Referral Routes of Alcohol Users 2013/2014

56%

GP referrals into the local treatment system was higher compared to self-referral and criminal justice routes. Such a trend may be attributed to the GP Alcohol Liaison Nurse Pilot Project which provided the service users with a referral pathway into the local treatment system, along with GP awareness of the single point of contact for the local substance misuse treatment system.

44% 41%

30% 27%

It is also noted that nearly six out of ten (59%) of the service users were treatment naïve when they presented themselves into the local treatment system. Recommendations • For referral routes of drug users, increase the visibility of the treatment system at the GP surgeries via the following activities:

13% 9%

Self-referral

13% 7%

GP Local

°° Engagement with GP-focused activities (such as the RCGP trainings)

Regional

°° Promotion of Single Point of Contact through the CCG newsletters by the Drug and Alcohol GP leads Criminal Justice

National

Figure 3: Referral Routes of Drug Users 2013/2014

Self-referrals recorded the highest number of referrals compared to the regional and national averages. On the other hand, referrals through GP surgeries and the criminal justice routes remain below the regional and national averages. On the other hand, Figure 4 below shows the referral routes for alcohol (n=151), which depicts a different picture from the drug referrals: 22


°° Engagement with the practice managers. °° Substance misuse pilot workers, such as the GP Alcohol Liaison Nurses and Substitute Prescribing workers to act as the ambassadors of the local treatment system by brokering the relationship between the surgeries and the treatment system. °° Raising awareness of those who visit the GP surgeries (potential service users and family members or carers impacted by drug use) through promotional posters and leaflets. • Focus on engaging with new alcohol service users, through creative routes such as targeting large employers such as the Ministry of Defence, Airbus, Rolls Royce, and the student population at the UWE and South Gloucestershire & Stroud College.


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In Treatment > 2 Years 357 Users In Treatment Between 2 and 6 Years 279 Users

7 Local Treatment Services

In Treatment > 6 Years 79 Users

Waiting Times Ensuring that the waiting times to access treatment is as minimal as possible is key to a recovery-orientated treatment. Figure 5 below shows the waiting times comparison between 2012/2013 and 2013/2014: Waiting Less Than Three Weeks to Access Treatment, 2012/2013 and 2013/2014 Comparison

98%

96%

94%

Figure 6: Time in Treatment for Opiate Users Recommendations • In line with the recovery agenda, a proportion of the opiate service users who have been in treatment for more than two years should be segmented to ensure that they are able to complete their treatment successfully. • Ensure that the length of treatment for alcohol is in line with the national performance, where nearly seven out of ten service users completed their treatment in less than six months nationally compared to six in ten service users who completed the treatment during the same period of time locally.

66%

Time in Treatment - Alcohol Users, Local and National Comparison 38% 35%

29%

30% 26%

Drug

23%

Alcohol 2012/2013

2013/2014

Figure 5: Waiting Times In 2013/2014, 96% (n=286) of the drug users waited less than three weeks to commence their treatment, against a target of 85% waiting under three weeks. This also represents a 2% increase of those who had been seen by the treatment providers in less than three weeks compared to the previous year. Similarly, 98% (n=154) of the alcohol users waited less than three weeks to commence their treatment against a target of 85%. This represents a 32% increase of those who had been seen less than three weeks compared to the previous year. It can be seen from Figure 7 above that the length of time of alcohol users in the local treatment between six and 12 months, exceeds the national average. 24


10%

Under 3 Months

3 - 6 Months

6 - 12 Months Local

10%

Over 1 Year

National

Figure 7: Time in Treatment for Alcohol Users South Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

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8 Service Users’ Demographics

Dual Diagnosis Status The term ‘dual diagnosis’ covers a broad spectrum of mental health and substance misuse problems that an individual might experience concurrently. Figure 8 below shows the proportion of service users with dual diagnosis status in 2013/2014: Dual Diagnosis Status 2013/2014 Not Answered, 5% Number with Dual Diagnosis, 12%

Number without Dual Diagnosis, 83%

Figure 8: Dual Diagnosis Status 2013/2014

In 2013/2014, the demographic patterns of the local drug users in treatment are: • Nearly seven out of ten service users (68%) were male • 98% of the service users are from the White background; this was a slight overrepresentation of users from the White background compared to the general population proportion of South Gloucestershire. • The majority of the drug users were aged 25 – 34. This proportion represents throughout the substances, with an exception of amphetamines and cannabis, where they were being used by younger cohorts. • Nearly three out of ten service users (28%) either previously or currently injecting. For alcohol users, the local demographic patterns show the following trend: • The male to female split in treatment for alcohol is very similar. • A large portion of the service users is aged 30 – 39, compared to the national average, which is 43.

It is interesting to note that in South Gloucestershire, just above one in ten service users has a dual diagnosis status (12%, n=51), compared to nearly two out of ten nationally (19%). Based on the feedback that the DAAT received from BAT, who is the dual diagnosis lead, it is anticipated that there is still a proportion of service users with dual diagnoses who have not been captured through the NDTMS data recording as a result of process (which requires better input) and understanding of the workers on dual diagnosis definition and referral pathways. Recommendations • Target younger cohorts for engagement of those using amphetamines and cannabis substances. Collaboration with the YPDAS may be beneficial as they primarily focus on these two substances for young people, which would ensure a better transition from the young people’s service into the adult substance misuse treatment system. • As we have a proportion of alcohol users who also receive care from mental health services, a referral pathway from such services may be worth exploring further by the local alcohol services. • Employ better data recording on service users with dual diagnosis status to aid in better understanding of the scale and complexities of the service users in the treatment system.

• Two out of ten service users for alcohol (23%) also cited a drug problem. • One in ten service users (14%) is currently receiving care from mental health services for reasons other than substance misuse, reflecting dual diagnosis issues among the alcohol service users. 26



27

9 Treatment Outcome Profile

In summary, the local treatment system was successful in challenging the service users to reduce their substance misuse for crack and cannabis. The system was less successful in doing so for other substances, particularly amphetamines. On the other hand, Figure 10 below shows the local treatment was successful in challenging amphetamine misuse, along with cannabis, injecting and adjunctive alcohol use: Abstinence Rate 69%

65%

40% 42%

Opiate

The Treatment Outcomes Profile (TOP) data, provides an overview of the effectiveness of the treatment system in terms of its impact on service users’ behaviour and their lifestyles. Service users who stop using illicit opiates in the first six months for example, are almost five times more likely to complete successfully than those who continue to use. Figure 9 below shows whether the service users in South Gloucestershire have made any progress in reducing their substance misuse in a significant way, in 2013/2014:

51%

25%

57%

54%

36%

Crack

Cocaine

Amphetamines

Cannabis

35% 35%

Adjunctive Alcohol Use

Injecting

National

Figure 10: Abstinence Rate Recommendations • Identify service users who are still using on top of their prescribed medications. Determine if they require stabilisation on the prescription first before challenging the behaviour of these service users and providing them with mutual aid or peer support groups to remain abstinent and recover from addiction. • Use the role of the previous service users as recovery mentors to ensure that recovery is visible throughout the treatment journey.

Significant Reduction in Use

• Use random drug testing and ascertain the accuracy of self-reported abstinence, to confirm treatment compliance. Such information can be used further to mark the users’ progress in treatment. 25%

25%

21% 18%

18% 15%

12%

50%

57%

Local

Reduction in Substance Use and Abstinence

13%

45%

53%

11%

• Ensure that the service users receive the range and intensity of interventions that will provide them with the best chance of recovery, which may include optimising doses of appropriate medications, split dosing regimens, supervised consumption, and active keyworking by the drug workers. • Consider the use of contingency management for a segment of service users to motivate them towards recovery Employment For the local drug users, those who were not on benefits are twice as likely to complete their treatment successfully compared to those who were on benefits. On the other hand, claiming benefits was not a factor that determined successful completions for alcohol users in structured treatment.

