Substance Misuse

Executive Summary

Alcohol and drug misuse is a cause of major public concern and has wide-ranging health, social and financial consequences to society. Alcohol and drug misuse costs taxpayers millions of pounds every year in dealing with associated health problems, lost productivity, adult and children’s social care costs and drug related crime and disorder. Alcohol and drug misuse can be a pathway to poverty, lead to family breakdown, crime, debt, homelessness and child neglect.

The following is within the scope of this JSNA Chapter:

  • Drug and alcohol use, its impacts and effective methods of reduction and treatment across the lifespan.
  • Data and information regarding those already in Surrey’s treatment system,
  • Identification of those who would benefit from treatment, focusing on those in priority groups.
  • Families / friends and carers of those with substance and alcohol dependencies

Who’s at risk and why?

There is a multitude of different influencing factors which lead to increased risk of drug or alcohol misuse and / or addiction, broadly these are an individual’s personality, social environment, biology and stage of development (age). If an individual has multiple risk factors their likelihood of taking part in harmful drinking and drug misuse, further it is those who have more complex needs who are more likely to develop dependencies and addiction3. This is further complicated by the differing types of drugs, the range of desired effects, actual effects and levels of addictions.

The JSNA Chapter identifies the following at increased risk of exacerbated health or development issues:

  • Children and Young People (CYP)
  • Older Adults
  • Those with complex needs (including dual diagnosis)
  • Those injecting substances

It also identifies the following cohorts of individuals at increased risk of engaging in drug and / or alcohol misuse and developing a dependency (including moderate dependency):

  • Lesbian, Gay, Bisexual and Trans* (LGBT)
  • Black Minority Ethnic (BAME)
  • Gypsy, Roma, Travellers (GRT)
  • Those using prescription or over the counter (OTC) and prescription medicines
  • Those in the Criminal Justice System

The level of need in the population

There has been an overall decrease in drug use reported by 11 to 15 year olds since 2001 which has been reflected in a reduction in the number of young people in specialist services. For example, in 2012, 17% of 11 to 15 year olds had tried drugs at least once in their lifetime, compared with 29% in 2001. Consistent with the national trend, the number of individuals under 24 years who accessed substance misuse services in Surrey dropped from 366 in 2012 to 294 in 2015/16.

In 2014/15 there were 2,151 adults in treatment for substance misuse and 1,063 in Surrey. Surrey has significantly higher wait times for those trying to access treatment for substance and alcohol misuse. However, Surrey has higher rates of successful competitions for alcohol treatment, opiate treatment and non-opiate / other drugs treatment. Surrey has approximately 20% of clients engaged in treatment who are receiving concurrent support from mental health services, for both alcohol and substance misuse services.

Services in relation to need

Substance Misuse interventions are well evidenced as being cost effective. In terms of return on investment evidence shows, every £1 spent on young people’s drug and alcohol interventions brings a benefit of £1.93 within two years and up to £8.38 in the long term. Every £1 spent on drug treatment saves £2.50 in costs to society. The substance misuse treatment system in Surrey is divided into a number of services and modalities which work in an integrated way to ensure a seamless transition from one area to another for the benefit of the clients until they successfully complete their treatment journey. The Service Directory provides a full list of all Drug and Alcohol Services (adult and young people) in Surrey.

Unmet needs and service gaps

The JSNA Chapter recognises that there are service gaps, or service development opportunities within the following areas:

  • Recovery Support
  • Housing and Housing Support
  • Hard to Reach Groups
  • Criminal Justice (Prison leavers and community sentences)

What Works?

All commissioned services follow National Institute of Clinical Excellence Guidance and Public Health England Guidance, these are listed in the main body of the JSNA. In addition this chapter provides case studies from the following services across the County:

  • Surrey’s Treatment System (Public Health)
  • Children and Young People: Youth Restorative Intervention (YRI) (Youth Support Service and Surrey Police)
  • Women’s Support Centre (Women in Prison) (Public Health)
  • Recovery Cafés and Recovery groups
  • High Impact Complex Drinkers Pilot

Recommendations for Commissioning

The recommendations detailed in Table 1 (Recommendations for Key Stakeholder from the Substance Misuse Partnership) do not replace the recommendations of the Substance Misuse Strategy (Part A and B), Recovery Needs Assessment, Housing Review, High Impact Complex Drinkers Pilot Report, but provide overarching recommendations to support the delivery of the specific recommendations found within these documents.

Introduction

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Alcohol and drug misuse is a cause of major public concern and has wide-ranging health, social and financial consequences to society. Alcohol and drug misuse costs taxpayers millions of pounds every year in dealing with associated health problems, lost productivity, adult and children’s social care costs and drug related crime and disorder. Alcohol and drug misuse can be a pathway to poverty, lead to family breakdown, crime, debt, homelessness and child neglect.

The World Health Organisation defines drug misuse as the use of a substance not consistent with legal or medical guidelines (1) . Drug misuse becomes problematic when individuals experience social, psychological, physical or legal problems in relation to their drug misuse and/or if they become dependent. Public Health England describes drug dependency as:
“A health disorder with social causes and consequences. In medical terms, it is a chronic condition characterised by relapse and remission (2)”

Alcohol misuse means drinking excessively or more than the recommended limits for alcohol consumption. In the UK, the Department of Health has categorised types of drinking by level of risk. One alcohol unit is equal to 10ml (in volume) or 8g (in weight) of pure alcohol. While it is not possible to say that drinking alcohol is absolutely safe, by keeping within the recommended guidelines, there is only a low risk of harm in most circumstances. The full Chief Medical Officer Guidelines can be found in the “Improving healthy lifestyles” JSNA Chapter.

Investing in a multi-agency response to addressing drug harm has benefits across society, in Surrey these efforts are overseen by the Substance Misuse Partnership which feeds into the Health and Wellbeing Board and Community Safety Board. The Partnership also has a number of sub groups to carry out specific actions or respond to emerging needs. The work delivered by the Partnership follows the actions and recommendations set out in the Substance Misuse Strategy; this is organised into two sections

  • Section A (Alcohol): aims to prevent and reduce the harm caused by alcohol to individuals, families and communities within Surrey.
  • Section B (Drugs): aims to deliver a coordinated multi-agency response to prevent and reduce the harm caused by drug misuse in Surrey and build recovery for drug users.

