Responding to Drug Use - Alcohol and Drug Service - Report to the Scrutiny Panel - Submissions - 17

Scrutiny Panel Report – Alcohol and Drug Service (M. Gafoor, Director) 1.0 Introduction

This report is prepared at the request of the Scrutiny Panel. It examines the implementation by the Alcohol and Drug Service (ADS) of the recommendations of the Imperial College Report (ICR) published in 2001. In particular, the report

addresses the issues outlined in Deputy Dorey's letter dated 15th April 2004 and in its preparation, data was obtained from various sources including:

- The Alcohol and Drug Service

- The Jersey Crime Survey

- Criminal Justice Review

- Health Related Behaviour Questionnaire (HRBQ)

1. Service Profile

The ADS is a statutory community based service for substance misusers and their relatives funded by Health and Social Services and the States' Substance Misuse Strategy. The service is staffed by a team of 10 and includes the Director, nurses, part- time counsellor, needle-exchange worker, arrest referral worker and administrative staff. Additionally, Dr Sharkey (Consultant Psychiatrist) and his trainee provide a half-day session each week and GP Dr Marks attends three times weekly. The service receives between 550 and 600 referrals a year and of these, a third is for drugs with a male/female ratio of 2:1.

2. The ADS: aims to provide a high quality and comprehensive specialist service to individuals with drug and alcohol related problems in order to minimise the physical, social and psychological harms caused by their substance misuse. It adopts a harm reduction philosophy based on the premise that some people will continue to use substances despite the risks involved. Hence an approach that first limits the harm whilst encouraging abstinence is viewed as pragmatic and achievable.
3. Service Provision

The ADS provides the following treatment and interventions:

- Methadone/Subutex reduction programmes

- Needle Exchange Scheme

- Community/hospital detoxifications

- Individual/Group counselling

- Family support, information and advice

- Medical health care (Hepatitis B vaccines, Hepatitis C and HIV tests)

- Training and Education to professional groups, voluntary agencies and schools.

0. Current trends of heroin use, injecting drug use and patterns of illegal drugs used in the Island
1. The ICR estimated there were 780 heroin users in Jersey in 2001 of whom 530 (67%) may have been injectors. The research also found that in a sample of 110 heroin users, 91% admitted sharing injecting paraphernalia with an average of 4 people in the last month. The high rate of injecting among Jersey drug users has been attributed to the costs of heroin in the Island and the need to maximise drug effects. The average retail price for a gram of heroin is between £200 and £250 compared to £50-£60 in the UK. As a consequence, heroin addicts in Jersey tend to have smaller habits' of between ¼ - ½ gram a day as opposed to their UK counterparts with an average daily use of 1-2 grams. In terms of other illegal drugs, cannabis and Ecstasy are easily available and although anecdotal reports suggest that cocaine use is becoming popular, this has not been borne out from drug-screens carried out on clients attending the ADS. Prescribed drugs such as valium and dihydrocodeine are commonly abused by heroin addicts either to alleviate heroin withdrawal symptoms or to enhance the drug's effects. One tablet of each drug can be purchased illicitly for 50p and £1 respectively and is invariably taken orally unlike parts of Scotland where tablets are crushed and injected with dire consequences. There is some evidence that over-the counter drugs such as Neurofen plus and cough mixtures are abused by some drug users. Given the strict controls of the Island's Methadone programme, there is little black- market' methadone available in Jersey although this drug has been brought into the Island from Thailand on a few occasions. In the UK, methadone can be easily bought on the streets and retails at £10 per 500 mls.
   2. Comment

Since 2001, there has been an average of 50 new heroin referrals a year made to the ADS and the overall number of opiate referrals has remained at around 148. In addition, the price of heroin has stayed the same and analyses from the States Laboratory have shown a reduction in the drug's purity. It is therefore reasonable to assume that the prevalence of drug use in Jersey has not increased. Also, with around 150 more heroin users entering treatment since the ICR's publication, 68.7% of the Island's opiate users are now in contact with services compared to 50% in 2001. It is worth noting that in the UK, research estimates that only 1 in 5 heroin addicts are in touch with treatment ( Hart noll et al, 1985).

In respect of prescribed drugs, data from Social Security has shown a substantial reduction in the availability of dihydrocodeine tablets and a downturn in the number of benzodiazepines prescribed.