7%

0% Opiate

Crack

Cocaine

Amphetamines Local

Cannabis

Adjunctive Alcohol Use

National

Figure 9: Significant Reduction in Use 28



29

Benefit Profile of the Drug Treatment Population 2013/2014

Employment Status, Drug Users 2013/2014 53%

21%

18%

29%

17%

19%

20%

14%

24%

23%

21%

19%

16%

14% 12%

11%

11%

9% 0% Regular Employment

Unemployed

2%

0%

Unpaid Voluntary Work

Long-term Sick/Disabled Local

2%

In Education

1%

3%

Other

Not stated 3%

3%

National

Figure 11: Employment Status of Drug Users 2013/2014 Jobseeker Allowance

Employment Support Allowance

Incapacity Benefit Local

Income Support

Disability Living Allowance

Other

National

Figure 13: Benefit Profile of the Drug Treatment Population 2013/2014 Benefit Profile of the Alcohol Treatment Population 2013/2014

Employment Status, Alcohol Users 2013/2014 40%

26%

36% 30%

25%

30%

21%

20% 15%

16%

15%

14% 12% 9%

9%

1% Regular Employment

Unemployed

0%

Unpaid Voluntary Work

0% Long-term Sick/Disabled Local

1%

In Education

2%

2%

Other

8%

1% Not stated

3%

Jobseeker Allowance


Incapacity Benefit Local

Based on 299 status recorded for drug users and 151 status recorded for alcohol users, Figures 11 and 12 above show that the service users in the local structured treatment system have a higher rate of regular employment compared to the national average. Similarly, the proportion of long-term sickness and disabled is also higher than the national average. The benefit profile of the drug treatment population in 2013/2014 shows that most of the benefit claims were lower than the national average, as shown by Figure 13 below:


3%

National

Figure 12: Employment Status of Alcohol Users 2013/2014

30

8%

Income Support


Other

National

Figure 14: Benefit Profile of the Alcohol Treatment Population 2013/2014

On the other hand, Figure 14 above shows that those who were claiming Jobseeker Allowance and Employment Support Allowance were overrepresented in the alcohol treatment system compared to the national profile. By comparing Figures 13 and 14 above, and Figures 15 and 16 below, it can be concluded that although the benefit profile of the local drug treatment population is smaller compared to the national profile, the median length of time of the users on benefits is longer compared to the national average, except for Incapacity Benefit and Income Support. South Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

31

Median Length of Time (Years) of Drug Users on Benefits 2013/2014 Jobseeker Allowance 8.0 7.0 6.0 5.0

Other


4.0 3.0 2.0

Locally, benefit advice, jobmatch support, and National Careers Advice sessions are the three popular employment interventions that are currently being delivered by DHI. On average, the agency conducted four groups for employment work activities on a monthly basis, with an average attendance of five service users. Service users who access the Employment Service tend to be those who are relatively stable, either having achieved abstinence or stability through Opiate Substitution Therapy. This is because employment support seems to be an unviable immediate goal for those with a pattern of chaotic substance misuse, as priority will be focused on initial support and stabilisation. Those who are looking for employment often face the following barriers:

1.0

• Finding and maintaining employment when presenting in a state of intoxication or withdrawal.

0.0

• Lack of work experience or work history, as the service users tend to have been out of employment for a significant period of time, or had never been employed prior to presenting to the treatment system. Disability Living Allowance

Incapacity Benefit

• Criminal records. A national survey conducted by the UK Drug Policy Commission found that two-thirds of employers would refuse to employ a former heroin or crack cocaine user, even if they were otherwise suitable for the job4.

Income Support Local

• Literacy issues, where some service users did not attend their school regularly towards the end of their education.

National

• Mental health issues

Figure 15: Median Length of Time of Drug Users on Benefits

• Low self-confidence On the other hand, the median length of time of alcohol users who were on benefits were shorter in South Gloucestershire compared to the national average.

Median Length of Time (Years) of Alcohol Users on Benefits 2013/2014 Jobseeker Allowance

As part of the employment interventions, DHI has ensured that the Information Technology equipment is up to date and accessible, trained staff are the Welfare Reform Champions, and enabled their staff to access specialist training via Citizen Advice Bureau (CAB), on topics such as welfare benefits, Personal Independence Payments (PIPs) and making claims. Recommendations • With the Jobcentre Plus,

9.0

°° Target Job Centre Plus as a new referral pathway for alcohol clients, as those who claim jobseeker allowance and employment support allowance were overrepresented in the alcohol treatment system compared to the national profile, signifying that there is a hidden cohort of substance misusers with those accessing the Job Centre Plus

8.0 7.0 6.0

Other

5.0


4.0

°° Ensure that the information on service users benefiting from the Job Centre Plus protocols (TPR1 and TPR2) is collected in the next financial year, to ensure seamless exchange of information of the service users with the Job Centre.

3.0 2.0 1.0 0.0

°° Work with the Criminality Champions of the Job Centre Plus to ensure that the barriers for those who have criminal records who want to go to work are challenged.


Incapacity Benefit

• Consider channel-shifting a proportion of the service users to volunteering first before employment. This may help to address the issues of low self-confidence and self-esteem before they apply for part-time and full-time roles. • Consider partnership working with Adult Learning Team of South Gloucestershire Council to increase the literacy of the service users to prepare them for employment.

Income Support Local

National

Figure 16: Median Length of Time of Alcohol Users on Benefits 32


4

UK Drug Policy Commission, ‘Drug Policy – Getting the Strategy Right for the Long Term’ (2010) South Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

33

Housing and Homelessness The analysis below is based on the self-reported housing status of adults when they first started their structured treatment. Accommodation Status at the Start of Drug Treatment 2013/2014

The accommodation analysis above is in congruence with the housing interventions that are being delivered by the Reintegration Service. As the majority of the service users, regardless of their substance use, had no housing problem, the housing interventions tend to cluster around maintaining occupancy, such as assistance with utilities, support with mortgage and rent arrears, and support with debts, on a quarterly basis. It is also noted that the uptake of the Access Scheme (previously known as the ‘Deposit Bond Scheme’) remains low. Going forward, the challenges of housing interventions for the service users in South Gloucestershire are:

77% 73%

• Under-occupancy charge. The service users may have to downsize and if they are classified as low priority, it is harder for them to access social housing. • Renting culture that the landlords do not tend to accept tenants who are in receipt of housing benefits. This is supported by the research of the National Landlords Association, which shows that the number of landlords letting to tenants in receipt of benefits has fallen from 34% to 27%. 5 • Landlords who accept tenants with housing benefits frequently ask for guarantors and rent in advance, between two and six months’ worth of rent. 15% 8%

• Single room rates often prevent service users who are under 35 to live with their children as they are only entitled to the shared accommodation rate under Housing Benefit requirement.

14%

9% 2%

0% Urgent Housing Problem

Housing Problem

No Housing Problem Local

Other

1%

2%

Unrecorded

National

Figure 17: Accommodation Status at the Start of Drug Treatment

• The roll-out of the Universal Credit means that the service users will receive their Housing Benefit on a monthly basis rather than being paid directly to the landlords. This presents a risk of rent arrears for those renting privately and in social housing. • Increasing competition from more affluent renters and students.

Of 299 status recorded, above two out of ten service users with drug problems (23%) had a housing issue, either urgent or not. The percentage of service users who had no housing problem in the local area exceeds the national average. On the other hand, Figure 18 below shows that, out of 151 accommodation status recorded for alcohol users, nearly nine out of ten service users had no housing problem.

