GLASGOW’S MAJOR HIV OUTBREAK AMONGST PEOPLE WHO INJECT DRUGS SHOWS NO SIGN OF SLOWING

The following blog is from the National Aids Trust, and was originally published  on 6th July 2018. For further information on the HIV outbreak please see their full briefing here. Blenheim recognises that this is a serious issue and fully supports all of the NAT’s recommendations.

In 2015, an HIV outbreak was detected amongst people who inject drugs (PWIDs) in Glasgow. Three years on the outbreak has still not been controlled, and over 100 PWIDs in Scotland have been diagnosed with HIV. Those diagnosed have complex needs and experience severe social exclusion, with 40% having a history of incarceration and 45% reported ever being homeless.

Work is underway to support those diagnosed and to prevent further infections but there are a number of policy issues that are impacting upon efforts to control the outbreak. This includes the closure of one of the main needle exchange services in Glasgow and the UK Government currently preventing the opening of a Drug Consumption Room (DCR) in the city.

In 2016, a needle exchange service in Glasgow Rail Station was set up for the explicit purpose of supporting efforts to control the HIV outbreak. The service has provided more than 40,000 sets of clean injecting equipment since opening. But late last year Network Rail closed the service due to a number of incidents. The closure of the service is short-sighted and will only mean that efforts to reduce the outbreak are negatively affected.

Furthermore, stakeholders in Glasgow have been advocating for a Drug Consumption Room (DCR) to be opened. There is evidence to suggest their effectiveness in significantly reducing sharing of injecting equipment (and therefore HIV transmissions) and drug related deaths. For the opening of a DCR to be lawful a change is required to the Misuse of Drugs Act 1971. Yet despite the crisis in Glasgow the UK Government has refused to change the law and is blocking the opening of any DCR.

Prevalence of HIV amongst PWIDs in the UK currently stands at around 0.85%. Key to this success has been a history of political investment in harm reduction as an approach to drug policy. In the 80s harm reduction services were scaled up dramatically in response to the HIV epidemic. Needle and syringe programmes were introduced, opioid substitution therapy (OST) was expanded, and education schemes regarding safer injecting techniques were run. This led to low levels of HIV amongst PWIDs which has remained a constant success to today. But this outbreak shows us that we cannot be complacent and that an HIV outbreak could occur elsewhere in the UK if steps are not taken to increase investment in and coverage of drug services.

There has however been a significant shift in England’s drug policy since 2010 with a move to a more abstinence-orientated approach, for example moving from maintenance on OST and taking people off OST too soon. This has coincided with severe cuts to the public health budget. Drug misuse treatment faced more reductions in funding than any other public health area in 2016/17 with a 14% reduction in funding, and there are further cuts planned up to 2020/21. This all means that access to drug treatment will be reduced, the very services that are needed to prevent outbreaks in the first place.

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We must resist the moral attack on women who use drugs during pregnancy

Andrew Selous MP recently asked the Secretary of State for the Home Office whether it is an aggravated offence for pregnant women to use cannabis, ecstasy, heroin and other illegal or street drugs.

This is a shameful attempt to shame, stigmatize and criminalize women for their actions during pregnancy. Furthermore, its focus on illegal drugs rather than alcohol and smoking indicates this is clearly a moral and shaming attack on women who use illicit drugs.

I do not want to fall into the trap of describing all women who use drugs during pregnancy as vulnerable, but many are, and some are amongst the most vulnerable in our society who need our support not condemnation. My experience is that often no one is more critical of their drug use during pregnancy than the women themselves.

This is a fundamental attack on women’s rights and is the start of a slippery slope if it gains support. If you think I am over-reacting then let me remind you that in 2014 a local authority in North-West England tried to claim criminal injuries compensation maintaining that a mother who drank heavily had criminally poisoned her child. The Court of Appeal eventually ruled that a child born with foetal alcohol syndrome is not legally entitled to compensation. On this occasion the courts upheld the rights of women over the rights of the unborn child, however we must be ever vigilant to ensure this remains the case.

I commend and thank Nick Hurd MP and the Government for standing up for the rights of women in his reply to this question.