0. Impact of the work of the Needle Exchange Worker/extent of drug-related harm, illness and death in the Island.
   1. In responding to the ICR's recommendations on the need to expand the provision of sterile injecting equipment, Health and Social Services appointed a needle exchange worker in early 2002. Prior to the worker's appointment, it was estimated that the annual number of clean syringes provided by four outlets were around 40,000. Additionally, the incidence of Hep C among drug users in Jersey was 50% and 20% of the Island's recorded HIV cases were found to be injecting drug users. According to statistics provided by the States of Jersey Coroner, there have been 30 opiate related deaths over the past decade with the highest number of deaths occurring in 2000 (6) and the lowest in 2003 (2). In comparison with other jurisdictions, heroin deaths in the UK rose by a one third to 557 or 43% of the 1296 drug related deaths in 2000 than in the previous year (Home Office 2002). In Australia, the incidence of opiate related deaths increased by 180% between 1981 and 1990.
   2. Comment

Since the appointment of the needle exchange worker, injecting equipment is now available from eight outlets including the ADS. Hence in 2002, around 68, 260 needles and syringes were distributed representing a 70% increase than in 2000. From a clinical perspective, it is significant that the take up of needles and syringes (approx 60,025) was less in 2003 despite increased access and availability. It is argued that this reduction relates to the fact that 44 new drug users entered treatment last year resulting in a decrease of the overall pool of drug injectors in the Island. More importantly, a recent evaluation of the scheme showed needle-sharing rates fell by one third to 60% during this period (De la Haye 2004). Additionally, a health needs analysis of prisoners in La Moye Prison indicated that 33% admitted sharing needles in the six weeks prior imprisonment (Dr Wool, 2003). I would note that the needle exchange worker provides harm reduction sessions to in mates.

In addition to her role of increasing the availability and returns of injecting equipment, the worker provides overdose prevention training to all drug users presenting for treatment. She also monitors the incidence of overdoses by liaising closely with agencies such as A&E, Ambulance department, States laboratory as well as taking account of clients' reports. The presence of more than two indicators triggers an early warning system to both clients and agencies. GP's are notified through a cascade system and are reminded to carry Narcan (a drug that that reverses the effects of opiates) that can be obtained from the ADS. Drug users are informed that an emergency call for an ambulance does not automatically warrant involvement of the Police, as was the previous policy.

Thus overall, I consider that the role of the needle exchange worker has made a significant contribution in both the prevention and minimisation of drug related harm in Jersey.

0. Current prevalence of infectious diseases such as HIV, HBV and HCV
1. The ICR reported that one in five of the Island's recorded 62 cases of HIV and one in two of all HCV cases were found in injecting drug users. In 2002, Dr Marks tested forty drug users attending the ADS for Hepatitis C and found twenty (50%) were positive to the virus. During the same year, Dr Muscat tested 47 in mates at La Moye prison of whom 16 (34%) were positive for Hep C and 1 (2%) for Hep B. There were 21 new cases of Hep C and 1 new case of Hep B reported last year compared to 42 and 2 cases respectively in 2001. Throughout this period, the ADS encouraged 44 drug users to receive Hep B vaccinations. In terms of HIV prevalence, 19 out of a total of 85 HIV (22%) cases to date are thought to be injecting drug users. There was only one recorded case last year and none in the previous year. More detailed prevalence data on infectious diseases can be obtained from Dr Muscat.
2. Comment

The ICR states in 2001 "without action, there is the risk that HIV and Hepatitis C could quickly spread among Jersey's injecting drug users". The above statistics clearly show a decrease in the number of new drug users who have acquired these diseases confirming the effectiveness of the subsequent harm reduction initiatives.

0. Assessment of the cost effectiveness of current harm reduction programmes.
1. Methadone Programme – was established in 1998 and has a current annual budget of £130k. Since its inception, the programme has treated 347 clients of whom, one third completed at their first attempt. Of the remaining two thirds attending the programme more than once, the majority reported improvement in their health, social functioning as well as a reduction in drug use and offending. Such outcomes are vastly superior to the UK where research has shown only 17% of clients on Methadone programmes successfully completed treatment (Gossop et al, 1986).

