In 2015 Druglink changed format to become a website. Below are the articles published before DrugScope closed in March 2015:
- Further down a stony road: reporting on the 2014 Street Drugs Trend Survey;
- Love me tender: the state of the UK drug treatment system;
- The Druglink interview: Professor John Strang
This article reproduces the Street Drug Survey feature but with some additional information and analysis gathered outside the survey in recent months. By Max Daly @Narcomania and Harry Shapiro.
The DrugScope annual snapshot survey of the UK drug scene was conducted in December 2014, and involved police, drug action teams and frontline drug workers in 17 towns and cities across the UK. In the majority of areas we spoke to, the street level purity of cocaine, ecstasy and heroin had gone up significantly, following several years of high adulteration across the board. Experts suggest the hike in quality is down to two interlinking factors: falling wholesale drug prices that have enabled Class A suppliers to improve their product in the face of competition from cheap yet potent new psychoactive substances.
Some areas reported the purity of cocaine, ecstasy and heroin doubling and tripling in the last year. In Bristol, police said cocaine purity jumped from an average of 10 per cent in 2013 to 30 per cent in 2014, while heroin had risen from an average purity of 10-15 per cent to 20-25 per cent. Police in Liverpool said cocaine had risen from a single figure average to 25 per cent, and heroin from 25 per cent to 40 per cent.
Several areas said that the better quality heroin had perhaps been responsible for a slight upturn in people coming into services for heroin use. In Glasgow, Nottingham, Cardiff and Bristol, the existing two-tier market in cocaine had, according to police and drug services, expanded to a three-tier market, with highly pure cocaine being offered for between £100 and £200 per gram. However, while ecstasy pills have returned to 1990s purity levels, the average bag of cocaine and heroin is still far less pure than it was 20 years ago.
Why the increases in street purity?
There are no obvious reasons for the purity increases, except to say that it is likely that different reasons pertain to different drugs. The increase in heroin purity is not that dramatic and pushes the drug back up to where it was a few years ago. Why it is happening now could be accounted for as an attempt to win back a falling customer base by increasing purity, but not to the level where prospective customers are overdosing.
There has been a fall in the wholesale price of cocaine, allowing dealers to introduce some premium priced product. So while the purity might have increased, so has the price, double the previous gram price in some cases – otherwise it would make no economic sense to sell higher purity cocaine.
The prevalence of MDMA tablets containing high levels of PMA/PMMA have been well publicised, even more so following four UK deaths over the New Year period. This is not a new phenomenon and has been traced back in theory to the MDMA precursor chemical drought in Europe following the huge seizure of safrole in Cambodia at the end of 2007. Chemists switched to the less controlled anethole, one of the main precursors for PMA and much of this product is still finding its way into the European and UK market.
At the same time, samples of MDMA with high levels of pure MDMA – in excess of 150-200mg – have been identified. Most recently, these have been yellow tablets in the shape of the UPS logo; warnings were issued after a number of users were hospitalised. So what is the story behind super-strength MDMA? According to journalist Mike Power writing for Mixmag, there is a group of Dutch chemists using a different and also legal MDMA precursor called PMK-Glycidate. According to Power, rather than the 2008-09 MDMA drought, this switch ion production has now resulted in a a glut of the drug in Europe. The stronger pills sell for a higher price and there is an element of competition as to who can produce the strongest pills in the most eye-catching designs and colours. Some of the new pills, like the UPS are deliberately designed to allow users to break them up into halves or quarters.
Upsurge in prescription drug use
While illegal drugs have been increasing in purity, most areas covered by the survey highlighted the significant use of the prescription drugs pregabalin and gabapentin, chiefly among Britain’s opiate-using and prison populations.
The drugs are prescribed to treat epilepsy, neuropathic pain and anxiety. But used in combination with other depressants, they can cause drowsiness, sedation, respiratory failure and death.
In 2011, according to the National Programme on Substance Abuse Deaths, there were 13 fatalities directly linked to the drugs in 2011, with another 18 people who had the drugs in their system when they died. In 2012, deaths linked to the drugs almost tripled, to 36, with the drugs present in another 33 deaths. The Office for National Statistics told DrugScope that pregabalin and gabapentin were mentioned on 41 death certificates in 2013 (pregabalin on 33 and gabapentin on 9).
Growing concern around the misuse of these drugs has led to some organisations writing to prescribers requesting that more care is taken to prevent them appearing on the illicit market. In December, Public Health England (PHE) and the NHS published advice for prescribers on the risk of misuse of the drugs.