Recommendations • Continue to work with the Empty Properties Department of South Gloucestershire Council to bring empty properties back to use by the service users. • Devise creative ways of using the funding for Access Scheme, as the uptake is currently low.

Accommodation Status at the Start of Alcohol Treatment 2013/2014

86% 82%

11% 3%

9% 5%

4%

Urgent Housing Problem

0% Housing Problem

No Housing Problem Local

Other

National

Figure 18: Accommodation Status at the Start of Alcohol Treatment 34


1%

0% Unrecorded

National Landlords Association (NLA), ‘Landlords Exit Local Housing Allowance Market’ (July 2013), available at: http:// www.landlords.org.uk/news-campaigns/news/landlords-exit-local-housing-allowance-market (last accessed: 17th February 2015). 5


35

Re-presentation 16.7%

Lower is better

10 Treatment Outcomes

11.6%

9.5% 6.8%

4.8% 6.3% 3.7%

Successful Completions The number of clients who completed their treatment programme successfully remains a priority for South Gloucestershire. Figure 19 below shows the local successful completions rate compared to the national performance: Successful Completions as a Proportion of Total Number in Treatment 2013/2014 41%

Opiate

0.0% Non-opiate only

Alcohol only

Up to 31st March 2014

Alcohol and nonopiate

Baseline

Figure 20: Re-presentation

41% 38%

Recommendations As the focus has been geared towards non-opiate users, the following ideas were presented by the service providers during the End of Year Review in June 2014, which will be taken forward in 2015/2016:

31%

• Six month TOP incentivisation pilot • Targeting service users with low TOP review scores for ‘quality of life’ measures for family and carer support • Quarterly analysis around unsuccessful completions

11% 8%

• Enhancing peer support programme • Review of service users’ consultation and feedback

Opiate

Non-opiate Local

Alcohol

National

Figure 19: Successful Completions as a Proportion of Total Number in Treatment

• Data and Performance Training with Public Health England, particularly on how to use data to improve local performance. The training took place in November 2014 • Using various media to remind clients of their appointments, including text messages • Offering a new appointment as soon as possible when the initial appointment is cancelled

During 2013/2014, 11% of the opiate users successfully completed their treatment compared to 8% nationally. Similarly, the local successful completions of alcohol (41%) exceeds the national average of 38%.

• Establishing reasons behind missed appointments and assisting service users to attend appointments

On the other hand, the successful completions rate for non-opiate was notably lower than the national average (31% locally as opposed to 41% nationally). This is despite the fact that in South Gloucestershire nearly nine out of ten non-OCUs have very low or low level complexities; however, only three out of ten from this cohort successfully completed their treatment.

• Use the NDTMS attributors to see if there are emerging trends of the service users who successfully completed their treatment and re-presented within six months’ time.

• Transferring historic clients into recovery support

Based on the NDTMS Adult Activity Report, the re-presentation up to 31st March 2014 remains above the baseline for opiate and non-opiate users. 36



37

Recommendations

11 Harm Reduction Needle Exchange A Blood Borne Virus (BBV) is transmitted when blood from an infected person gets into the bloodstream of another. It has been shown that Injecting Drug Users (IDUs) are at increased risk from BBVs due to the risks associated with their injecting behaviour such as sharing needles and injecting paraphernalia, frequency of injection, repeated injecting with used needles and inadequate cleaning of injecting paraphernalia6. There are ten pharmacies that are currently delivering Needle Exchange services across South Gloucestershire. A map of these pharmacies is available in Appendix 4. In addition, mobile Needle Exchange and Outreach Services are provided; the services are flexible to ensure county-wide coverage.

• Considering the increasing number of needle exchange users, particularly the steroid cohort, encourage more pharmacies to deliver the Needle Exchange programme to help reduce the harm from injecting drug behaviour • Promotion of harm reduction messages to IDUs in other health areas, such as safer sexual practices, and encourage discussions around reduced sexual inhibitions when under the influence of substances. Blood-borne Viruses Drug users who share injecting equipment can spread blood-borne viruses. As part of health protection interventions, provisions of methadone and sterile injecting equipment, benefit the users and the communities through long-term health savings. Figure 22 below shows the proportion of service users who started and completed a course of vaccination for Hepatitis B and C in 2013/2014 in South Gloucestershire, based on the new treatment eligible for a HBV vaccination who accepted one (n=150 in 2013/2014 and n=83 in 2012/2013):

Figure 21 below shows the pharmacy needle exchange in 2013/2014, where it can be seen the majority of the needle exchange activities took place in JRW Billing in Kingswood, Boots in Staple Hill, and Boots in Yate.

Blood-borne Viruses Vaccinations

87%

Pharmacy Needle Exchange 2013/2014

Asda Pharmacy, Cribbs Causeway, 11

Hayfield Pharmacy, Filton, 15

80% 69%

Lloyds, Patchway, 35

Boots, Yate, 236

Boots, Staple Hill, 481

32%

Boots, Cadbury Heath, 54

26% Co-op, Kingswood, 128

1%

6%

5%

Started a Course of Vaccination

Completed a Course of Vaccination 2012/2013

JRW Billing, Kingswood, 609

10%

2013/2014

Injectors Who Eligible for a HCV Test Who Received One

2013/2014 (National)

Figure 22: Blood-borne Viruses Vaccinations

Figure 21: Pharmacy Needle Exchange The changing needs and challenges of the Needle Exchange Service are three-fold: •

Increasing number of steroid users in the local area and the local service (see below).

•

Growing trend of NPS users who inject

• Lack of returns of the used needles. This raises concerns of the needles not being disposed of appropriately and the need to reduce the risk to the public.

The proportion of those who started and completed a course of vaccination for Hepatitis B remains lower than the national level, because there is no seamless transfer of information on such vaccinations from the GP practices to the local treatment services. Obtaining robust data on those who started and completed a course of Hepatitis B Vaccination should remain the focus of the DAAT. On the other hand, the proportion of injectors who received a Hepatitis C Vaccination superseded the national average in 2013/2014.

Patrick, D. M. et al, ‘Incidence of Hepatitis C Virus Infection Among Injecting Drug Users During an Outbreak of HIV Infection’ (2001) Canadian Medical Association Journal 889 6

38



39

• Age – the average age of the steroid injecting user is 28 years old. They tend to have used steroids before, either orally or injecting. • Substances – The substances can be divided into three broad categories, subject to differences in volume and strength: °° Bulking, such as Anabol, anadrol, and Danabol. °° Cutting, such as Anavar, Boldenon and Durabolin.

how to dispose of the used equipment safely. In terms of the side effects, seven out of ten service users reported the experience of side effects, such as water retention, aggression, acne, erectile dysfunction, and high blood pressure. Recommendations • Engagement with the gyms, to ensure that they are aware of the issues around injecting, with a view of delivering safer injecting interventions and appropriate on-site needle disposals.

°° Human Growth Hormone, such as HGH and Genotropin. • Engagement with the GPs, to ensure that they are aware of the issues around inject• Injecting habit – The steroid users tend to use ing and signpost the potential users through more than one substance at a time, either by the Single Point of Contact for the local submixing different injectable steroids and injectstance misuse services. ing them at the same time (stacking), spacing out different injectables throughout the week, • Engagement with the pharmacies, to gather or mixing injectable and oral steroids. soft intelligence around steroid use in South Gloucestershire. • Frequency of injecting – The majority of these users tend to inject twice a week • Encourage the injectors to consider BBV interventions and debunk the myths around • Blood-borne Virus (BBV) testing – Nearly such interventions as part of the health proseven out of ten users (n=52) have not had tection programme. Hepatitis B and C tests, and refused interventions. Reasons for refusals include the fact that they had not used drugs in the past, did not believe that they were infected, and feared the outcome. • Location of injecting – Nearly nine out of ten users (87%) inject steroids at home.