2. Subutex – a relatively new drug used in the treatment of opiate addicts, was introduced by the ADS following a successful pilot. The drug can be taken on alternate days and offers another treatment option for clients who are unable to tolerate methadone or attend the chemist daily due to work commitments. It also blocks the effects of heroin at higher doses thereby minimising the risks of overdosing. In 2003, 45 clients received Subutex treatment. Of these, 42% (19) successfully detoxed and of the remaining 26, 2 dropped out, 3 relapsed on heroin, 4 were arrested, 8 returned on the methadone programme and 9 were un-contactable. In light of such positive outcomes, funding for Subutex has been approved in Building a Safer Society' strategy.
3. Needle Exchange Programme - costs £45k annually, of which £35k is staff costs and £10k for equipment. The effectiveness of the scheme has been stated above.
4. Community Detoxifications

In 2002, the ADS completed 111 community detoxes, 43 (39%) for alcohol and 68 (61%) for opiates. Of the total numbers detoxed, 15(13%) failed to complete, one died of an accidental overdose and one died during the course of the year. Twenty-five (22%) did not return, twenty-two (20%) relapsed shortly afterwards and forty-seven (42%) enjoyed some degree of abstinence or were still abstinent at the end of 2002. During 2003, the service completed 114 detoxes of which 47 (41%) were for alcohol and 70 (59%) for opiates.

5. Court Liaison Officer (£40k) – was appointed in 2000 with the aim of diverting substance misusers away from the criminal justice system into treatment. During 2003, a total of 85 reports were prepared for the Magistrate's Court and of the fifty-six (67%) treatment orders issued, 45 clients (80%) successfully completed. Research from the Home Office shows that the completion rate for treatment orders in the UK to be 30% (Home Office 2002).
6. ADS - Between 2000 -2002, the ADS received 1,782 referrals of which 941 (52%) were alcohol related and 627 (35%) drug related. The service also saw 57 relatives (3.1%) for advice and information and 157 young people (8.8%) for drug and alcohol education awareness during this period following referrals from Centeniers. Each worker has a caseload of around 58 clients and the average waiting time for treatment is 2-3 weeks compared to 4.6 - 9.1 weeks in the UK (NTA stats available if required). Home Office research states that for every £1 spent on treatment, the Criminal Justice System saves £3.

0. The role of law enforcement agencies and the introduction of the arrest referral scheme.
   1. The use of illegal drugs and the problematic use of legal substances is a major component of the work of the criminal justice system. Indeed, the majority of police work is concerned with either the consequences of the misuse of alcohol or illegal drug use. Thus, the partnership between the criminal justice agencies and the ADS is a critical one. Over the past three years, significant progress has been made in terms of moving away from mandatory custodial sentences, towards non-custodial sentences and treatment programmes for drug users. It is stressed that this diversion policy is only appropriate for those individuals whose offences are directly attributed to their addiction rather than those who are trafficking in drugs for profit.
   2. The ADS has worked closely with the prison authorities in developing counselling and harm reduction initiatives for in mates with substance misuse problems. In particular, a member of the team attends the prison once a week to undertake assessments and counselling as well as to facilitate offenders in engaging with the ADS upon release.
   3. Arrest referral schemes have been in existence in the UK since 1999 and their effectiveness in breaking the cycle of drug related crime by getting drug users into treatment is well documented. The Jersey Arrest Referral scheme was established as an eighteen-month pilot in May 2003 through a joint initiative with the ADS and the police and became operational last September. By visiting people at the time of arrest when they are faced with the consequences of their drug or alcohol misuse, the worker capitalises on a window' of opportunity and encourages them to enter treatment programmes.
   4. Since in post, the Arrest Referral worker has completed 81 assessments of which 46 were for alcohol and 35 drug-related. Of these, 40 clients have entered treatment, an uptake of 50 % compared to 25% in the UK (Home Office 2003).

0. Development of support systems for problem drug users through welfare agencies, drug education and harm reduction initiatives.
1. It is widely recognised that no single agency can by itself effectively deal with the wider social issues commonly associated with problematic drug use such as housing, unemployment and educational problems. The ADS has in recent years, developed close working relationships with a range of statutory and voluntary agencies. In addition to its work with substance misusers, the service has taken a lead role in the following projects:

- Setting up a harm reduction group for drug users at St Paul's centre

and La Moye Prison

- In conjunction with the Health Promotion Department, developed

Sharpshooters – a magazine that informs drug injectors about safe

Injecting techniques and minimising drug-related harms

- Providing drugs education to young people as requested by

Minden Base, Brooks Advisory Service, St Mark's hostel and

Secondary schools

- Developing a web-site for young people that disseminates harm

reduction messages

- Setting up a detoxification service for homeless substance misusers

with the Shelter and other homeless agencies

- Contributing towards a homeless forum organised by the Housing

Department.