The following is within the scope of this JSNA Chapter:

  • Drug and alcohol use, its impacts and effective methods of reduction and treatment across the lifespan.
  • Data and information regarding those already in Surrey’s treatment system,
  • Identification of those who would benefit from treatment, focusing on those in priority groups.
  • Families / friends and carers of those with substance and alcohol dependencies

Who’s at risk and why?

There is a multitude of different influencing factors which lead to increased risk of substance or alcohol misuse and / or addiction, broadly these are an individual’s personality, social environment, biology and stage of development (age). If an individual has multiple risk factors their likelihood of taking part in harmful drinking and drug misuse, further it is those who have more complex needs who are more likely to develop dependencies and addiction(3). According to a statistical analysis carried out by on the data collected by the Crime Survey for England and Wales (CSEW) the most important factors associated with drug use were age, sex, marital status and frequency of alcohol consumption.

Socialising in the night-time economy, for example attending pubs and clubs, has also been associated to increased drug taking behaviour. Being a victim to crime also places individuals at increased risk of drinking at increasing or harmful levels and drug taking(4) .This is further complicated by the differing types of drugs (stimulants, hallucinogens, performance enhancer, depressants and pain killers), a range of desired effects, actual effects and levels of addictions. The following sections identify populations who have been identified as being at increased risk or having differing needs from the general population.

Children and young people (CYP)

Young people are more likely to take drugs then adults; data from the CSEW 2014 -15 showed 19% of 16-19 year olds and 20% of 20-24 years have taken drugs. Whilst few young people will develop a substance misuse or alcohol dependency, however, even for those who do not use frequently the risks associated with alcohol and substance misuse in CYP include damage to the developing brain, interference in the normal challenges of development, exacerbation of other life and developmental problems. Nationally the majority of young people accessing specialist drug and alcohol interventions have problems with alcohol (37%) and cannabis (53%)(5) . Those who are likely to develop a dependency are likely to be vulnerable and experiencing a range of health and social problems, therefore the needs of CYP differ from adults who can access core treatment services. These vulnerabilities might include:

  • Looked-after child
  • Parent who is misusing drugs and / or alcohol
  • At risk or involved in of child exploitation
  • Living in poverty
  • Have a diagnosed mental health problem
  • Affected by domestic abuse

Drug use among young people is associated with other risky behaviour. Young people were more likely to have taken drugs in the last year if they were smokers or had drunk alcohol. 11 to 15 year olds who had been excluded from school or who had played truant were also more likely to take drugs.(6)

Older Adults

There are two cohorts of older people who have a dependency, those who have had a lifelong dependency or history of drug and alcohol use and those who develop a dependency in later life. Ageing brings increased risks to independence and wellbeing through disease, frailty, sensory impairments and other long term conditions, especially in the “oldest old” (i.e. people over the age of 85). The use of drugs and alcohol is known to worsen some health conditions, particularly as older adults are less tolerant due because of physical changes (i.e. altered responsiveness of the brain, liver efficiency). In addition individuals who are drinking at harmful levels are at increased risk of alcohol-related cognitive dysfunction and dementia(7) .

Data from Public Health England suggests that that there is an ageing population of heroin users, this could be one of the reasons for the increase of Drug Misuse Deaths as these clients have complex health and social needs which impact their chance of long term recovery (8). A recent report titled ‘Drug Problems in Later Life’ estimated that 30-40% of older adults who use benzodiazepines or opioid analgesics on a long term basis become dependent on them.
(9)

Lesbian, Gay, Bisexual and Trans* (LGBT).

Substance misuse research has demonstrated that client sexual orientation or gender reassignment influences treatment outcomes (10), findings suggest that LGBT are more likely to use substances but are less likely to access treatment. Data on the experiences of Trans* individuals is limited as for many the preference is to simply identify as a man or woman, or do not want to identify with the binary female / male conventions . Trans* clients fear that disclosing their previous gender identify could result in discrimination and feel vulnerable to attack, harassment or ridicule.

According to research published by Stonewall, which surveyed over Lesbian, Gay and Bisexual (LGB) individuals 12,000 individuals, report having negative experiences in Healthcare settings.

  • 52% LB and 34% of GB reported negative experiences in healthcare services
  • 39% LB and 16% GB were assumed to be heterosexual
  • 6% LB and 3% GB were given inappropriate advice (i.e. pregnancy or safe sex advice)

Drugs

The findings from the CSEW 2013/2014 survey presented provides a breakdown of data by sexual orientation. The findings were standardised by gender and age to ensure that sexual orientation was the driver behind increased drug taking. Of the respondents in the combined dataset, 97% reported that they were heterosexual or straight; 2% gay or lesbian and 1% bisexual. Analysis presented here combines adults who identified as being gay or lesbian with those who were bisexual, i.e. 3% of the respondents in total.

  • 33.0% of gay or bisexual men had taken illicit drugs in the last year compared to 11.1% of heterosexual men
  • Gay or bisexual women were four times more likely to have taken illicit drugs in the last year, 22.9% reporting use compared to 5.1% of the heterosexual respondents.
  • When compared to the general population the biggest difference was in use of amyl nitrite for gay and bisexual men (0.8% and 14.7% respectively)
  • The biggest difference when comparing gay and bisexual women to the general population was the use of cannabis (17.5% compared to 3.8% respectively)

Alcohol

Lesbian, gay and bisexual (LGB) people have been found to be more likely to use and misuse alcohol compared to heterosexual men and women.(11) Research into alcohol from the aforementioned Stonewall studies indicates that:

  • 34% of gay and bisexual males, and 29% of lesbian and bisexual females, reported binge drinking at least once or twice a week
  • Binge drinking is more than twice as common amongst lesbian, gay and bisexual people when compared with the wider population
  • Lesbian, gay and bisexual people demonstrate a higher likelihood of being substance dependent

Black and Minority Ethnic (BAME)

Drugs

For BAME groups the CSEW presents a combined data set from 2011/12, 2012/13 and 2013/14 CSEWs due to the small data set from 2013/2014. The findings were standardised by gender and age to ensure that ethnicity was the driver behind increased drug taking. Of those who responded 1/10 identified as BAME. Key findings highlight:

  • Adults from mixed ethnic backgrounds were the most likely to have taken any illicit drug in the last year, compared with adults from other ethnic groups, 17.1% of this group had taken drugs in the last year
  • Mixed ethnic groups also had the highest levels of Class A drug use in the last year.
  • Last year cannabis use was highest among adults from a mixed ethnic background than for adults from other ethnic groups. The overall mixed ethnic individuals had a higher prevalence of cannabis use, within the last year, than any other group (13.8%), for example when compared with adults from a white background (7.0% overall).
  • Adults from the Asian or Asian British and Chinese or other ethnic groups generally had the lowest levels of last year drug use.
  • Within black or black British backgrounds, those from a black-Caribbean background had higher levels of cannabis and any drug use in the last year (8.0% and 8.9% respectively) than adults with a black-African background (2.8% and 3.9% respectively).
  • Across genders the difference mirrors that of the general population, other than those from Indian, Pakistani, Bangladeshi, Chinese and black African groups where the gender difference not significantly different

Alcohol

Research and statistics have consistently shown that people from minority ethnic groups have higher rates of abstention and lower rates of consumption than the majority white ethnic group. However, drinking varies greatly both between and within minority ethnic groups and across gender and socio-economic group, resulting in a very complex national picture of alcohol consumption and alcohol-related harm across ethnicity. (12)

Gypsy, Roma, Travellers (GRT)

GRTs are widely recognised as being marginalised and socially excluded, which places them more at risk of poor mental health excessive alcohol consumption and substance misuse.(13) It is estimated that we have around 10-12,000 GRT residents, which would mean that Surrey has the fourth largest GRT population of any local authority. The Surrey Brighter Futures Needs Analysis (2013) and Strategy for Surrey (2014-2015) focus on 0-19 year olds, but also capture wider issues. These identified that young people pick up adult habits earlier than the general population as this includes primarily recreational drinking among young men. However, evidence in surrey suggests that consuming alcohol has become more normalised in girls and young women.

Drug use among men is anecdotally widely reported, most often cannabis and cocaine, and some dealing is reported to occur. The risks associated with drug taking are amplified by reduced access to services, which may be thought to be culturally inappropriate and / or by lack of awareness within the community. These problems are further contributed by a high number of individuals who have mental health issues and therefore suffer from the difficulties faced by those with dual diagnosis in addition to limited access to services. Further information and how Surrey County Council and its partners intend to improve life chances for the GRT community is outlined in the Brighter Futures: Surrey’s strategy for Gypsy, Roma and Traveller children and young people. 2014-2017.

Influencing wider determinants of health

The relationship between the wider determinants of health and substance misuse is complex; there is no typical drug user.
(14)

Drugs:

  • Those most socially excluded and those from areas of high deprivation are more likely to be adversely affected by drug misuse, and are at an increased risk of not being able to return to a drug free lifestyle. (15)
  • Those who are unemployed or are economically inactive are more likely to use any drug compared to those who are employed. 7.9% of those who are employed have used a drug in the last year compared to 17.2% and 10.1% respectively. (16)
  • Those living in urban areas are more likely to use drugs then those living in rural areas.
  • Trends regarding cocaine use have changed over the last 10-15 years. In 2001/02 cocaine use had higher prevalence among households of CSEW “Urban Prosperity” (characterised as prosperous professionals, young urban professionals and students living in town and city areas) . (17)
  • Trends from 2001/2 through to 2013/2014 households in areas classed as “Hard Pressed” (characterised as low-income families, residents in council areas, people living in high-rise and inner-city estates) showed significantly significant increase in past year use.
  • Between 2012/2013 and 2013/14 there has also been a significant increase in areas classed as “Comfortably Off” (characterised as young couples, secure families, older couples living in the suburbs and pensioners) and of “Moderate Means” (characterised as Asian communities, post-industrial families and skilled manual workers).
  • Whilst those in areas of Urban Prosperity cocaine powder use still remains more common, these trends highlight a widening of the social spectrum involved in the use of cocaine powder.

Alcohol

People who are employed are more likely to drink alcohol than their unemployed counterparts. They are also more likely to drink to increasing risk and higher risk levels.(18) Those on the highest income bracket are more likely to drink alcohol than those on lower incomes. They are also more likely to drink more frequently and above recommended limits.
(19) It is this higher income group which has seen the highest consumption increase in the last decade. (20) Despite this, the negative impact of alcohol on health disproportionately affects the unemployed, manual workers, and those on lower incomes – people from deprived groups experience far greater health harm from alcohol than those from higher socioeconomic groups.(20). Alcohol-related deaths are up to three times more likely in those who are from the most deprived fifth of the population.(3)

Those in the Criminal Justice System

Evidence highlights that there is a complex interaction between dependence on drugs and alcohol and crime(3). Whilst the relationship is not thought to be causal, there is evidence that those who are committing crimes are more likely to misuse substances and suffer from dependence issues, and that those who are dependent on drugs and alcohol have higher rates of supply and possession criminal offences. Ex-offenders are at an increased risk of becoming socially excluded, which increases the chances of alcohol and drug misuse.

Alcohol and drug misuse in prisons poses a serious threat to staff and prisoners; through increased violence, health risks to those consuming the substances, and threat to the security of the prison. These effects also place pressures on the communities they are placed within and families and friends of prisoners at risk of being affected by organised crime (for example debts of prisoners) (21) . Alcohol and drug misuse in prisons also greatly reduces the ability to prevent or reduce reoffending and reform.
Drugs

The modern crime prevention strategy highlights the strong relationship between drugs and acquisitive offences in England. It is estimated that 45% of acquisitive offences, not including fraud, are committed by those who would be considered to be Problematic Drug Users. In some cases individuals will have already been committing crimes, thus the use of drugs is not always the primary driver of criminal activity, however heroin and crack use, can accelerate and extend criminal careers.

Drug users with complex needs are more likely to have repeated interactions within the criminal justice system and frequent prison stays.