Recommendations

Emerging Steroid Use

• Continue to prompt the GPs to return the data on the commencement and completion of HBV courses through the CCG newsletters, and direct engagement with the GPs and Practice Managers.

Based on the intelligence gathered by the Outreach Services of DHI, at the end of October 2014, there were 77 service users accessing the Needle Exchange Service for steroid injecting. This cohort use steroids to gain muscle weight or to strip fat to produce muscle definition. The demographic profile of these service users is:

• Consider sustainable ways of improving the data collection on vaccinations through delivering the interventions as part of the local treatment services rather than ‘outsourcing’ them entirely to the GP surgeries. 40


• Living with children – A quarter of the injectors (n=19) reported to have children under 18 living within the households, which raises the question of safeguarding. These injectors were offered a lock box to store their injecting equipment, and the prompts yielded a 70% uptake of the lock box. • Hotspots of the steroid users – Whilst the Needle Exchange services are offered across the county, the hotspots of the steroid injecting users are: °° Ministry of Fitness, Kingswood BS15 8NH °° Fitness First, Longwell Green BS15 9LA Harm minimisation advice, particularly safer injecting techniques tends to be provided for the service users, such as how to set up the injecting equipment, how to store clean equipment, and South Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

41

In addition, service users can take part in the peer support group activities. Figure 24 below shows the breakdown of activities undertaken as part of the peer support group, where the most popular activities include acupuncture and meditation/reiki: Peer Support Group Activities 84

70

12 Service Users’ Support

55

41

40

33 24

30 24 24

21

20 13

11

11 1

Acupuncture

SMART and Mutual Aid

37

Bike Maintenance Group

Q1 2013/2014

Gardening Group

Q2 2013/2014

Q3 2013/2014

19 8

11 11 5

Meditation / Reiki

Music Group

Q4 2013/2014

Q1 2014/2015

4

9

11

10

2 2

Special Events Q2 2014/2015

1

Women’s Group Q3 2014/2015

In South Gloucestershire, service users are supported through provisions of mutual aid, SMART recovery, and peer support group activities to help them manage their recovery from addictive behaviour.

Figure 24: Peer Support Group Activities

Between 1st April 2013 and 31st December 2014, on average, there were 11 SMART Recovery Groups that took place every quarter in Warmley and Yate respectively. The number of groups seems to be consistent throughout the quarters, although more SMART groups tend to take place in Warmley in line with the location of the local Treatment Centre.

There are also Alcohol Anonymous (AA) meetings that take place across the county, particularly in Downend, Thornbury and Patchway, although these meetings are not affiliated with the local substance misuse. A map of AA meetings is available in Appendix 5. Service Users’ Voice

SMART Recovery Groups 2013/2014 - 2014/2015

14 13

13

13

13

13

12 11

12

11

11 10

Support for Family and Carers The FAM Service provides support for family and carers whose family members suffer from drug and alcohol addiction. The FAM Service has a target of engaging with 100 family members per annum, and 50 carers per annum.

9

Between 1st April 2013 and 31st December 2014, on average, the FAM Service have 94 active members every quarter.

4

Q1 2013/2014

A qualitative analysis on the service users’ feedback (Rolling Comments) is currently being undertaken by the DAAT, to understand the level of engagement of service users with the treatment system, and to determine the common themes of issues raised by them, at a strategic level. The analysis should complement the Needs Assessment analysis to form a full picture of the service users’ engagement in the South Gloucestershire substance misuse field.

Q2 2013/2014

Q3 2013/2014

Q4 2013/2014

Warmley

Q1 2014/2015

Q2 2014/2015

Q3 2014/2015

Yate

Figure 23: SMART Recovery Groups 42



43

FAM Service Activities

Active FAM Members

112

106

102

104

100

94

82 81

78 72

55 46 33

32 26 20

38 37 37 38

Q2 2013/2014

Q3 2013/2014

Q4 2013/2014

Numbers in Service

Q1 2014/2015

Q2 2014/2015

Q3 2014/2015

22 21 9

FAM triages

Target (100) Q1 2013/2014

Figure 25: Active FAM Members

30

21 20 21

6 Q1 2013/2014

36

34

Number of group sessions delivered Q2 2013/2014

7

Number of 1:1 sessions delivered Q3 2013/2014

12

12 4 3

Number of 4 two sessions delivered

Q4 2013/2014

Q1 2014/2015

1 1

6 5

2 1

Family sessions delivered Q2 2014/2015

1 2 2 2 1 Facilitative Training sessions Q3 2014/2015

Figure 27: FAM Service Activities On the other hand, on average, there are 13 grandparents in FAM Service every quarter. According to Figure 27 above, the largest number of interventions delivered by the FAM Service clustered around 1:1 and group sessions.

Grandparents in FAM Service

Recommendations • Continue to encourage service users to attend the SMART Recovery Group to assist them with the recovery journey, particularly in challenging behaviours such as using on top of script and relapse. • Consider volunteering as part of the peer support group activities. This will prepare the service users to attempt at applying for employment and training. • Continue to explore whether family sessions and facilitative training sessions remain relevant for the FAM Service, and if so, ensure a higher uptake of such sessions by parents and carers. 10

11

Q1 2013/2014

Q2 2013/2014

12

13

12

Q3 2013/2014

Q4 2013/2014

Q1 2014/2015

Grandparents in service

14

Q2 2014/2015

16

• Consider new ways of bringing in grandparents who are affected by substance misuse of their family members.

Q3 2014/2015

Target (50)

Figure 26: Grandparents in FAM Service

Looking into the demographic patterns of the users accessing FAM service, almost six out of ten users aged 50 – 69, and seven out of ten FAM users are female. 44



45

Number of Drug Referrals 2013/2014

21

11

13 Residential Rehabilitation

Number of referrals

Unsuitable or Did Not Progress to Rehab

Figure 28: Number of Drug Referrals for Residential Rehabilitation

Whilst drug treatment mostly deliver in the community near to service users’ families and support networks, residential rehabilitation is another alternative of treatment, which may be cost effective, particularly for those who are ready for active change and a higher intensity treatment.

treatment. Data collection remains an issue for residential rehabilitation across all areas in England; therefore the information below is based on the local data.

In 2013/2014, there were 21 drug referrals into the residential rehabilitation. 11 referrals (52%) As residential rehabilitation tends to be expen- were assessed as either not suitable or did not sive, assessments are undertaken by the Com- progress to rehabilitation. Clouds House and munity Care Assessor (CCA) to determine the Chandos provided more than half of the rehabilisuitability of the service users to embark on such tation venues for the year.

46


On the other hand, there were 13 alcohol referrals received in 2013/2014. Five referrals were assessed as unsuitable and did not progress to rehab, and the majority of these were referred to Serenity House. The reasons for the incomplete CCAs include those assessed as not suitable for rehab or the service users chose to drop out. Nearly half of the rehabilitation places for alcohol service users were provided by Broadway Lodge Primary.