The PHE/NHS England bulletin reported that in England in 2013 there were 8.2 million prescriptions of both medicines, a 46 per cent rise in prescribing of gabapentin and 53 per cent rise in pregabalin since 2011. Prisoners are twice as likely to be prescribed these drugs as those in the community and the drugs have caused a number of deaths in jail.
One drug worker in York told the survey, “We’ve seen a big rise in the illicit use of pregabalin and gabapentin. The effects are horrendous and life threatening. People become so heavily intoxicated because they are mixing several drugs at a time. The drugs can reduce the heart rate and if taken with methadone can be extremely dangerous, so we now have to consider whether people are using these drugs when we prescribe methadone.
“Initially we had thought there was a batch of dodgy heroin with Rohypnol in it, but [we found instead that] they were using pregabalin and gabapentin alongside heroin. Often they don’t know what strength capsules they are taking because they look similar. Both drugs are readily available and certainly have a street value attached to them. We have sent a letter to GPs asking them not to prescribe it so much.”
The drugs are causing some opiate users to act in a more chaotic, disinhibited way, such as injecting in public; there are reports of sex workers getting robbed and beaten after taking uncharacteristic risks. A drug worker estimated that in one homeless hostel in Bristol, 70 per cent of residents were using pregabalin, with only some being prescribed the drug. Another drug sector professional said that there were large amounts of the drugs, particularly pregabalin, being used in the city and causing “more uninhibited behaviour” among service users.
The rise of these anticonvulsants as street drugs in the UK was initially spotted by criminologist Steve Wakeman during an investigation into austerity-era heroin use on a housing estate in north-west England. Writing for Druglink magazine in September 2013, Wakeman said the drugs were “in considerable demand” and used by all the heroin users he spoke to.
Wakeman found that pregabalin and gabapentin’s ability to enhance the effects of heroin and therefore reduce the amount needed, and also to facilitate self-detox, meant that most of the heroin users on the estate did not attend services, and could be part of a larger, hidden heroin-using population. If so, what appears to be a surprise decline in heroin use during hard times could actually be a case of diversification.
The survey also found that diazepam pills are still highly popular, even though their ingredients are unpredictable. Research carried out into a range of different batches of blue diazepam pills seized in Scotland found many contained very high doses of the drug, while some contained potent benzodiazepine analogues such as etizolam and phenazepam. Even pills marked with the same logo contained a wide variety of substances.
Vulnerable groups at risk from NPS
New psychoactive substances (NPS) figured highly in the survey, with virtually every area reporting a continued rise in use by a varied population. Of most concern was the rapid rise in the use of synthetic cannabinoids such as Black Mamba and Exodus Damnation by opiate users, the street homeless, socially excluded teenagers and by people in prison.
In Birmingham, a homeless charity described how a large number of their opiate using clients and street drinkers were smoking synthetic cannabinoids, leading to health emergencies.
“It’s a nightmare with our clients. When they come in for opiate treatment it’s hard to deal with them after they’ve smoked it. They are collapsing in the street. One man needed CPR last month. Some of them have been hospitalised several times. They are using it because it’s cheap, it’s strong and because those who are out on license will not go back to jail if they are caught taking them because they’re legal.”
As our survey found last year, synthetic cannabinoids continue to be sold not only in head shops, but in a variety of other outlets including newsagents. According to people interviewed for the survey, synthetic cannabinoids were readily available in prisons and many people referred into services from jails came out with dangerous levels of use of the drugs.
Two areas, Ipswich and Sheffield, reported that small synthetic cannabinoid production units had been uncovered. One drug worker said that inmates at a Liverpool prison had become so used to emergency services being called out when people collapsed after taking Black Mamba that ambulances are now known as ‘the Mambalance’.
Injection of unknown white powder NPS, a practice flagged in the 2012 Druglink survey, continues in some parts of the UK, although it has remained largely confined to small towns, where drug users are more isolated and poorer, rather than major cities.
Drug-related deaths rising
In the wake of new statistics released by the government in September 2014, that found drug deaths had risen sharply in 2013, feedback from the survey revealed there is little hope of the situation improving in 2014.
In Northumberland there were 21 drug-related deaths in 2014, compared to six in 2013. In Nottingham, there were 10 non-fatal overdoses and four deaths in one six week period in 2014, the same total number of deaths for the previous year.