High rates of drug use and dependence are found among prisoners, often with the highest levels of drug use among the most prolific of offenders (21). In a recent thematic review carried out by HM Prison Inspectorate, which surveyed 10,702 prisoners, 52% of had used illicit drugs 2 months before entering prison, this was highest among young prisoners. Cannabis was the most commonly used drug (38%), followed by cocaine (29%). Despite the high trends of NPS (particularly Spice/ Black Mamba) use within prison only 6% reported using before entering prison. 1 in 10 reported using medication (10%) or opiate substitution (9%) which was not prescribed to them, this was commonly used with another primary drug such as heroin.

There is a general decline in prisoners entering prison with an opiate addiction which mirrors a national trend of reducing numbers using heroin in the community, however, these prisoners are often highly complex, with severe mental, physical and health issues. Data from the NTA between April 2014 and September 2015 shows that 25% of prisoners began treatment on arrival. This is consistently higher among women (41%) when compared to men (27%) according to the HM Inspection which was carried out between April 2014 and April 2015.

When looking at the risk of developing dependencies or problems in prison 8% of males and 4% of females reported developing a problem whilst in prison. This figure varied across the range of different facilities, 3% of those in open facilities reported developing a problem compared to 10% of prisoners in category C facilities.
Alcohol

Alcohol is a key factor which affects crime rates, re-offending and triggers anti-social behaviour. In Surrey, the latest data available through probation records taken from the Offender Assessment System, shows that alcohol is identified as both a higher need area (54%) than drugs amongst Surrey offenders linked to the Probation Trust . It also more closely aligned to the cause of offending (32%). Of the 592 Surrey based offenders with violent convictions (e.g. Affray), 53% had an alcohol treatment need. Within this group 66% of domestic abuse perpetrators had been identified as having an alcohol treatment need. Of those offenders with a conviction of violence against the public (e.g. Grievous Bodily Harm) 57% had an alcohol treatment need.
(22)

The Office for National Statistics (23) reported that a large proportion of male and female prisons were drinking above lower risk levels, before entering prison (24) . Among men, 58% of remand prisoners and 63% of sentenced prisoners reported increasing risk/hazardous drinking; including 30% in both groups with AUDIT scores which indicated higher risk/harmful drinking and alcohol dependency.

Those with Complex Needs

Dual Diagnosis

Those with dual diagnosis have some of the poorest health, wellbeing and social outcomes, and are often unable to access appropriate and / or relevant care and support (25, 26) . Further it is hard to accurately estimate the number of individuals with dual diagnosis due to inconsistencies in care and reporting(25). It has been estimated that the prevalence of co-existing mental health and substance use problems (termed ‘dual diagnosis’) may affect between 30% and 70% of those presenting to health and social care settings(27, 28) , . Childhood abuse is, for example, known to contribute to the prevalence of comorbid personality disorder in addiction populations(29). Women who use substances and have been exposed to sexual, physical and emotional abuse as children are more likely to experience emotional distress than a control group of women substance misusers who do not have that background
Drugs

Problematic Drug users (PDU’s) or Opiate and Crack Cocaine users (OCU’s) refers to someone who uses opiates (e.g. heroin, morphine, codeine) and/or crack cocaine (30). Often OCU’s are marginalised from society and have experienced disadvantage from early on in their life. OCU’s make up 7% of those on benefits, and tend to have poor or unstable housing conditions, poor health, low levels of educational attainment and are more likely to be unemployed (31) . Further, OCU’s are at increased risk of drug misuse deaths (see section “Those injecting substances”).
Alcohol

Complex alcohol users are a highly diverse service user group, often characterised by the complexity of their needs, multi-morbidity and exclusion from society. These complexities often act as a barrier to accessing services and these individuals are often crisis driven with regard to their service use and do not exhibit the motivation and level of stability required to access and engage with specialist treatment services. As such, they may be classified as ‘treatment resistant’, ‘intentionally homeless’ or ‘hard to engage’. Modelling carried out with Alcohol Concern identified over 2000 clients, however, it is highly likely that estimates will double count clients as they are known to more than one service. However, even an estimate of 15-20% of these estimates would still present a level of need of between 300-400 clients (32).

Those injecting substances

Those who inject drugs are at increased risk of viral and bacterial infections including HIV, Hep B, Hep C and MRSA, this results in high levels of illness and death (33). The latest data from PHE shows those injecting psychoactive substances:

  • Are more likely to have HIV compared to the general population (1% compared to 0.19%)
  • 38% shared needles, syringes and mixing containers
  • 9/10 cases of Hep C can be attributed to drug use, this estimates that 2/5 are living with chronic Hep C illness
  • There is an 86% uptake of testing
  • Hep B has fallen in recent years but 13% of those who inject are infected and 1 in 200 are living with Hep B
  • There is a 75% uptake of the vaccine to those who are offered it.
  • 38% of women and 31% of men surveyed reported having an abscess, sores or open wound.
  • NPS Injectors are considered to be further at risk as they are not used to injecting practice (34).

England continues to have a high number of drug-related deaths with opiate overdose remaining a major cause of death among injecting drug users. Key findings from the 2016 Office of National Statistics report on drug misuse deaths show:

  • In 2015 there were 3,674 drug poisoning deaths involving both legal and illegal drugs registered in England and Wales (35).
  • Deaths involving heroin and/or morphine doubled in the last 3 years to 1,201 in 2015, and are now the highest on record. (2011- 596 deaths)
  • Men were almost 3 times more likely to die from drug misuse than females (65.5 and 22.4 deaths per million population for males and females respectively).

There has been an increase in the injecting of image and performance-enhancing drugs (IPEDs), whilst the levels are not as high as those who use psychoactive substances their risk remains higher than the general population. PHE latest report shows:

  • 0.56% have HIV of those surveyed in 2014/5
  • 13% reported sharing equipment at least once
  • 5.1% reported having Hep C and only 41% reported being tested.
  • 2.5% reported being infected with Hep B and there is a 38% uptake rate of the vaccine.
  • 14% reported having an abscess, sores or open wound.

Those who are injecting also are able to contract and transmit HIV through anal and vaginal intercourse. Of those surveyed, and injecting psychoactive substances, 66% reported having sex in the past year, 40% of these individuals had two or more sexual partners and only 22% reported using a condom. Men who have sex with men (MSM) are also considered to be at increased risk of transmitting and contracting through intercourse (34), more information regarding sexually transmitted diseases or infections can be found in the Sexual Health JSNA Chapter.