“The Government is determined to protect vulnerable women from drug misuse. Advice about alcohol and drugs is available to pregnant women as part of their routine antenatal care. Pregnant women who misuse alcohol or drugs will be put in contact with a midwife or doctor who has special expertise in the care of pregnant women with alcohol or drug problems. They will be able to refer them to an alcohol or drug treatment Programme and other organisations that can help

The response indicates a clear and welcome Government policy of help not stigma, a far cry from the scary agenda of moral judgement from a few years ago.

The NHS is failing to provide life saving Naloxone at the point of release from prison in the majority of prisons

Those leaving prison having had an opiate problem are seriously at risk of having a life threatening overdose or dying as a result of one. Both Public Health England and the Government have been clear in their recommendation that all local areas need to have appropriate Naloxone provision in place. However, prisons have so far failed to implement provision at the point of release across much of the prison estate. This is putting lives at risk.

Blenheim workers have found it is rare for any of our service users to be released from prison having been provided with Naloxone, medication which is literally life-saving in the case of overdose.

Public Health England’s strategy to reduce drug related deaths identifies discharge from prison as the point of maximum risk of overdose and maintaining contact with treatment services as the key intervention to stem the rise in drug related deaths. Naloxone is the emergency antidote for overdoses caused by heroin and other opiates/opioids (such as methadone, morphine and fentanyl).The main life-threatening effect of heroin and other opiates is to slow down and stop breathing. Naloxone blocks this effect and reverses the breathing difficulties.


Read more in Blenheim’s report – ‘Failure by Design and Disinvestment: the Critical State of Custody-Community Transitions


The NHS is responsible for provision of treatment services in prison including Naloxone but refuses to take a national view. At one point the NHS even argued that as the prisoner would use Naloxone outside of the prison it was not their responsibility and each local authority should arrange to fund, provide, and negotiate arrangements with prisons for the supply of Naloxone at the point of release. To expect them to do this with more than one hundred prisons is something that anyone can see is ludicrous. Currently the NHS says it is for local NHS areas to decide.

It has proved difficult to get NHS England to provide clarity about what is going on as they are reluctant, or unable to do so when asked. Below are a couple of responses given to questions by Grahame Morris MP that will have been prepared by officials for the Government’s response.

Question – To ask the Secretary of State for Health and Social Care, how many and what proportion of prisoners with a history of opioid misuse were provided with Naloxone when released from prison in the latest year for which information is available; and from which prisons those prisoners were released.

Reply in May 18 – “Information on how many prisoners are provided with naloxone when released from prison in England is not currently available. This data is due to be published in 2019”

Question – To ask the Secretary of State for Health and Social Care, if he will bring forward legislative proposals to make the supply of the opioid-overdose antidote Naloxone to all at-risk prisoners upon their release a mandatory requirement for prisons.

Reply – “Naloxone has a vital role in saving lives and the Government is committed to widening its use in England.”

There is no national programme that mandates the supply of Naloxone for at-risk prisoners on their release, and the Government does not have any plans to bring forward legislation to make this a mandatory requirement for prisons.

The commissioning of substance misuse treatment for prisoners is the responsibility of health and justice commissioning teams in 10 of NHS England’s area teams, supported by a central health and justice team. The Government expects commissioners and providers of substance misuse services in prisons and in the community to work together closely in respect to prisoners being released from custody to ensure seamless transfers of care.

So according to NHS England they have not got a clue about what is happening and their best estimate is they may know in 6 months time. Or as I suspect, they are putting off releasing the information and will do so for the foreseeable future. How long does it take to ask prisons the following three questions?

  1. Are you providing Naloxone at point of release?
  2. Are you providing Naloxone and overdose training?
  3. How many Naloxone kits have you given out?

Well let me try and help them out a bit. There are currently at least 36 prisons in England and Wales claiming to give out naloxone on release, a low percentage. There may also be others that I and my sources are unaware of, however just because someone at a prison says they are providing Naloxone it doesn’t mean they are handing out many or any kits. Whilst not an English or Welsh example, in Scotland, where all prisons are supposed to be providing Naloxone at the point of release, the position is depressing. In one prison in the last year only 24 kits had been handed out and in another none had been handed out. Operational difficulties are often cited as the reason for this, a common excuse which covers most prison failures.