Organisations that have looked into the deaths in their area found a mixture of possible causes for the rise, including more heroin users dropping out of services, a downscaling of outreach work, people overdosing on higher strength heroin and in one area, an emerging group of inexperienced users.
A drug sector professional in Durham said that research her team had carried out by looking at coroner’s reports in Northumberland, found that most deaths were not in fact overdoses but as a result of long-term organ damage in ageing opiate users. Of the areas that mentioned a rise in drug deaths, some said increased access to naloxone had prevented overdoses becoming fatal.
New research from Manchester University studied the causes of mortality among nearly 4000 opiate users who died between 2005-2009 and found that drug overdose was only one part of the picture. See the DrugScope blog covering the key points of the research
Ecstasy and PMA-related deaths
Deaths involving these drugs have been rising significantly in recent years. Between 2010-2013, there was a total of 145 deaths where either MDMA or PMA were implicated with the numbers rising year on year especially where PMA is implicated; no deaths at all in 2009 and 2010 and just 1 in 2011, but 20 and 29 in the following two years.
There are a number of reasons why this might be happening. PMA and much stronger MDMA could both be factors. Furthermore, there are many younger users who were not exposed to the harm reduction messages of the mid 1990s, coupled with venues who are reluctant to have drug workers on the premises offering help and support for fear of challenges by the police and local authorities to license renewals and the advent of totally unregulated illegal raves which attract younger people who can’t gain admittance to mainstream venues. However there are a range of harm reduction initiatives coming on stream, which will be the focus of future article.
A complex and unpredictable drug scene
The survey respondents also spotted a string of interesting trends that, although not repeated across the country, are nevertheless noteworthy.
More services in London, including needle exchanges, are seeing gay men seeking help for problems related to ‘chemsex’, the often intravenous use of crystal meth and mephedrone during sex parties. A pilot unit is being set up at a sexual health clinic at London’s Charing Cross hospital in a bid to pull in more problem users. On a far smaller scale than London, Liverpool and Glasgow reported they had seen some service users involved in chemsex scenes there, although crystal meth was expensive and difficult to get hold of.
Also in London, experts flagged up the increased use of high strength, boutique strains of skunk such as ‘Amnesia’, ‘Sour Diesel’ and ‘LSD’ by young people. One drug worker said many of those getting into problems with these drugs were young offenders, who were often black or mixed race, buying from older friends who have the equipment and knowledge to cultivate this specialist cannabis where the focus is on growing quality strains, rather than high yield.
“Some kids as young as 15 are having problem with these strains of skunk, like paranoia, hearing voices and thinking adverts on TV are talking to them,” he said. “Some are quite addicted, they smoke £40 a day and it’s stronger than normal skunk. These strains like Amnesia are name-checked in the lyrics and YouTube videos of gang culture.”
In Liverpool and Glasgow, cannabis cultivation, has been adopted as the major business of white British criminal gangs, who see it as far less risky way of profiteering than cocaine and heroin. Also in Liverpool, one interviewee said the use of nitrous oxide had reached new heights among students, with the used canisters (known as whip-its) littering the pavements in some areas.
The official statistics do show that what could be called ‘traditional’ drug use has been in overall decline for some years, albeit with recent spikes in cocaine, ecstasy and ketamine use. However, with the advent of the newer drugs and increasing use of prescribed drugs, it would seem that the drug scene has become more complex, diverse and difficult to predict.
An increasingly aggressive marketplace, the prospect of ever-deeper budget cuts and wildly varying quality in commissioning have prompted growing apprehension about the future of services among respondents to DrugScope’s State of the Sector 2014 report. By Harry Shapiro.
From the late 1990s, successive UK governments invested heavily in the drug treatment system. No health system is perfect, but over the next 10-15 years, the UK built up one of the most comprehensive drug treatment systems in the world led by the National Treatment Agency (NTA). Love ‘em or loathe ‘em, the NTA were in effect the Home Office boots on the ground delivering on the key plank of the drug strategy – to break the link between drugs and crime. And unlike virtually every other area of the strategy, the NTA could point to a robust dataset in the NDTMS to demonstrate effectiveness and thus maintain the investment. Treatment waiting times plummeted as the prime directive was to get as many people into treatment as possible and hold them for as long as it took to effect improvements. Where the system was less successful, was getting people out the other end and although the NTA began encouraging a shift in focus as far back as 2005 – it was the firestorm of the ‘abstinence versus harm reduction’ debate of 2008 that began to shift the political climate made manifest following the 2010 General Election.