Those using prescription or over the counter (OTC) and prescription medicines

Addiction to OTC and prescription medicines is an emerging issue and therefore presents a potentially new cohort of individuals with a treatment need. Three distinct but overlapping populations have been identified as using OTC medicines:

  • Those who use prescription and OTC medicines as a supplement or alternative to illicit drugs, or as a commodity to sell
  • Those who overuse prescription or OTC medicines to cope with genuine or perceived physical or psychological symptoms
  • Those for whom the prescribed use of a medicine inadvertently led to dependence, sometimes called involuntary or iatrogenic addiction(36) .

Broadly the medicines being used are:

  • Benzodiazepines and z-drugs, prescribed mainly for anxiety (benzodiazepines only) and insomnia
  • Opioid and some other pain medicines, both prescribed and bought over-the-counter
  • Stimulants, prescribed for ADHD or slimming
  • Some OTC cough and cold medicines, and anti-histamines and stimulants.

Other priority groups:

  • Pregnant women – see ‘Maternity and breastfeeding/infant feeding JSNA’ chapter
  • Domestic Abuse – see ‘Community Safety JSNA’ chapter
  • Sex workers – see ‘Sexual health JSNA’ Chapter

The level of need in the population

Children and Young People

There has been an overall decrease in drug use reported by 11 to 15 year olds since 2001 which has been reflected in a reduction in the number of young people in specialist services. For example, in 2012, 17% of 11 to 15 year olds had tried drugs at least once in their lifetime, compared with 29% in 2001.

Consistent with the national trend, the number of individuals under 24 years who accessed substance misuse services in Surrey dropped from 366 in 2012 to 294 in 2015/16. Locally this may be due to the focused prevention and brief Intervention work undertaken by the Youth Support Service to reduce the number of CYP requiring specialist substance misuse support.

There were also decreases in the proportion of 11 to 15 year olds who had taken drugs in the last year from 20% in 2001 to 12% in 2012 and the last month from 12% to 6%. (37)

The majority (94%) of young people in Surrey’s services began using their main problem substance under the age of 15, this is similar to the national picture(37). In 2015/6 Surrey has a lower number of under 15’s (29%) then the national average (41%) and had nearly double the number (29%) of 18-24 year olds compared to the national average (15%).

Among young people using services in Surrey; 7% are ‘looked after children’, 6% have been affected by domestic abuse, 21% were not in education, employment or training and 10% were identified as having a mental health problem (38). Young people’s specialist substance misuse treatment services in Surrey have reported an increase in the number of young people reporting the use of New Psychoactive Substances, however, this is thought to be declining since the introduction of the Psychoactive Substance Act 2016(39) . 85% of young people who engaged with the CYP drug and alcohol Service completely reduced or ceased drug use in 2013/14.(40)

Adults

The substance misuse Tableau Dashboards show four pages, these contain data from two sources, Halo and National Drug Treatment Monitoring System (NDTMS).

Halo is the client management system used by a number of the treatment services in Surrey. It contains live data that is changed and updated each day. The National Drug Treatment Monitoring System (NDTMS) is run by Public Health England (PHE) and collects monthly updates from all the treatment providers in England. The majority of drug and alcohol treatment reports produced by PHE use data from the NDTMS. When these reports contain figures for Surrey they include all Surrey residents including those treated outside the county. For these reasons, figures produced by Halo will never match up perfectly with those on PHE reports.

Key findings from the four key dashboards are as follows.

Substance Misuse: Accessing Treatment:

  • The estimated number of opiates and/or crack cocaine users who are 15 to 64 years Surrey is 2,610, this equates to a rate of 3.56 per 1000 of the population.
  • 2015/16 significantly lower numbers of individuals successfully engaged in community based structured treatment following release from prison in Surrey (15.3%) compared to 29.4% across the South East.
  • 20.4% of clients are accessing community mental health services whilst receiving support for drug misuse. This is the same across the South East.
  • Surrey has significantly higher number of clients waiting longer than three weeks to access services. An increase of 7.1% in 2014/15 from 5.7% in 2013/14 is in line with national trends of increasing wait times
  • Figures from 2013-2015 show Surrey has lower mortality rates than England, South East and Kent, 2.2/ 100,000 population, however, this has been trends show this increasing. In 2014-2006 the mortality rates were 1.4 per 100,000 population.

Substance Misuse: Successful Completions

  • Surrey (43.2%) has significantly higher rates of successful completions for non-opiates treatment compared to England (37.7%) and the South East (37.7%). Trend data shows following a stable period from 2010 to 2012, rates had been consistently inclining from 2012-2014 but since 2014/15 rates have begun to decrease slightly.
  • For those in treatment for opiates successful completions in Surrey (8.6%) are again higher than England (6.7%) and the South East (7.2%). Nationally and regionally there has been a decline in successful completions since 2011. Surrey follows this trend, other than an increase from 2012-2013 before declining again.

Substance Misuse: Adult Alcohol Misuse

  • In 2014/15 there were 1,063 individuals in treatment, a slight decrease from the previous year of 1,103.
  • Trends for admissions to hospital for mental and behavioural disorders due to alcohol roughly mirror those of England with slight increases and decreases across alternating years. Following a regional and national dip, Surrey experienced its lowest rates in 2012/13 at 37/ 100,000 population, since before 2008/9.
  • However trends show this increasing again in 2014/15 this increased to 41.2 per 100,000 population.
  • Despite this Surrey remains significantly lower than the south east (58.9 per 100,000) and England (87.3%) in 2013/14.
  • Surrey has a similar percentage of clients engaged in treatment who are receiving concurrent support from mental health services, 19% compared to 18% in the south east and 20% across England.
  • Wait times in Surrey are significantly higher compared to England and the south East. In 2014/15 22.5% of clients waited longer than three weeks to receive treatment. The average across the South East was 4.2%.
  • Surrey’s rate of successful completions has been increasing since 2013, 40.5% of Surrey’s clients now successfully complete. This is the same as the regional average and higher then national average (38.4%) which has experienced a slight decline since 2014.