47

Number of Alcohol Referrals 2013/2014 13

5

14 Local Alcohol Treatment System Number of referrals

Unsuitable or Did Not Progress to Rehab

Figure 29: Number of Alcohol Referrals for Residential Rehabilitation Successful discharges for drug users were recorded at 55%. The reason for unsuccessful discharges include relapse, self-discharge, move to a new area, or aggression. On the other hand, successful discharge rates for alcohol service users was higher (75%), and the remaining users are still in the rehab programme, indicating that there was no unsuccessful discharges for alcohol users. Community Rehabilitation Apart from residential rehabilitation, community rehabilitation is also delivered as part of the treatment intervention in South Gloucestershire. Currently being provided by Serenity House, two programmes offered are Alma (an abstinence-based programme in which the service users are not allowed to use any substances; if they relapse, they will be dismissed from the programme) or Delta (a more flexible programme in which if the service users relapse, there will be a three day exclusion before they can resume their programme again). In terms of the treatment data, 84% (n=16) referrals to Serenity House progressed further into either the Delta or Alma Programme. The majority of the referrals was related to alcohol misuse, for Alma Programme. Of these service users, 79% of discharges (planned discharges and discharged less than two weeks) were recorded. Those who had unplanned discharges were because of relapse, health issues, or self-discharge. Recommendations

Alcohol misuse remains a significant challenge across a wide range of agencies. Apart from health challenges, it has also been recognised as contributing towards violent crime, particularly in Kingswood, Yate, and Chipping Sodbury7. The following estimates of existing drinkers in South Gloucestershire give an indication of the potential level of need in the local area, based on the Local Alcohol Profiles of England estimates: • Higher risk drinkers – 19,425 • Increasing risk drinkers – 55,881 • Binge Drinkers – 61,735 In addition, alcohol-related hospital admissions have increased on a yearly basis since 2009/2010 with 1500 per 100,000 population for males and nearly 800 per 100,000 for females. The rate is considered the least amount of harm, compared to the nearest neighbour, and the national average. There were 217 service users in the alcohol treatment system in 2013/2014. 78% (n=217) were drinking at higher risk levels in the 28 days prior to entering treatment. Nine out of ten service users were in treatment less than 12 months. In terms of successful completions, 41% of the service users successfully completed their treatment, against a national average of 38%. In South Gloucestershire, the focus on alcohol is driven by prevention and brief intervention. This is evidenced by the increasing number of service users entering the non-structured treatment system for alcohol, surpassing the drug users, as reflected in Figure 30 below:

• As data collection at the service providers’ level remains an issue, it will be proposed that all residential rehabilitation providers should provide their NDTMS monthly upload data to the DAAT, to ensure that what is reported through the NDTMS reflects the practice. • Plans are currently in place to have service users from HMP Eastwood Park to attend Serenity House, once they have completed their Drug Recovery Community journeys, to ensure continuity of treatment from the prison to the community and aid NDTMS reporting.

48


Avon & Somerset Police and Crime Commissioner (PCC) Needs Assessment (2014), available at: http://www.avonandsomerset-pcc.gov.uk/Document-Library/Police-and-Crime-Plan/ASPCNA-October-2014.pdf (last accessed: 23rd February 2015). 7


49

Number of Attendances - ACE and IBA

Number of Triages Completed 93

163

56

64

61

58

127 116

114

53

48

44

41

38

32

Q2 2013/2014

Q3 2013/2014

Q4 2013/2014

Alcohol Triages

Q1 2014/2015

29

Q2 2014/2015

48

Q3 2014/2015

Q1 2013/2014

Q2 2013/2014

Q4 2013/2014

Q1 2014/2015

Q2 2014/2015

Q3 2014/2015

IBA Courses

As a result of the increase in the number of alcohol users in the local non-structured treatment, referrals to Alcohol Specialist Service have also increased remarkably, reflecting the increasing complexity of the users presenting to the local treatment system: Referrals to Alcohol Specialist Service

41

39

22

Q3 2013/2014

Figure 32: Number of Attendances for ACE Groups and IBA Courses

Number of Sessions Delivered - ACE and IBA

45

41

36

34

27

26

25

71

47

ACE Groups

The number of Basic Awareness Sessions for Hazardous and Harmful Drinkers (ACE Groups) and Intervention & Brief Advice (IBA) courses delivered for the service users has been increasingly popular in 2013/2014, as shown by Figure 31 below.

32

71

46

Drug Triages

Figure 30: Number of Triages Completed for Alcohol and Drug Users

33

76

73

38

31

Q1 2013/2014

139

136

135

22

29 26

21

20

11

13 10

5 Q1 2013/2014

Q2 2013/2014

Q3 2013/2014

Q4 2013/2014

Q1 2014/2015

Q2 2014/2015

Basic Awareness Sessions for Hazardous and Harmful Drinkers (ACE Group)

Q3 2014/2015

IBA Courses

Figure 31: Number of Sessions Delivered for ACE Groups and IBA Courses The increasing popularity of the ACE Group and IBA courses is also reflected through the increase in the number of attendances for these courses, as depicted by Figure 32 below:

50


Q1 2013/2014

Q2 2013/2014

Q3 2013/2014

Q4 2013/2014

Q1 2014/2015

Q2 2014/2015

Q3 2014/2015

Figure 33: Referrals to Alcohol Specialist Service The success of the focus on prevention and brief intervention have been seen through the low alcohol mortality rate, and the months of life lost in South Gloucestershire are among the lowest one across England, as shown in Figure 34 below: South Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

51

Mortality and Months of Life Lost

11.49

8.96

15 Drug-related Deaths

5.38

3.31

0.06 Months of Life Lost (Male) Months of Life Lost (Female)

0.1

Alcohol-specific Mortality 2010 - 2012 Local

0.07

0.11

Mortality from Chronic Liver Disease 2010 - 2012

0.34

0.4

Alcohol-related mortality 2012

National

Figure 34: Referrals to Alcohol Specialist Service Recommendations • Following the identification of hotspots in Kingswood, Yate, and Chipping Sodbury, ensure that engagement processes are focused on these three areas, particularly on the Night-time Economy establishments. • Continue to strengthen the prevention and brief intervention for alcohol at the local level, to ensure that the mortality and months of life lost continue to be lower than the national average.

The PHE defines a drug related death as ‘a • Long-term service users had additional physdeath where the underlying cause is poisonical health problems. ing, drug abuse or drug dependence, and where • The following lessons have been learnt: any of the substances controlled under the Misuse of Drugs Act 1971 are involved.’8 • Amend DAAT questionnaire to enable agencies to input information around previous suiThe Drug and Alcohol Related Death Panel meetcide attempts and timeframes of such activing is held on a quarterly basis. Representatives ities. of the Panel include the DAAT team members, Lead GPs for drug and alcohol, treatment provid- • Include screening questions on service proers, Pharmacy Management and Avon & Somervider assessment forms on caring responsiset Constabulary. bilities. Following the assessment, the agency will liaise with Adult Social Care and GPs In 2013/2014, there were three drug and alcoregarding the suitability of the service user hol related deaths recorded in South Glouceshaving caring responsibilities and collecting tershire, of which two were related to drug misprescriptions. use. In the current financial year, there were 11 drug-related deaths recorded in South Glouces- • Seek information on the last visit to the GPs, tershire, which is an unprecedented increase. which may indicate underlying health needs. The following themes emerged as part of the Panel scrutiny: • An increased level of support should be offered to high risk or suicidal service users. • Increase the key workers’ confidence in asking a range of difficult questions. • Improve data sharing activities between agencies particularly when a case has been transferred from one agency to another, particularly on mental health, suicidal attempts, and bereavements.

8

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• Ensure that staff members are able to initiate difficult conversations around suicide and declining mental health. If service users indicate deterioration in mental health or suicidal thoughts, 1:1 support should be increased. • Ensure that the information given by the agencies is accurate prior to the circulation of papers to the Panel. • Integrate the lessons learnt process as part of the team briefing by the service providers, which will improve the understanding of all staff rather than an individual case worker.

NTA, ‘Commissioning Services to Reduce Drug Use Related Deaths’ (2003).