Given the mood music offstage in the run up to the election about a total rethink on opiate substitute treatment and talk of the introduction of time limited therapy – there was every reason to believe that many of the gains of the previous decade would be lost or at least severely undermined. However, neither has taken root as government policy and despite some political pressure in this direction, all the available clinical expertise has advised against such moves – and prevailed. Similarly, the notion that abstinent-based residential rehabilitation would solve all problems was replaced by more constructive moves to bring together the worlds of community treatment and residential rehabilitation in the service of the more positive aspects of what became known as the Recovery Agenda – largely the involvement of peer group support in community settings. Less positive has been what one clinician has dubbed ‘recovery-ism’ which has many facets but which could be summarised as an ideology masking a race to the bottom in service delivery.
Politically, though, in the face of an ageing heroin and crack using population and a fall in treatment presentations, drugs has nothing like the clout it once had. There is wafer thin personal political commitment to the issue in this parliament. The NTA is no more, replaced by Public Health England which by definition is more concerned with whole population substance issues, primarily alcohol. The remnants of the Drug Intervention Programme came under the control of the Police and Crime Commissioners, few of whom have shown any real interest in the drugs/crime nexus and overall, the leverage linking drugs and crime has weakened, not least because all the predictions about soaring criminality in the face of austerity have not transpired. Since 2010, the ring-fence has come off the treatment spend, devolved to local authorities now struggling with post-2008 budget meltdown which is projected to get much worse.
One big ticket item in the early days of the Coalition was the notion of ‘payment by results’. Albeit the model was different, even so, this has never been made to work in mental health, so why should the drug and alcohol sector have been any different? The answer of course, was – it isn’t. As one survey respondent put it:
“The vast majority of commissioning…it’s all about ‘here’s the budget envelope, here’s how many people you need to see, here’s how many assessment you need to do and give us the systems and solutions of hoe to do all that…PbR as defined by government departments and a piloted in our sector is a mess. It’s down to a flawed conception that PbR is all about systems and bureaucracy.”
So where does this leave the drug and alcohol treatment sector at the turn of a new year? The sector is certainly shrinking and the landscape undoubtedly favours the bigger providers with the infrastructure necessary to be in an almost constant round of bid writing and being able to meet the very high turnover threshold demanded by many commissioners. And it is the commissioning process that comes in for the heaviest criticism in the survey. Increasingly commissioners are unwilling to re-negotiate contracts to sort out any problems or make readjustments based on local needs and simply go for re-tendering the whole service. Increasingly too, commissioners are looking to award whole service contracts to one large provider who might then sub-contract bits of the service to smaller agencies, although many of those have either gone out of business or been absorbed into main providers. There are concerns that we are moving to a supermarket model of provision where only the largest providers survive all these tectonic shifts in the system.
All of this causes high degrees of uncertainty and anxiety among frontline workers and their clients; concerns about whether you will still have a job when the new employer takes over – and even if you do, the often voiced pressure of fewer staff expected to handle the caseload. As one provider said, “we’ve been told our contract ends and all our staff will be put over to another provider. All the treatment we have known for over 20 years will cease and change…It’s an extremely tense and sensitive time”.
Inevitably this has a knock-on effect on the clients especially the disruption of losing your trusted key workers. Concerns too have been raised about the increasing use of volunteers to replace paid staff with the effect that a bid can look like better value for money for the commissioner because there are more staff. Volunteers who are often ex-users – have been a long-standing and valuable complement to the professional staff team for many years. But if they are proliferating simply to cut costs, then there are questions to be asked about competency and the degree to which clients are losing out especially where relatively expensive, but vitally important NHS clinical staff are being written out of the bidding equation.
And where are we at with ‘harm reduction’ these days – a term guaranteed to invoke garlic and crosses in some political quarters? The survey does not reveal too much in this area, but one worker who spoke to Druglink (and so not part of the survey) said, “all the talk these days is about ‘throughput’ and ‘results’; senior managers and commissioners have very little that is positive to say about methadone maintenance. As far as needle exchanges are concerned, there has been a definite closure of centre-based exchanges or reduced hours, access to workers and equipment available in others. In my area, the whole town centre drug service was moved to the outskirts into the metal health service with reduced hours and access – without any consultation with anybody”.