Substance Misuse: Surrey’s treatment system

  • Epsom and Ewell has the lowest number of individuals in treatment (196), Reigate and Banstead has the highest number (442)
  • Woking has the highest number of opiate users in treatment (55), followed by Guildford (46), Tandridge has the lowest (12)
  • Reigate and Banstead has the highest number of clients in treatment for alcohol misuse (273), followed by Elmbridge (241) and Tandridge has the lowest (118)
  • Epsom and Ewell has the highest number of clients in treatment for non- opiate use (47), Reigate and Banstead has the highest (116) followed by Spelthorne (114)
  • Numbers in treatment are not a reflection of the level of need in Local Authorities, it could relate to the ease of access to services, local transport in the area, number of clinics, promotion, etc.
  • The majority of clients spend less the 12 weeks in treatment (2,750), a small proportion stay in treatment for over a year (38)
  • 13% of those who have been diagnosed with a mental health condition are in regular employment compared to 33% of those who are not dual diagnosis
  • 51% of those with dual diagnosis are on long term sick benefits compared to 22% of those who are not dual diagnosis

Services in relation to need.

Substance Misuse interventions are well evidenced as being cost effective. In terms of return on investment evidence shows:

  • Every £1 spent on young people’s drug and alcohol interventions brings a benefit of £1.93 within two years and up to £8.38 in the long term
  • Every £1 spent on drug treatment saves £2.50 in costs to society (41)

Specifically to health, criminal justice and local authorities, Public Health England estimates that nationally:

  • Young people’s drug and alcohol interventions result in £4.3m health savings and £100m crime savings per years
  • Drug and alcohol interventions can help young people get into education, employment and training, bringing a total lifetime benefit of up to £159m
  • Drug treatment prevents an estimated 4.9m crimes every year
  • Treatment saves an estimated £960m costs to the public, businesses, criminal justice and the NHS
    Further information on why it is important to invest in Substance Misuse Services can be found in Public Health England’s document “Why Invest”.

The substance misuse treatment system in Surrey is divided into a number of services and modalities which work in an integrated way to ensure a seamless transition from one area to another for the benefit of the clients until they successfully complete their treatment journey. The Service Directory provides a full list of all Drug and Alcohol Services (adult and young people) in Surrey.

Targeted Public Health commissioned services

Children and Young people

Education and Prevention: Public Health commission the development and production of a PSHE (Personal, Social, Health and Economic) – Drug & Alcohol Education Toolkit for Key Stage 4 (14 to 16 years old). The toolkit and other support documents can be found here.
CYP Specialist Treatment Service: specialist treatment service offering a range of support for young people, aged 11 to 21, who have problems with drugs or alcohol.

Housing Support: residential support for young people (aged 17-30) identified through substance misuse services to move onto independent living.

Women’s services:

Women’s support centre – The Women’s Support Centre offers women a safe and homely space in which to access gender-specialist support services. There is a specialist arm funded by Public Health which focuses on substance misuse.

Criminal Justice

Integrated Offender Intervention Service (IOIS): Holistic support for in the criminal justice system in addressing substance misuse issues.

Core services Public Health Services

Direct access services: Advice, information and support to alcohol and drug users, their families and carers. Open access services allow for people to drop-in, or telephone directly for an appointment.
Carer groups: Provide support to partners, families and carers of alcohol and drug users and represent the carers’ voice in planning and delivering drug services.
Structured treatment services: Ongoing support for alcohol and drug users who wish to address their drugs issues. Interventions may be clinical, therapeutic and/or practical. Support is care planned and provided over an agreed period of time.

Residential and inpatient treatment services: High level support delivered in a residential setting. This may be a rehabilitation or detoxification programme, or a mixture of both.
Aftercare services: Follow-on support for alcohol and drug users who have been through structured treatment, released from custody or post-rehabilitation
Recovery Services: Recovery services support those who have been through commissioned services and those who may be seeking life from dependence without the support of commissioned services. The potential of expanding recovery support is in those already in recovery, including supporting the growth of mutual aid, self-help, peer mentors and grass root activities. In 2016 Public Health carried out a Recovery Health Needs assessment to assess the current best practise, evidence and provision of recovery support and services across Surrey. Full results and recommendations can be found in the Recovery Needs Assessment 2016.
Advocacy: support service which provides advocates for those in clinical treatment who need help to express their wishes and feelings, support them in weighing up their options, and assist them in making their own decisions.
Needle and syringe programmes: provision of safe and clean injecting equipment to reduce the transmission of BBV’s and infections caused by sharing. Services also provide harm reduction advice and signposting to treatment services.

CCG-commissioned services:

Hospital Alcohol Liaison Services

Alcohol Liaison Nurse (ALN) Services are based in Surrey’s hospitals and deliver alcohol screening to patients and provide brief advice and extended interventions to those drinking at risky levels. They may also support administration of appropriate and safe alcohol detoxification, liaison with community drug and alcohol services and alcohol training/support to the wider hospital workforce.
Joint commissioning takes place for the delivery of:

Youth Support Service (PH, CSF and OPCC)

Targeted and specialist service which works in partnership with services to provide 121 or group support. This service has two specialist arms, Youth Restorative Intervention and a substance misuse worker.
Safe havens (ASC and CCG’s)

The co-location of professionals and a shared approach to service user care has enabled statutory and independent professionals to develop an understanding of each other’s roles and build confidence to share information to support people across Surrey in mental health crisis. Safe Havens are often used by those who have a co-existing mental health and substance misuse dependency.
High Impact Complex Drinkers (OPCC and PH)

Introduction of community outreach workers who stabilise and motivate those most at risk and who are repeatedly impacting in crisis on emergency services. Once stabilised the outreach workers look to transfer the client into a core service whilst working with partners to develop an integrated response that offers measurable benefits to individual service users and the services they come into contact with.
Surrey Police:

Enhanced arrest referral: routine drug testing in custody (i.e. in police cells)
Boroughs and Districts

Homelessness support services and housing provision, further information can be found in the Planning, housing and housing related support JSNA Chapter

Unmet needs and service gaps

Recovery Support

Recovery is much wider than just being free from drug dependency; it includes physical and mental wellbeing, employment opportunities and basic life skills. An individual’s recovery is largely determined by their level of recovery capital, this refers to the sum of resources that can support an individual and can include physical assets, relationships, personal resources (i.e. health) and values, beliefs and attitudes which link individuals to society. Currently there are limited support services for individuals, although there is a range of mainstream services (i.e. benefit support, social activities, employment support), many service users are stigmatised and excluded from these services.