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Alcohol It was estimated that 22% of children in the UK are living with parents who are drinking hazardously and 6% of them are living with dependent drinkers. Using these estimates, it can be summarised that in South Gloucestershire, 15,946 children live with parents who have drinking issues, which equates to almost one in three children in the local area:

Estimate of children in South Gloucestershire who are living with parents who are drinking hazardously Estimate of children in South Gloucestershire who are living with parents who are dependent drinkers

16 Safeguarding Children

Estimates

Under 10 Years

Between 10 - 14 Years

Under 18 Years

22%

7042

3245

12529

6%

1921

885

3417

Table 2: Children Who Live with Parents Who are Hazardous and Dependent Drinkers The Children Act 1989 sets out the responsibilities of local authorities and other services for protecting children and promoting their welfare. The key principle of the Act is that the wellbeing of the child is of paramount importance. The Act also places a duty onto agencies to engage with drug users who have dependent children, or to engage directly with the children themselves, to assess their needs if their health and wellbeing may be at risk. Drug Advisory Council on the Misuse of Drugs (ACMD) estimated that between 2% and 3% of all children are affected by parental drug use. Whilst the prevalence was estimated without taking into account the local drug use, the following information provides a useful starting point for all parties to think about safeguarding measures involving parental substance misuse: On the other hand, just above five out of ten service users (51%, n=371) have a parental status in the local treatment system in 2013/2014. Of these 371 parents, two out of ten (24%) live with children, who tend to be female. The proportion remains in line with the trends in 2012/2013.

In 2013/2014, more than six out of ten service users (64%, n=139) have a parental status, with 54 service users living with children. The service users who live with children, tend to be female. Comparing the prevalence estimates of children who are living with parents who are drinking hazardously and who are dependent drinkers, with the number of service users who have parental status, it can be concluded that there is a large portion of service users, who are parents that can be targeted for alcohol interventions. Recommendations • Education establishments such as primary and secondary schools can be targeted to reach out to the hidden cohort of service users of drug and alcohol who may require treatment interventions. Activities may include: °° Drug and alcohol awareness evening with parents °° Training school staff to identify students who may live with parents who have drug and alcohol addiction

By comparing the prevalence estimates of children who are affected by parental drug use with the number of parental substance misuse who were in the treatment system, it can be conceded that there are more parents with substance misuse who have not been in contact with the local treatment system.

Estimates Between 2% and 3% of all children are affected by parental drug use

ACMD low estimate (2%) ACMD high estimate (3%)

Under 10 Years

Between 10 - 14 Years

Under 18 Years

640

295

1139

960

442

1708

°° Linking with the Children & Young People Services Team of South Gloucestershire Council as they attend Multi-agency Disciplinary meetings to discuss students’ issues that include parental substance misuse.

Table 1: Children Who are Affected by Parental Drug Use Manning, V. et al (2009) ‘New Estimates of the Number of Children Living with Substance Misusing Parents: Results from UK National Household Surveys, BMC Public Health, 9:377. 9

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55

ment Effectiveness Project (ITEP sessions) were delivered, along with 18 one-to-one awareness sessions.

er’s Nightclub in Kingswood and other Night Time Economy (NTE) establishments across the county.

The Cannabis Impact Programme is due to come to an end by end of March 2015 because of re-orientation of the substance misuse treatment towards other substances.

Future initiatives will include inviting David Haye, the UK prominent boxer to promote the NPS Pilot Project throughout NTE venues across South Gloucestershire, provision of amnesty bins at the NTE venues to enable Avon & Somerset Constabulary to analyse the popular NPS on market, and availability of hand-held devices to detect drug use in the last 48 hours, to deliver on-site interventions at the NTE venues.

NPS Pilot Project The concern surrounding use of NPS is a relatively recent phenomenon. The DAAT has commissioned DHI to deliver the NPS Pilot Project for 12 months, between November 2014 and October 2015.

17

South Gloucestershire DAAT prides itself with implementing innovative ways of tackling local substance misuse issues. This is partly achieved by investing in various pilot projects to test the new ways of working in the local area. To date, there are five pilot projects that are currently being undertaken in South Gloucestershire, which reflects the new strategic direction in the local substance misuse field: • Cannabis Impact Programme • NPS Pilot Project • GP Alcohol Liaison Nurses Pilot Project • Alcohol Interface Nurse

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Innovative Pilot Projects

• Opioid Analgesic Dependence (OAD), forthcoming 2015/2016. Cannabis Impact Programme The South Gloucestershire Cannabis Impact Programme was originally piloted in 2011 to provide cannabis-specific intervention, as many clients accessing the treatment system had identified cannabis as their primary or secondary substance of choice. The programme is currently being provided by the CJIT. By end of Q2 2014/2015, there were 52 referrals made into the Programme, with DHI being the biggest source of referrals for the Programme (65%). During this period, 37 International Treat-

It is estimated that there are 14,135 NPS users in South Gloucestershire aged between 16 and 59. In addition, it is estimated that the theoretical maximum number of NPS users in South Gloucestershire, who may also require treatment intervention is 1343. The local treatment data in 2012/2013 and 2013/2014 shows that there were 28 unique clients who cited NPS as primary drug use and another 19 cited NPS as secondary drug use. In this instance, the difference in figures reflect the gaps and unmet needs within the local treatment system in dealing with NPS users, which are not apparent on the surface.

Alcohol Interface Nurse The South Gloucestershire Alcohol Harm Reduction Strategy 2014 - 2017 purports to reduce alcohol related harms and encourage personal and social responsibility through effective joint working across the health and social care system. This includes developing whole system commissioning to reduce the harm caused by alcohol, together with integrating services across organisations and shifting the balance from the treatment of disease to prevention and management of disease in the community setting. An element of the workplan associated with the strategy is the creation of an Alcohol Interface Nurse post to work with the existing Alcohol Specialist Nurse post at North Bristol Trust (NBT) and two GP Alcohol Liaison Nurses. The work of the Alcohol Interface Nurse commenced in February 2015. The aims of the Alcohol Interface Nurse are to:

The challenges caused by NPS in the South Gloucestershire area are fourfold: Public Health concerns, particularly lack of health risk information associated with substances and presentation to the primary and secondary care; lack of intelligence surrounding the ever evolving NPS market; links between the NPS market and the • Identify and clarify characteristics of the ‘freorganised criminal activities; and consumer proquent flyers’, taking community knowledge tection, particularly through the mis-description into hospital; of substances sold in head shops. • Develop systems and processes which aim Since November 2014, to reduce the number and attendance rate of ‘frequent flyers’, facilitate appropriate and • 13 service users entered into the local treattimely discharge and identify appropriate serment system, for NPS. vice provision within the community and primary care; • Delivery of training courses to 42 professionals from the prisons and youth hostels • Work with clinicians within Walk-in Centres and Minor Injury Units to identify alcohol-spe• Creation of social media accounts, through cific attendances taking a whole system view Twitter and Facebook have been set-up as and encouraging the development of intepart of the reach out activities. grated alcohol treatment pathways; • Designation of harm reduction pamphlets to • Monitoring and evaluation of post to enable accompany NPS packets at head shops commissioners (NHS England) to review GP • Satellite outreach programme at the Chasservice provision for South Gloucestershire South Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

57

residents consuming harmful or dependent levels of alcohol.

• Facilitation of timely discharge from acute trust

who are not deemed to require support from specialist services.

• Facilitate discharge and work with those attending A&E

• Promotion of timely and evidence-based interventions via robust and resilient services to address the right need at the right time

• To work within the current alcohol treatment pathway in South Gloucestershire and ensure clear and effective communication among agencies, which includes signposting and onward referral to already established groups and services such as ACE group.