Centrally, the current government moved at snail’s pace on the exclusion of foil from Section 9a of the Misuse of Act and continues to creep towards the introduction of take home naloxone where Wales and Scotland have been leading the way.
Moving through the treatment and recovery journey, the outlook for residential rehabs continues to look precarious, summed up by one respondent whose facility is only getting spot bed purchases rather than longer-term contracts, “if someone asked me how residential rehab can be protected, it would be two things; commission nationally or for 2-3 years like the community providers. Let us have some security of income…rather than not knowing from week to week where our income is coming from.”
Coming out the other side, there is a very mixed picture in terms of access to housing, training and jobs – all key elements of ‘recovery’ however you define it with much of the work being side-swiped by welfare reform where according to both this survey and a recent BBC Radio File on Four programme increasing numbers of often vulnerable people with multiple needs are being left with little or no income because of benefit sanctions. As shown by our survey of those with the most complex needs1, including those with drug and alcohol problems, welfare reform was cited as having the most nmegative impact of peoples mental hwealth and wellbeing.
Despite pockets of positive outcomes, overall the Work Programme simply doesn’t work for our client group with service providers citing a range of problems trying to engage with JobCentre Plus teams.
With falling indices of use and presentations, the political temptation to tick the ‘job done box might be overwhelming, but would also be a mistake. Evidence from the most recent DrugScope Street Drug Survey suggests that high risk drug users are expanding their repertoire to include newer anti-anxiety drugs and synthetic cannabinoids with little indication that services are either adapting to changing circumstances or even have the capacity to do so.
The picture isn’t wholly bleak; as one service CEO said:
“There are absolutely superb commissioners who are entirely focused on the welfare of service users and the welfare of the communities they serve more broadly”. But there is no hiding the fear that drug and alcohol treatment services could be in for a very rough time – with commissioners pretty powerless to do much about it. Local councillors hold the whip hand, they determine the level of budget cuts in different areas: as one said recently to the operations manager of a leading provider, ‘Why should be fund a lifestyle choice?’
State of the Sector 2014-15 – four key themes
The commissioning cycle
There was a consensus that commissioning and testing the market has a place in ensuring effective and affordable drug and alcohol treatment. However, many respondents were concerned that, although difficult to quantify, rapid commissioning cycles had a harmful and disruptive effect on service provision.
As in 2013, a majority of participating services had been through contract negotiation (12%) or competitive tendering (42%) in the preceding 12 months, with more (49%) expecting to go through one or other process in the following 12 months.
Respondents and interviewees expressed a number of concerns about this process, which can broadly be categorised in the following ways.
Disruption to services. Many respondents emphasised the destabilising and demotivating effect of uncertainty about jobs, employers and in some cases the future of entire services. Respondents were keen to emphasise that their concern was related to the potential impact on their workforce and the potential implications for service provision and clients.
Provider diversity. Several respondents acknowledged the need to make economies but cautioned that one of the consequences of an increased emphasis on cost could be reduced provider diversity. Small and medium-sized organisations were felt to be particularly disadvantaged in this process, while the residential sector faces distinct and complex challenges of its own.
New systems, new challenges. Many respondents saw the value in testing the market and acknowledged the contribution commissioners make to an effective and successful treatment system. There was a desire to see more support offered to commissioners, who may themselves have taken on new roles, potentially within a new setting. Several expressed the hope that future commissioning can lead to closer partnership working between sectors and more seamless services to individuals, even in the face of a challenging climate.
Funding for the sector
The funding picture seems increasingly clear. While there are clear limits to what can be inferred from the findings of our survey, service manager and chief executive interviews give cause to believe that over the period 2014 to 2016, substantial disinvestment is expected and being planned for, although this will vary from place to place. We identified an average net reduction of 16.5% in funding to services, this masks what appears to be considerable volatility, with many respondents reporting substantial increases or decreases.
Some of the chief executives interviewed acknowledged that the sector has been relatively well funded over the last decade and has enjoyed a considerable degree of budgetary protection in more recent years. That this period may be drawing to a close has not come as a surprise to them or to others, but it raises questions of how England’s world class treatment system can be maintained.
Some answers to this question may lie in the survey responses and interviews; respondents indicated eagerness to innovate, to make efficiencies and to forge new partnerships. Respondents also indicated an enthusiasm to market their services – commercially to commissioners, but also to new clients, people they may otherwise not have reached. Chief executives in particular acknowledged the need to take a whole person approach based around social inclusion and recovery capital, while emphasising that specialist treatment for substance misuse and dependency has a distinct place that must be maintained.