Housing and Housing Support

With limited housing availability, Surrey mirrors national trends towards an increase in homelessness and temporary accommodation. Those living in temporary accommodation in Surrey have risen from 205 in 2010 to 748 in June 2015 (42). In Surrey the price of housing is high, both in the rented and owner-occupied sectors. The number of affordable housing units in Surrey is also lower than elsewhere in the UK and vacancies are therefore limited. At the end of September 2015 there were just under 16,000 households registered as needing affordable housing in Surrey.(42)

Findings from an exercise carried out by ASC highlighted limited funding for housing and support services, limited choice and control for clients, and inappropriate placements (i.e. being placed in a hostel with additional needs which cannot be catered for). Moreover, there was a general lack of awareness regarding those with additional needs such as substance misuse and / or mental health across service providers and neighbours. Specifically to substance misuse many support services will not accept clients who are still drinking or using substances. Many clients are labelled ‘intentionally homeless’ and turned away from accessing anything more than a night hostel. Once in this position health conditions are often exacerbated and levels of substance misuse increase to tolerate the living conditions which makes it increasingly difficult to maintain treatment.

Hard to Reach Groups

Despite the identification of those who at increased risk, at present substance misuse services see a small proportion of clients who are GRT, LGBT* or BAME. There is a need to better understand the needs of these client groups to ensure that services are culturally appropriate and can support their needs and to better understand how we engage with these groups to support them to access treatment services, where appropriate.
Criminal Justice (Prison leavers and community sentences)

In April 2013 NHS England took on the responsibility for commissioning health care services of prisoners, this includes substance misuse services. NHS England and the National Offender Management service work to a national partnership to achieve this. Offenders in the community are expected to access the same healthcare services as those of the general population, this is the responsibility of Clinical Commissioning Groups and Local Authorities(43) . Since this transition there have been a number of changes to the services offered and which has resulted in confusion across partners and stakeholders which impacts on continuity of care when an offender exits prison or for those who are supervised in the community. Better case management, data and information sharing and improved pathways are needed to better understand the needs of those in the criminal justice system.

What works

All commissioned services follow best practise and guidance as detailed in the following NICE guidelines:

Substance misuse interventions for vulnerable under 25s: Public Health Guideline [PH4]

Needle and syringe programmes: Public health guideline [PH52]

Drug misuse in over 16s: psychosocial interventions: Clinical guideline [CG51]

Drug use disorders in adults: Quality standard [QS23]

Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence: Clinical Guidance [CG115]

Alcohol-use disorders: prevention: Public health guideline [PH24]

Alcohol-use disorders: diagnosis and management: Quality Standard [QS11]

Severe mental illness and substance misuse (dual diagnosis) – community health and social care services. In development [GID-PHG87] Expected publication date: November 2016

Where NICE guidance does not exist Public Health England (formerly the National Treatment Agency) guidance showed be followed. Most recent guidance includes, but is not limited to:

Service user involvement: A guide for drug and alcohol commissioners, providers and service users (2015)

New psychoactive substances (NPS) in prisons – A toolkit for Prison Staff (2016)

Quality governance guidance for local authority commissioners of alcohol and drug services (2015)

Substance misuse services for men who have sex with men involved in chemsex (2015)

Further publications can be found here.
What is working well in Surrey?

Surrey’s Treatment System (Public Health)

Surrey’s specialist CYP’s service consistently perform at a higher than national level with regards to the number of positive discharges from their service. This means that young people are leaving in a planned way and are therefore less likely to re-present into treatment at a later date. Follow-up telephone calls are made with each young person to ensure that they are doing well and young people are encouraged to re-engage should they need to, before hitting crisis point.

Surrey’s adult’s substance misuse treatment system performs well in supporting and working with individuals to leave care planned treatment successfully with no need to return to treatment in the future. Surrey performs within the top quartile for the PHOF outcome 2.15 i/ii/iii ‘Proportion of all in treatment, who successfully completed treatment and did not re-present within 6 months’ in comparison to other Local Authority comparators in the lower end of the top quartile. This is measured by Public Health England, using the Diagnostic Outcomes Monitoring Executive Summary Quarterly report.

The number of individuals seeking support for ‘other drugs’ continues to remain higher than the national level, with a very positive outcome when leaving treatment. We currently commission a service to specifically target this population group which would account for the higher than average numbers in treatment.

For any client who has used Surrey’s treatment system, options are also available to continue to support clients with their recovery journey, including a good coverage of SMART and 12-step fellowship groups across the county, and ‘follow up’ calls after discharge.
Children and Young People: Youth Restorative Intervention (YRI) (Youth Support Service and Surrey Police)

The YRI initiative seeks to improve the experience of the criminal justice system for all: the victim, the offender, their families and the wider community. This is achieved by operating a pre-court disposal and an alternative to the youth caution, the youth conditional caution and prosecution. Outcomes achieved through delivering this service include prevention of re-offending, repairing the harm to victims and improving their satisfaction with the Criminal Justice System (CJS), and to providing better value for money in the youth justice system.

Evidence to date has shown that traditional punitive approaches are more harmful to the well-being of a young person, this intervention recognises the need for an integrated response to address the underlying social, educational, health and welfare needs of vulnerable young people who are entering the criminal justice system. Substance misuse is identified as a risk factor in offending and as a barrier to employability, therefore the substance misuse YRI workers form a core part of the integrated team. Substance misuse YRIs engage the young person to discuss the offence (possession), explore substance use, identify risks/causes for concern and provide a brief intervention (covers legal /health risks).

Evaluation of the service carried out in 2014 concluded that the Surrey YRI was highly effective at reducing first time entrants into criminal justice and the evaluation found that the YRI positively influences reoffending rates with fewer young people presenting with new offences. Surrey saves £3 for every £1 spent on the YRI programme.
Women’s Support Centre (Women in Prison) (Public Health)

The Women’s Support Centre delivers support for women who have complex needs (i.e. mental health support needs, history of sex working, use of substances, history of domestic abuse, involved in the criminal justice system) providing advocacy and promoting successful resettlement, personal development, education, training and employment of women affected by the Criminal Justice System. In 2011 a report from the service showed that substance misuse accounts for the largest percentage of offences (35%). Public Health commission additional capacity for Women’s Support Centre to provide support for women with drug and/or alcohol problems in Surrey, who fall between the gaps of current service provision. These women will be involved in a cycle of offending, imprisonment and exclusion. This additional resource contributes towards reducing the harm that illicit drug and alcohol use causes to the individual, their family and the community.