Based on the current evidence and the likely demand, the following successes of the role are • Understanding of factors influencing sucpredicted in the next 12 months: cessful and unsuccessful discharges • Reduction in the number and attendance rate of ‘frequent flyers’ and those who are dependent drinkers

• Seamless support for the clients who experience a transition from secondary to primary care and community treatment

• Availability of intelligence of alcohol misuse, by bringing community knowledge into hospital

• Positive impact on secondary care – such as reduction in hospital admissions and A&E attendances.

• Appropriate service provision within the secondary care

• Satisfaction by the service users and improvements that can be made to aid future service planning.

• To be based across surgeries within the priority neighbourhood areas in South Gloucestershire and provide training and advice to GPs to increase their confidence and knowledge when working with this patient group. • To work in partnership with the GP to deliver community alcohol detoxification to patients who are not deemed to require support from specialist services. • Positive impact of the service on service users. The Nurse has provided alcohol interventions for problematic/dependent alcohol service users in three GP surgeries, namely Thornbury Health Centre, Courtside Surgery (Yate), and Kingswood Health Centre. The Nurse has been based at each surgery one day a week (carrying out duties such as supporting GPs in community detoxification) and spends the remaining two days attending multi-disciplinary meetings, action planning for complex service users, and completing administrative tasks associated with the role.

GP Alcohol Liaison Nurses

cord their current drinking levels using the AUDIT Tool and to provide brief structured interventions and/ or make onward referrals to specialist alcohol services.

The GP Alcohol Liaison Nurse Pilot commenced in May 2013. It was deemed to be a successful Pilot Project, which secured an additional capacity of another Nurse and extension for another • To provide comprehensive assessment, care 12 months. planning, and time limited evidence based interventions including Mind-Mapping, CogThe objectives of this Pilot Project are: nitive-Behavioural Therapy (CBT), and Solution-Focused Brief Therapy (SFBT). • To support the Alcohol Local Enhanced Service (LES), which involves screening patients • To work in partnership with the GP to deliver accessing primary care to establish and recommunity alcohol detoxification to patients 58


ment towards curbing the misuse of prescribed medications can be traced from the United States, where drug overdoses are the second largest cause of premature deaths from unintentional injuries. Evidence suggests that there is an emerging trend of misuse of prescribed medications in the UK, albeit in a pernicious manner. This is demonstrated by the annual number of prescriptions per person in the UK, which has increased from 11.9 in 2001 to 18.3 per person in 2011. In addition, a national research by Nuffield Health found that GPs are 46 times more likely to prescribe medication for depression and other mental illnesses than other medically proven alternatives, such as social prescribing. The statistics on drug-related deaths from the Office for National Statistics (ONS) in England and Wales, collected between 1993 and 2013, show that anti-depressants were the most frequently cited substance on the death certificate for drug -related deaths, regardless of whether they were used in conjunction with other substances or not. Furthermore, the number of drug-related deaths among males are triple that for women. The most drug-related deaths are recorded for men aged 30 – 39 and women aged 50 – 69.

In South Gloucestershire, the percentage of service users in treatment citing use of prescription or over-the-counter medication (no illicit use declared by the patients) has been on an increasing trend since 2010; with benzodiazepines and Between April 2014 and December 2014, 46 re- prescribed opioid usage increasing yearly. It is ferrals were received into the service, where the also observed that the rate in South Gloucestermajority of them came from Kingswood Surgery. shire is the highest among other local authorities Of those, 89% (n=41) started treatment, of which in the South West region, and six times highjust above a quarter started GP supported detox. er than the South West average. On the othOther popular interventions include IBA, 1:1 key- er hand, the percentage of clients citing use of work Session and relapse prevention. prescription or over-the-counter drugs (with illicit Of 41 service users who entered into the service, use) is decreasing, and is lower than the South 78% of them (n=32) exited the service success- West average. According to the service users’ and carers’ voice, the concerns are around misfully. use of prescribed medications as a ‘quick fix’ for Opioid Analgesic Dependence (OAD) Pilot a long period of time. Project Figure 35 below shows the latest information on The DAAT has received an approval from the the percentage of service users in treatment citJoint Commissioning Group (JCG) to undertake ing use of prescription or over-the-counter meda 12 month Pilot Project on Opioid Analgesic De- ications: pendence. The genealogical investigations of the moveSouth Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

59

Figure 35: Prescription or OTC Drug Use 2013/2014 There are four local challenges that have been identified in the prescribed medications, namely supporting the GPs with better prescribing practices, identifiable links between misuse of prescribed medication and social deprivations, availability of data and intelligence, and connection with the other health services.

series of training sessions for GPs to address the issues, help patients to initiate behaviour change to address their addiction, conduct publicity campaigns, refer patients into treatment, and address issues surrounding online pharmacies.

Support for the GPs can also be strengthened by To address these challenges, it has been pro- help from a trained pharmacist, where each GP posed that a Specialist Service in Primary Care surgery would have a trained surgery pharmacist is vital, to support and advise GPs to provide to work with the GPs through formulation and treatment, to recognise when a patient needs operation of patient programmes. Linking with more specialist care, and to support patients Mental Health and Physical Activity Services who cannot be treated in standard primary care is also desirable, to address co-morbid mental settings. It is also anticipated that such a ser- health problems among patients and to provice will be the first one in England and Wales in vide some forms of social prescribing, particchampioning the awareness of, and movement ularly through physical activities, and ecotheratowards addressing prescription medicine mis- py activities. use. In addition, the service can provide a

18 Crime

Patterns of substance misuse have a considerable impact on community safety and confidence. These are translated through the drug and alcohol related offences analysis below, based on the intelligence provided by Avon & Somerset Constabulary for South Gloucestershire. Drug-related Offences Looking at the five year trend, the drug-related offences in South Gloucestershire have continued to decrease since 2011/2012. Based on Figure 36 below, drug-related crime is at its lowest in 2013/2014:

Drug-related Crime in South Gloucestershire

1044 939

919

774

494

2009/2010

Nuffield Health (2014) ‘Prescribing Exercise Key to Defusing ‘Ticking Mental Health Time Bomb’, available at: http:// www.nuffieldhealth.com/fitness-and-wellbeing/news/prescribing-exercise-key-to-defusing-ticking-mental-health-timebomb (last accessed: 24th February 2015). 10

60


2010/2011

2011/2012

2012/2013

2013/2014

Figure 36: Drug-related Crime in South Gloucestershire


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Figure 37 below shows the top five drug-related crimes in South Gloucestershire. Possession of cannabis remains the highest across the years, with 2013/2014 recording a significant reduction (-153%) compared to 2012/2013.

Alcohol-related Crime in South Gloucestershire

Top Five Drug-related Crime in South Gloucestershire

518 529

1170

1122

533

1025

985

784

414

211

65 33

Possess Cannabis

43

42

45

39

59 37

45

53

39

54

41

34 13

Production of Controlled Drug Class B (Cannabis) 2009/2010

Assault occasioning ABH

2010/2011

2011/2012

Possession Controlled Drug - Class A (Cocaine)

2012/2013

31

22

34

32

36

Common Assault and Battery

2009/2010

2010/2011

2011/2012

2012/2013

2013/2014

Figure 38: Alcohol-related Crime in South Gloucestershire

2013/2014

Figure 37: Top Five Drug-related Crime in South Gloucestershire Analysis into the demographics of the drug-related offenders in South Gloucestershire in 2013/2014 reveals the following patterns: • Nearly half of the offenders (48%) were aged 25 to 34. • Nearly nine out of ten offenders (89%) were male. • Two out of ten offenders (20%) came from the following wards: Kings Chase, Hanham, Patchway, Parkwall, and Bradley Stoke South. • 18% of the offenders came from the Priority Neighbourhood Areas of South Gloucestershire, with Kingswood being the highest.