Again, the residential sector may face a separate set of challenges relating to the way it is funded and places purchased. The possibility of block loss of capacity – where many services become financially unviable simultaneously – was raised as a concern, along with the likely difficulties of reinstating that capacity should it be lost.
Gaps in provision
Gaps in provision have been highlighted by respondents and interviewees. A minority of these gaps are largely or entirely external to the treatment system and the other services it works with. While people with histories of drug and/or alcohol misuse are likely to be particularly disadvantaged, problems such as access to appropriate, secure and affordable housing and access to paid employment are by no means unique to this cohort. Several respondents and interviewees articulated in some detail the steps they are undertaking to address these gaps.
Whereas the above might be described as external challenges, others are more particular to the sector. Access to mental health treatment and support for complex needs again features very highly, with the 22% of respondents indicating that access has deteriorated over the 12 months to September 2014.
In addition to the barriers to mental health treatment often reported by agencies working with people with coexisting mental health and substance use problems, respondents suggested that there is a growing gap in provision in the mental health sector. A relatively recent introduction, Improving Access to Psychological Therapies (IAPT), is seen as offering provision at the mild to moderate end of the spectrum and community mental health teams (CMHTs) at the more severe end, with the suggestion of a growing gap between the two, leaving a portion of clients unserved.
While mental health, housing and employment – direct contributors to recovery capital – featured prominently among gaps identified in State of the Sector 2013, access to support for older clients was indicated as a gap by a far larger proportion of people in 2014-15. It is not obvious why this is the case – although the average age of the population in specialist treatment is ageing, that alone seems unlikely to account for the proportion of respondents mentioning services for older clients changing so substantially over just 12 months.
The ageing population in treatment may be reflected in another gap identified – access to services for transition age adults. Providers are increasingly aware that a different service offer may need to be made for younger people coming into adult services. An ageing adult population in treatment and the changing profiles of younger people moving into treatment may require commissioners and providers to work together to develop new models of provision.
Services in prisons were generally more optimistic, acknowledging that treatment in prisons has made significant progress over a relatively short space of time. With a caveat around the survey sample, there are more signs of stability than in the community and residential parts of the sector. There was also optimism that some aspects of the reforms, either in hand or planned, could yield positive results. For example, an increased focus on ‘through the gates’ work and the extension of probation support to short sentence prisoners under Transforming Rehabilitation, if implemented as planned, was seen by many as offering the potential to reduce reoffending and improve outcomes.
Less positively, the reduction in prison officer and support staff headcount was seen as adversely affecting the delivery of substance misuse treatment and related support in prisons, and the role of novel psychoactive substances – particularly synthetic cannabinoids – as well as prescription medication was seen as being extremely harmful. Perhaps unsurprisingly, resettlement support and access to accommodation appear as the biggest gaps – although here again, the situation may be improved by more through the gates activity.
The current edition of Drug Misuse & Dependence: UK Guidelines on Clinical Management (colloquially known as ‘the Orange Book or ‘Orange Guidelines’) was published in 2007. It is about to undergo its fifth iteration with a scheduled publication date of early 2016. Professor Strang is chairing the expert group. Interview by Harry Shapiro
So the first question is – why now?
When any guidelines are prepared, there always comes a time when they need updating or revision, typically after publication of new evidence. The new Guidelines then give the reader an up-to-date balanced view of the evolving evidence and experience in the field. A second reason for wishing to update is after people identify a real omission. This may be because the issue wasn’t around originally (or at least not with the same level of available guidance) – treatment for chronic hep C is a good example of where we do need to update the guidelines. There is also a third category where, in hindsight, we should have done more back in 2006; for example, the incredibly high rates of smoking among drug and alcohol populations. Within our client group, we have 90% smoking as opposed to 19% in the general population. For proper whole-person clinical care, surely we need to address this.
Previous editions of the guidelines have pretty much started from scratch. What’s the plan now?
I did have a concern that we might lose the valuable material within the existing guidelines – they command a high level of respect in the field and valuably point practitioners towards what the evidence tells you blended with what clinical experience tells you. For that reason, the plan this time is to update and revise, not start again.
Historically, there has been a high degree of division within the expert group, especially between GPs and the consultant psychiatrists over what one might call ‘the battle to prescribe’. Is the process more consensual these days?