On the NHS website it says:

  • NHS England Health and Justice teams commission to the ‘principle of equivalence’ which means that the health needs of a population constrained by their circumstances are not compromised and that they receive an equal level of service as that offered to the rest of the population.
  • NHS England health and justice commissioning supports effective links with Clinical Commissioning Groups (CCGs) and Local Authorities to support the delivery of social care within secure settings and the continuity of care as individuals move in and out of them.

The failure to provide naloxone at point of release, along with the breakdown in continuity of care (documented in response after response to the ACMD in relation to custody to community transitions) demonstrate a clear failure to live up to the statements above. I am starting to wonder how much stigma and prejudice underlies this failure. I am sure diabetics requiring insulin do not suffer the in the same way.

So to recap, why does Naloxone at the point of release matter? There is an international evidence base about the high risk of overdose and death of opiate using prisoners, in particular in the period immediately post-release. A recent large scale Norwegian study¹ examined the deaths of all prisoners in the first six months of their release over a fifteen year period (1 Jan 2000 to 31 December 2014); the sample comprised 92,663 prisoners released a total of 153,604 times. The study found that overdose was the most common reason for death at every time period within the first six months post-release.

During the first week post-release, overdose deaths accounted for 85% of all deaths, with accidents accounting for 6% and suicide for 3%. Overdose deaths peaked during the first days post-release, and thereafter declined gradually during the first month post-release. During the second week post-release, the total number of deaths approximately halved (versus first week), with overdose deaths accounting for 68% of all deaths. During weeks 3–4 and months 2–6, overdose death accounted for 62% and 46% of all deaths, respectively.

The authors suggest that the high proportion of overdoses in the immediate period following incarceration might reflect prison settings where released inmates typically have a history of heroin or opioid use, and may also be particularly high in settings where polydrug injection is a common mode of administration. For several years, Norway, like the UK, has been ranked as one of the European countries with the highest rates of overdose mortality, often explained by high rates of injecting drug use and an ageing polydrug-using population.

Recent UK research² also found that the first week following prison release was the period of highest risk of mortality with drug-related deaths the main cause.

By now it will come as no surprise when I say we do not have an accurate figure of the number of drug-related deaths of recently released prisoners in England and Wales.

Please NHS, help sort this out and start preventing these needless deaths.


Read more about Blenheim’s campaign here


References

¹Anne Bukten, Marianne Riksheim Stavseth, Svetlana Skurtveit, Aage Tverdal, John Strang & Thomas Clausen (2017) High risk of overdose death following release from prison: variations in mortality during a 15‐year observation period. Addiction Volume112, Issue 8 August 2017 Pages 1432-1439.

² Phillips, H. Gelsthorpe, L. & Padfield, N. (2017) Non-custodial deaths: Missing, ignored or unimportant. Criminology and Criminal Justice 

The scandal that shames prisons, substance misuse services and most of all the fragmented probation service

This month I will give oral evidence to the Advisory Council on Drug Misuse (ACMD). What I say is nothing new, it is a scandal and it leaves many dead and puts many other vulnerable people with a recognised mental health disorder at significant risk.

I will be raising with ACMD our concerns over two principle issues surrounding our service users being released from custody.

I will raise our concern at the high levels of drug related deaths in the immediate post custody period.

I will raise the fact that service users are dropping out of treatment, or probably more accurately being dropped by the treatment system at a critical time. This renders them both more vulnerable to overdose, harm and relapse and undermines positive treatment and rehabilitation both in the community and in custody.

I will highlight the recurrent practical barriers to continuity of care and to bring it to the ACMD’s attention a range of positive practices to address these.  These issues are not new, report after report has raised them, I am desperate to see a solution but fear the work of the ACMD will gather dust on a shelf whilst people continue to die and miss opportunities to change their lives for the better.  Why is this allowed to continue? It is simple in my view, society does not care enough about people who have been in prison with drug problems and agencies have failed to focus on people rather than paperwork. 

I will highlight the growing international evidence about the high risk of overdose and death of opiate using prisoners in the period immediately after release.  Key government agencies are aware of this and I have personally sat in on briefings detailing the huge increase in the risk of death and overdose in the UK. I will point out that recent UK research has found the first week following prison release was the period of highest risk of mortality with drug related deaths the main cause. A Norwegian study found in the first week post release overdose accounted for 85% of all deaths of those transitioning back into the community.  This will come as no surprise to anyone working in the sector.