Figure 39 below depicts the top five alcohol-related crimes in South Gloucestershire, with assault occasioning actual bodily harm recording the highest rate of crime since 2009/2010. Most of the alcohol-related crimes are on a decreasing trend. Top Five Alcohol-related Crime in South Gloucestershire 359 337 305 284

243 209 201

• It is also important to note that just above three out of ten offenders (32%) are out-of-county offenders, which indicates cross-border offending.

209 189 162 113 108 87

Alcohol-related Offences

70

65

Assault occasioning ABH

Common Assault and Battery 2009/2010

Harassment Alarm or Distress

2010/2011

2011/2012

60 39

35

Similarly, alcohol related offences in South Gloucestershire in 2013/2014 decreased remarkably compared to 2012/2013 (-31%).

75 60

58

47 28

38 20

Theft from Shops and Stalls Other Criminal Damage to a Dwelling less than £5000 2012/2013

2013/2014

Figure 39: Top Five Alcohol-related Crime in South Gloucestershire 62



63

Analysis into the demographics of the alcohol-related offenders in South Gloucestershire in 2013/2014 shows the following patterns: • Eight out of ten offenders (84%) are males. • Just above six out of ten offenders (61%) came from the aged groups of 25 to 34 and 34 to 44. • Two out of ten offenders (26%) came from the following wards: Kings Chase, Hanham, Patchway, Yate North and Parkwall. With the exception of Yate North, other wards are also the top four wards with the drug-related offences in South Gloucestershire. • 21% of the offences occurred in the Priority Neighbourhood Areas. Of the 21% offences, the majority of the offences took place in Kingswood Priority Neighbourhood area. • Just under three out of ten offenders (29%) live outside South Gloucestershire. This indicates that the night time economy may have had some impacts on the offending patterns. Recommendations • Ensure that the referral pathways for the offenders with drug and alcohol misuse problems are strengthened. With Swanswell Charitable Trust has been commissioned to deliver AIRS to deal with offenders with substance misuse issues across Avon & Somerset and the opening of the Patchway Custody Suite, South Gloucestershire is in the best place to ensure that the transition from the custody to the community treatment system is seamless. • Continue to promote joined-up local services to build resilience in communities, through effective use of local authority licensing powers, and action on local drug markets and town centre drinking, particularly in priority neighbourhood areas. • Continue to work closely with Domestic & Sexual Violence Services to support drug and alcohol clients experiencing these issues.

19 Substance Misuse Impacts on the Communities Along with fear of crime, drug misuse and drug ing in public is being tackled, while one in four dealing are amongst the greatest concerns to (24%) are satisfied with how excessive alcothe quality of life in the city and can blight local hol consumption is being addressed. communities. The impact of drug misuse on the • Interestingly, three in ten respondents do not community’s confidence in South Gloucesterknow whether they are satisfied or dissatisshire can be measured through the Viewpoint fied with the way in which the council and the Survey (2014), which is a citizen consultation commissioned providers are tackling drug panel made up of residents who respond to surand alcohol misuse. This suggests that there veys on a range of issues. In addition, substance may be a lack of awareness of the work that misuse features in every Priority Neighbourhood the council and the commissioned services area in South Gloucestershire. are doing to improve the drug and alcohol Based on the respondents’ perception of alcohol problem in the local areas. and drug problems in South Gloucestershire: Recommendations • Nearly half of the respondents (48%) feel that • Increase publicity on council’s effort upon drinking in public is a problem. tackling drug and alcohol addiction problems • 46% of the respondents feel that excessive and assess its effectiveness. This will address alcohol consumption and drug taking is a the lack of awareness of the work that the problem in their area. council and the commissioned services are doing to improve the drug and alcohol probOn the other hand, the satisfaction with how the lem in the local area, as identified through the council is tackling alcohol and drug consumption Viewpoint Residential Survey 2014. issues is indicated by the following: • One in three (32%) respondents indicate that they are satisfied with the way in which drink-

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65

Appendix 1 – Substance Misuse Service Users in Treatment 2013/2014

66



67

Appendix 2 – Cross-border Clients Journeys to GP Surgeries

68



69

Appendix 3 – List of 32 Similar Areas for Performance Benchmarking

Opiate LOC Barnet Bedford UA Brent Buckinghamshire Central Bedfordshire Croydon Dorset Ealing Essex Hammersmith and Fulham Harrow Hertfordshire Isle of Wight Kensington and Chelsea Kent Merton North Tyneside Oxfordshire Poole Redbridge Richmond upon Thames Slough South Tyneside Southend-on-Sea Sunderland Surrey Thurrock Waltham Forest Wandsworth West Sussex Windsor and Maidenhead Wokingham 70


Non-opiate LOC Barnet Bexley Blackburn with Darwen Bournemouth Bromley Cheshire West and Chester County Durham Coventry Cumbria Doncaster Gateshead Greenwich Hammersmith and Fulham Hounslow Islington Kensington and Chelsea Kingston upon Thames Northamptonshire Portsmouth Reading Salford Sandwell Sheffield Slough Somerset Southwark Suffolk Tameside Thurrock Tower Hamlets Waltham Forrest Warwickshire South Gloucestershire Substance Misuse Needs Assessment South Gloucestershire DAAT

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Appendix 4 – Pharmacy Needle Exchange Locations

72



73

Appendix 5 – Locations of Alcoholic Anonymous Meeting

74



75

A&E AA ACE Groups ACMD ACORN AIRS AUDIT AWP BAT BBV BME CAB CAF CBT CCA CCG CJIT DAAT DHI FAM HBV IBA ITEP JCG JSNA LES LOC MARAC MoU NBT NDTMS NICE NPS NTE OAD OCU ONS PHE PIPs RCGP SFBT SGSDAS SMART Recovery TOP UWE YPDAS

76


Glossary Accident & Emergency Alcohol Anonymous Basic Awareness Sessions for Hazardous and Harmful Drinkers Advisory Council on the Misuse of Drugs Consumer classification tool that segments the UK population Arrest, Intervention, and Referral Service Alcohol Use Disorders Identification Test Avon & Wiltshire Mental Health Partnership NHS Trust Battle Against Tranquilisers Blood Borne Virus Black and Minority Ethnic Citizen Advice Bureau Common Assessment Framework Cognitive-Behavioural Therapy Community Care Assessor Clinical Commissioning Group Criminal Justice Intervention Team Drug & Alcohol Action Team Developing Health & Independence Family Also Matters Service Hepatitis B Virus Intervention & Brief Advice International Treatment Effectiveness Project Joint Commissioning Group Joint Strategic Needs Assessment Local Enhanced Service Local Outcome Comparators Multi-agency Risk Assessment Conference Memorandum of Understanding North Bristol Trust National Drug Treatment Monitoring System National Institute for Health and Care Excellence Novel Psychoactive Substances Night Time Economy Opioid Analgesic Dependence Opiate and/or crack users Office for National Statistics Public Health England Personal Independence Payments Royal College of General Practitioners Solution-Focused Brief Therapy South Gloucestershire Specialist Drug & Alcohol Service Self-Management And Recovery Training Treatment Outcomes Profile University of the West of England Young People Drug and Alcohol Service

To find out more about this document, please contact: Nasrul Ismail South Gloucestershire Drug & Alcohol Action Team (DAAT) Department for Children, Adults and Health (CAH) PO Box 298 Public Health & Wellbeing Division Civic Centre High Street Bristol BS15 0DQ Email: [email protected]


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