I wasn’t involved in the very first ‘Orange Guidelines’ in 1984, and perhaps back then there were these divisions. There was also much less in the way of proper evidence for interventions, and these early guidelines revolved around clinical experience and opinion. I then did chair the 1991 sessions and they were mainly concerned with assimilating HIV into treatment following on from the two ACMD AIDS and Drug Misuse reports. I don’t recall any major differences of opinion. Over time, the guidelines working group has become progressively larger, and you may then get individuals advocating that their professional group isn’t recognised enough or that their treatment orientation isn’t adequately represented, etc. But at least by 1999, the Guidelines working group included third-sector and service user representation and was mostly consensual between the GPs and the psychiatrists, and it triggered the whole Royal College of General Practitioner (RCGP) training programme on addiction treatment. In fact, the Senior Medical Officer at the Department of Health was a job share between a Consultant Psychiatrist Michael Farrell and a GP Clare Gerada, who thus covered both constituencies. In 2007, it became a much larger group with the emergence of fuller service user and carer representation and the 2015 group is larger still. The geography of the group has changed too; it covered just England in 1984, then England, Wales and Scotland in 1991, and now the whole UK.
There have been concerns expressed that the decision to revisit the guidelines has been politically motivated in order to undermine harm reduction and force the abstinence agenda. It is an open secret that the publication of the report from the ACMD Recovery Committee was delayed because of political pressure.
Bear in mind that I don’t work for the Department of Health or Public Health England. It is also important to make clear that I and the working group have had concrete assurances about our independence of function and that that the wish to update the Guidelines is not politically motivated. My understanding is that we will be undertaking this review in the same spirit as previous guidelines. We are presenting a practitioners’ guide to evidence-based interventions and some commentary on its implications for how you apply them. In fact the 1999 guidelines were the first to seriously ask – what does the research evidence tell us? If there are new studies which have been done since 2007 which means previous advice needs to be altered, then that’s what we would do. Obviously we will be aware that the political tone has changed, but that doesn’t alter what we say, any more than we would if we were reporting on how best to manage a surgical procedure, or diabetes, or hypertension.
It is quite possible that the opinions expressed around the table and the material we consider will need an awareness of cuts, austerity etc – so I am not saying that we’ll be blind to all that, but there would be active resistance to any idea that we are producing a political document. It’s more like a ‘how-to’ manual for clinicians.
And if there is an issue that has been well covered elsewhere – like time-limited treatment as considered by the ACMD Recovery Committee, then we would examine that and, perhaps, just summarise that, if there is no need to revisit that topic. But even if a new study came out about a topic, we would only look at that to decide if it was of such importance that it alters the overall conclusion, rather than trigger a review of the whole literature.
There was a recently concluded consultation process. What were the headline views from that?
There were comments on categories that I think we might address in a fairly limited way to check that, for example, the 2007 guidelines are factually correct or whether we could rewrite the original guidance more clearly. So an example of that would be the view that there wasn’t enough guidance on supervised consumption which surprised me because I thought there was quite a lot on that. But nearer the time, we might consider something like trigger videos on some of the hot topics. I think that would be a very accessible way of bringing the document alive. Where people want us to revisit issues, we might well refer them to other documents like Medications in Recovery (NTA 2012) if these had adready competently covered these areas. We will also be referring to NICE guidance and Cochrane reviews too and we will provide the links.
We don’t plan to devote lots of space just to descriptions of new aspects of the drug field, except where there is clear guidance to be given. If there is a new pattern of problem use, our description of the problem will be quite light because we are not writing a textbook. We might identify an area and say there is very little evidence about effective intervention and so you should draw on basic principles. Just because something is a major clinical problem, doesn’t mean there is a big evidence base on how you manage it.
So take mephedrone injecting. We might describe the nature of the problem, the nature of the presentations, but there may only be a brief section in terms of evidence-based management advice. The size of the attention we give to an area will probably depend more on the size of the body of evidence, rather than how worried people are about the topic.
In contrast, we now know a lot more about hepatitis C and its treatment and in particular the treatment of people who have had or who still have ongoing addiction problems and so I expect there will be a substantial section about that. To take another example, contingency management was briefly covered in 2007, but I think the UK and international literature is much stronger now. Treatment in prison and on prison release would warrant more attention – and another obvious issue would be take-home naloxone, particularly as the guidelines are not just for England (and Scotland and Wales have been international leaders in introducing wider pre-supply of emergency naloxone). So these are the sorts of areas where we might be able to do some useful updating.