National drug treatment figures produced by the National Drug Treatment Monitoring System (NDTMS) show the shocking figure of just 30.3% of those in treatment in prison are in treatment 21 days after release. Even more alarming is the fact that 38% of those seeking continued treatment upon release are either not on medication or did not get the type or quantity they felt they required.

The long standing failure to address this has been made worse by the changes in probation provision since the Governments Transforming Rehabilitation project in 2015, something Blenheim fought hard in Parliament to prevent.  The depletion of criminal justice work within substance use treatment services following the cut in the Drug Intervention Programme (DIP) funding supporting it has further hampered the capacity to address this long standing issue.

There are significant barriers to resolving these issues, not only the reduced funding at every point of the justice and treatment systems, but arguably a more significant barrier is the confusion and miscommunication caused by frequent realignment of services.

There are excellent examples of good practice across the UK but good quality supported transitions between custody and community for people dependent on drugs are the exception rather than the norm.

If we are to change this both criminal justice and treatment services it needs to be adequately resourced.  We also need to see a returned to a proactive case management approach focused on people not paperwork.

At Blenheim we are doing what we can to reduce these risks. The Grove in Haringey remodelled last year and their strategy works towards helping people that get stuck in the cycle of offending break free by working in partnership with the police, courts and prisons to identify those at high risk and put individual plans and interventions in place to best support them.

Dave had been in and out of prison over the last 10 years and was stuck in a cycle of offending, homelessness and drug use. The Grove’s Prison Link Worker started working with Dave early on in his last sentence and they met regularly working on building coping techniques often used in the community, such as; relapse prevention, motivation, life skills and reconnecting with people. Dave wanted to attend rehab when he was released so Yvonne sought funding for this and arranged transport to the centre on his release day.

Dave completed rehab, is abstinent six months on and has reconnected with some of his family.

This sounds simple but if this was being done consistently across the UK then we wouldn’t be where we are today.

I dream of a day when every prisoner has a successful transition from prison to community treatment. Having worked in the criminal justice system and drug misuse sectors for thirty years I know the barriers, I also know it is possible where there is a will there is a way.

LONDON’S CALLING: LET’S ELIMINATE HEPATITIS C

John wrote this blog for AbbVie after chairing a London HCV elimination roundtable on World Hepatitis Day, hosted by AbbVie. You can read the original blog here


It’s estimated that 43,500 people are living with the now curable blood borne virus in London – among the highest prevalence in England – with 40% failing to access treatment support.1Already, great work has been done to treat 2,500 people in the last year,2 but we still need to improve links to healthcare in local communities that can reach those most at risk.

Among those who inject drugs, or have previously injected, almost 50% have hepatitis C – a figure that sadly has remained mostly unchanged for the past 10 years.3 For over 50 years, we’ve been able to provide open access drug support services to thousands of people across London. We’re now working closely with The Hepatitis C Trust and other service providers, like Addaction and CGL, to deliver hepatitis C interventions within drug service settings across the UK.

Our ability to eliminate hepatitis C will ultimately be limited by our capacity to find and treat those who remain undiagnosed, and to help those who are diagnosed engage with treatment support. This can only be done if we have a local focus on the wider social issues that are impacting the lives of people most at risk.

Chairing a roundtable on World Hepatitis Day (28 July), I was able to address local healthcare professionals, and representatives from the London Assembly, Public Health England and the charity and voluntary sector, to agree on the following priorities for eliminating hepatitis C in London:

 


1. A pan-London approach:
 Put hepatitis C on the policy agenda to develop a joint plan for tackling the curable virus and become a leader in testing, treating and curing

2. Piggy back on existing successes: Seize the opportunity of screening programmes for HIV and tuberculosis to offer combined tests for blood-borne viruses

3. Raise awareness and reduce stigma: Develop culturally appropriate and sensitive disease awareness programmes to de-stigmatise the condition and alert people to new treatments that cure hepatitis C

4. Call for an end to rationing: Raise awareness among key decision makers that London is disproportionally impacted by rationing of treatment and push for changes to the contracting of medicines

5. Treat to prevent transmission: See treatment as prevention and build this into public health priorities

6. Flexible funding and flexible pathways: Offer testing and treatment in a way that is appropriate for patients and based on clinical need

These priorities will support our ability to work with NHS commissioners and London authorities to support government prevention and treatment targets for the elimination of hepatitis C by 2030.