In 2016 the Women’s Support Centre now sits at the core of the Transforming Women’s Justice Initiative, a partnership programme with the Ministry of Justice, the OPCC, Surrey Police and Surrey County Council. This work will see vulnerable women diverted out of the criminal justice system to tackle the root cause of their offending behaviour.
Recovery Cafés and Recovery groups

Following the success of a Recovery café in Guildford, Recovery Cafes are now being set up and delivered across the county with the support of Surrey’s Treatment services and Peer Mentors. These provide an opportunity for clients to socialise and support each other with their recovery journeys. Many service users report social anxieties and phobias a predominant feature of the cafes is the sense of ‘normality’. Once initial support is provided, by Surrey’s services, to develop these cafes these become peer-led with service users working together to develop new opportunities with one another. This process allows for clients to begin to develop a sense of identity away from their addiction and service provider. Members of the cafes have set up barbecues, clean-up projects, even sit-down meals and days out. There is now also a recovery football team which plays weekly in the Surrey Mental Health League.

The Surrey Springs project has evolved from the Guildford Recovery café and is now peer-led, the project has worked with Guildford Borough council to secure an allotment which is now a regular meet up point for over 10 members. The vision for the allotment is to develop an idea of how businesses can be developed around selling produce. The members of the group are looking to expand to deliver arts and crafts sessions.
High Impact Complex Drinkers Pilot

This one year pilot developed an integrated approach to supporting vulnerable adults who have complex needs and alcohol dependency. The core aim of the pilot was to understand how partner organisations can use their resources more effectively to achieve the greatest impact for these clients. This initially focused on building bridges with partners like A&E, housing support services, substance misuse services and social care. Public Health commissioned two substance misuse workers to deliver outreach for those who find it difficult to engage with substance misuse treatment services, stabilising, motivating and reducing harm in the community. Once this was achieved the community workers had a function to support their client’s access to a variety of support networks or services, including the most clinically appropriate substance misuse service. The cost analysis on the pilot showed an expected 1:4 (£) return on investment for two case workers working with a rolling caseload of 36 clients across a 12 month period.

Further information and future direction can be found in High Impact complex drinkers Pilot Evaluation 2016 and High Impact Complex Drinkers Key Messages and Next steps.

Recommendations for Commissioning

These recommendations do not replace the recommendations of the Substance Misuse Strategy (Part A and B), Recovery Needs Assessment, Housing Review, High Impact Complex Drinkers Pilot Report, but provide overarching recommendations to support the delivery of the specific recommendations found within these documents.
Table 1: Recommendations for key stakeholder from the Substance Misuse Partnership

SCC B+ D CCG’s Police NHSE CJS Providers
Prevention and Early Intervention
Increase and improve the data we have on drug and alcohol use in children and young people
Increase and improve the data we have on drug and alcohol use in priority / hard to reach groups in Surrey (including, BAME, LGBT)
Strengthen pathways between key health and social services and drug services to identify and intervene early in particular with vulnerable children and families.
Building Recovery
Tackle the stigma related to drug misuse, to build supportive communities that facilitate recovery.
This includes visibly championing Recovery through various media channels to improve public and professional perception and reduce stigma
We will use our collective influence to ensure the wider health and social care community provides coordinated support that enables drug and alcohol users to access relevant services to achieve and sustain a drug and alcohol free life and make a positive contribution in their local community.
Ensure our treatment system engages people in treatment and supports them to successfully complete their treatment and recovery journey. This includes offering a treatment system which supports the person holistically and supports family, friends and carers
Improve access to facilities for recovery groups and service provision
Explore opportunities to link Recovery groups into wider health and wellbeing initiatives (i.e. time banking, wellness services and social prescribing).
Develop an Integrated Care Pathway for drugs and alcohol to ensure that people identified with an alcohol or drug problem experience a seamless patient journey and an excellent standard of care.
Ensure that services are culturally appropriate and are actively trying to engage in those from the priority groups outlined in the Chapter.
Safer and supportive communities
We will ensure offenders with substance misuse issues have clear routes into treatment.
Work with criminal justice to better understand the needs of those in the criminal justice system including those who are in Prison, as to improve continuity of care. This includes using the NHS England Needs Assessments, data available to NOMS and CRC
Improving sharing of hospital data to improve community safety
Developing a process so that public health data can be used to improve alcohol licensing
Complex Needs
Work to reduce the barriers faced by those who need to access both Mental Health and Substance Misuse Services. This includes, improved working relationships, training / awareness raising for professionals, joint delivery of services and commissioning of services.
Explore how we better share and improve intelligence to inform our approach and support collaborative working.
Implement a data sharing protocol to allow for joint care planning for vulnerable individuals
Reduce stigma and attitudes of professionals for those who have previously been labelled ‘hard to reach’, ‘treatment resistant’, ‘intentionally homeless’ etc. Build an understanding across the county that these clients can be supported and a sustained (rather than time limited) approach to client engagement reflecting the often slow and faltering pace of change.
Housing
Learning from best practise and neighbouring areas to provide housing for socially excluded groups.
Providing additional support to ensure that individuals can maintain housing / accommodation

Key contacts

Helen Harrison
Acting Consultant in Public Health
h.harrison@surreycc.gov.uk
Consultant Lead for Health Improvement
Smoking, Substance Misuse, MECC
Martyn Munro
Acting Public Health Principal
martyn.munro@surreycc.gov.uk
Commissioning lead: Clinical Services,
Complex Needs including Mental Health
Heather Ryder
Acting Public Health Principal
Heather.ryder@surreycc.gov.uk
Commissioning lead: Criminal justice, Harm reduction, Children and Young people
Marcus Butlin
Public Health Information Analyst
marcus.butlin@surreycc.gov.uk
Treatment data lead
Laura Saunders
Public Health Lead
l.saunders@surreycc.gov.uk
Treatment and Recovery

Chapter references

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Local government’s new public health role
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Signed off by

Surrey substance misuse partnership