 

hepatitis-c

As a charity, we are committed to innovating and campaigning for best practice and positive change in the drug and alcohol field. By working with government, health organisations and industry we can help prevent, test and treat hepatitis C when people come to us for drug and alcohol support. This is an important step in the right direction that allows more people to gain access to healthcare support out-of-hospital and in their community. It is with great optimism that we join London in a call to support the elimination of hepatitis C, once and for all.


[1] Public Health England, Hepatitis C: guidance, data and analysis. Hepatitis C: commissioning template for estimating disease prevalence, March 2014. Available at https://www.gov.uk/government/publications/hepatitis-c-commissioning-template-for-estimating-disease-prevalence Accessed July 2017

[2] Harris, R. J. et al. 2016. New treatments for hepatitis C virus (HCV): scope for preventing liver disease and HCV transmission in England. J Viral Hepat, 23: 631–643. doi:10.1111/jvh.12529. Available at http://onlinelibrary.wiley.com/doi/10.1111/jvh.12529/full Accessed July 2017

[3] Public Health England, Hepatitis C in the UK, July 2016. Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/565459/Hepatitis_C_in_the_UK_2016_report.pdf Accessed July 2017

Drug and Alcohol Worker should be a regulated title

Drug and alcohol workers provide support to some of the most vulnerable people in our society, yet we still do not have a legally enforceable minimum level of competence or regulation for those working in the sector.  It is extraordinary that professional drug and alcohol workers are still not regulated and recognised like social workers, counsellors, hearing aid dispensers or art therapists are.

The 2010 Drug Strategy recognised that “developing a competent substance misuse workforce is crucial to ensuring a high standard of service delivery” and the National Treatment Agency (NTA), before its demise, stated that “it is important that commissioners and services continue to work towards a workforce which is fully competent and able to demonstrate its competence”.

But we need more than just people with the ability to do their job; we need a workforce which puts its potential into practice on the ground. We need practitioners to work to the highest ethical standards because of the potential vulnerability of our client group.

The first step to a competent workforce is for each person to have a “role profile” identifying:

  • The range of competences they require to do their job properly
  • The knowledge, understanding and skills needed to perform each of these to the standard required.

Having identified the competences and underpinning skills required in a person’s role, we need to ensure that:

  • They are regularly assessed against their role profile, to identify any shortfalls in their knowledge
  • Any such shortfalls are addressed through training, supervision and so on.

To make sure everyone has the basic skills required to work in the field, all practitioners should be able to show evidence of their competence in an agreed minimum of relevant units from the Drug and Alcohol National Occupational Standards (DANOS).

Finally, practitioners need regular supervision to ensure they are putting their abilities into practice and acting ethically.

When DANOS was published, the following target was set:

  • All workers and their managers should have, or be working towards, evidence of their basic competence to work in the field.
  • All line managers should be undertaking, or have completed, a training course in line management.

Unfortunately the NTA, then a key driving force behind this target, did not monitor progress against this and removed targets for workforce development from its requirements of local areas. This left the DANOS targets in limbo and open to unscrupulous providers employing people without the competence, knowledge or ability to deliver services on the ground.

Blenheim has stuck by the DANOS targets because we believe they remain important.  Blenheim is compliant with the training and competence requirements and all our staff are required to sign up to the FDAP Code of Conduct.

The QCF (Qualifications and Credit Framework) is the national credit transfer system for educational qualification in England, Northern Ireland and Wales. The Substance Misuse Awards and Certificates, on the QCF, are clearly the way forward for verifying practitioners’ professionalism in our field and the QCF provides the opportunity for ongoing assessment of professional development.

Professionally qualified workers (qualified to practise in the UK in a regulated health or social care profession) have already demonstrated the ability to work with people, but not the specialist knowledge required to put this into practice in the drugs and alcohol field. They should at least be undertaking a competency-based substance misuse qualification and the Substance Misuse Award (QCF) is well-placed to address this. While anyone practising as a counsellor or psychotherapist, if not already certified by an appropriate body (like BACP, UKCP, UKRC or FDAP), should also be working towards becoming so.

I welcome Substance Misuse Management Good Practice (SMMGP) picking up responsibility for FDAP. However, there is now an urgent need for leadership and regulation of qualification and competence in our field and clear pathways for progression within the wider Health and Social Care sector.

We are gifted with committed and highly skilled practitioners; let us give them the formal assessment, qualification and recognition that they deserve and also offer a clear professional career opportunity for the practitioners of the future.

Blenheim offers a wide range of sector-specific training to improve practitioners’ approach, whilst understanding the importance of being responsive to a diverse range of needs and skills. As we continue to await the new drug strategy, I worry that there may be no focus on skills and qualifications for drug and alcohol workers in the near future. It makes me proud to work for an organisation which places such a strong emphasis on training and development.

We are celebrating Volunteers’ Week, and have welcomed a fantastic new cohort of volunteers to the organisation. I know they’ll receive the very best training to bring the best possible benefits to our service users, and look forward to the day when everyone in our sector receives this training and is recognised for it.

Where is the drugs strategy?

Trying to get a response from Government about when the drug strategy will be published seems increasingly like expecting a sensible response from an Alice in Wonderland character.

Alcohol and drugs cause huge harms in our communities yet the Government has no intention of publishing an alcohol strategy and the drugs strategy, written over a year ago, continues to gather dust on the launch pad as it is postponed again and again.

Meanwhile drug-related deaths in England and Wales have hit record levels, with cocaine deaths reaching an all-time high in 2015 and deaths involving heroin or morphine doubling over three years to reach record levels. The failure to publish the drugs strategy means the Home Office is failing to provide the strategic leadership across Government departments at a time when we are seeing the highest number of drug deaths ever recorded. New drugs are causing significant problems and life threatening issues in prisons, amongst the homeless and in emergency departments. Funding for drug and alcohol services are being cut dramatically and benefit changes are resulting in increased homelessness and deprivation.

In February 2016, the Government said it would shortly be publishing a new Drug Strategy. At the 2016 Christmas adjournment of the House of Commons, Mary Glindon MP reminded the House that, barring an unexpected delivery from Santa Claus, it was still not to be seen. She asked again early this year, and was told that it would be “soon”. So “soon” in Government terms, means months, and “shortly” means more than a year. For a brief few days it looked as if we may see the strategy published prior to Easter but alas; it appears the Easter Bunny, like Santa, will fail to deliver.

Local authority funding for drug and alcohol treatment has been slashed by 42% since 2010. Many clients seeking treatment for addiction lead chaotic lives and many struggle with a whole host of difficulties that go far beyond their addiction. They might be embroiled in the criminal justice system and need advice, they might have housing problems or be struggling with trauma, or they might have been in care and survived institutional abuse.

There are more than 1 million alcohol-related hospital admissions each year, and alcohol is a contributing factor in more than 200 different health conditions. As Chief Executive of a drugs and alcohol charity, I see the harm that alcohol does on a daily basis. I saw the impact as a police officer. I saw the impact as a probation officer. I saw the impact on children and families as a social worker. Despite the huge impact on crime, community safety, children and links to addiction, mental health problems, cancer and liver disease, the Government has indicated it will not be developing a national alcohol strategy.

NHS England has put in place an inefficient system for rationing access to hepatitis C treatment, an illness that mainly impacts on current or former injectors of illicit drugs. Despite effective treatments being available, only 4% of people with the disease are treated annually. Imagine a plane with a hundred seats but security checks that will only let 4 of the hundred passengers fly. Then because of this inefficient system, the NHS says it cannot justify a deal with pharmaceutical companies to provide access to treatment for everyone.

The Government is putting lives at risk by failing to publish a drugs strategy, failing to have an alcohol strategy and discriminating against those needing hepatitis C treatment because most are from marginalised groups. What is particularly sad is that PHE, NHS England and the Government have done some great research into what needs to happen, but what appears to be missing is the strategies and the accompanying resources.

I would love the Government to prove me wrong by publishing the drugs strategy, writing an alcohol strategy, and agreeing a deal to fund hepatitis C treatment for all. Additionally, there would be a need to agree and ring fence resources to ensure equitable access to drugs and alcohol treatment across England, making drug and alcohol treatment a mandatory responsibility for local authorities.

Do this, and I might stop complaining. In fact, I will be first in the queue to offer my congratulations.