0. Progress in co-ordinating and combining data sources in order to strengthen the evidence base.
1. The ADS has an established database that records demographic information, nature and patterns of substance misuse as well as outcomes.
2. Doctors are legally obliged to notify the Medical Officer of Health of patients who are addicted to drugs. A notification list is circulated to GP's, hospital doctors and dentists twice yearly in order to avoid double scripting'.

3. Data on prescribed drugs of abuse are routinely monitored by the Department of Social Security and the Drug Dependency Committee currently chaired by the Director of the ADS, addresses unusual prescribing patterns.
4. The prevalence of legal and illegal drug use among young people is monitored bi- yearly through the HRBQ.
5. The Prison Health Care staff now routinely records substance misuse information on a database funded by the Substance Misuse Strategy.
6. Comment

Despite considerable efforts to establish a central substance misuse database within the Island recommended by the ICR, it was not possible to find a company that could develop a data-base compatible to the systems used by local GP's and Health and Social Services. It was subsequently felt that the investment of public funds in a stand- alone data base was inappropriate. However, the methods cited above demonstrate a more systematic and co-ordinated approach towards data collection than previously. It is envisaged that a comprehensive data base for substance misusers will be developed alongside the proposed Health and Social Services integrated computer system.

0. The views of clients' both drug users themselves and their relatives, on the effectiveness of the service and ways it might be improved.
1. The ADS regularly seeks the views of clients through the use of anonymous self- completion questionnaires and the Director has encouraged service users to contact him with ideas on how the service might be improved.
2. In 2003, the ADS circulated anonymous questionnaires to 68 clients and of the 45 (66%) who responded, 43 (95.6 %) were very satisfied with their key worker and 84% with the service.
3. Asked how the service might be improved, 19 clients (42%) responded with the following comments:

- 8% wanted a more flexible Methadone programme whilst 12% thought it should be stricter.

- 23% felt that the service should offer out of office hours cover

- 7.5% felt the service was unfair and not very good

- 22% wanted take-away' doses and Dihydrocodeine prescribing.

10.0. Summary

Since the publication of the Imperial College Report three years ago, the Alcohol and Drug Service has played a major role in implementing the report's findings. It has expanded the provision of treatment and needle exchange services as well as creating opportunities for getting substance-misusing offenders into treatment from arrest to sentence. A key feature of the service lies in its flexibility of response and ability to both attract and retain clients in treatment. As highlighted in this report, the ADS have demonstrated its effectiveness in providing evidenced based interventions and responding to local needs. In addition to its clinical role, the service contributes to a range of education and prevention initiatives for young people. It is worth noting that the use of heroin, cocaine and Ecstasy in year 8 and 10 pupils has reduced significantly since 2000 (HRBQ, 2002). The reduction in needle sharing, drug related deaths and acquisitive crime thus far is also encouraging.

In conclusion, whilst this report has focused on drug-related harm in view of the information requested by the Shadow Scrutiny Panel, the problems caused by legal drugs such as tobacco and alcohol have not been ignored. Members of the panel will be aware that the States approved the Tobacco Strategy last year and the Island's Alcohol Strategy incorporating a range of fiscal, legal and public health measures will shortly be debated.

Finally, I would note that the projects outlined in the recently approved Crime and Drugs Strategy will further contribute towards minimising the harms caused by crime, anti-social behaviour and substance misuse.

Michael Gafoor

Director, Alcohol & Drug Service (28. 05.04).

References

1. Del La Haye, K (2004) Evaluation of Jersey's Needle Exchange Scheme using

anonymous self-completion questionnaires.

2. Gossop M, et al (1986) Opiate withdrawal: In-patient versus out-patient programmes and preferred versus random assignment to treatment. British Medical Journal, 293:104-4.
3. Hart noll R, et al (1985) Estimating the prevalence of opiod dependence. The Lancet, 1:203-205.
4. Home Office (2002) Arrest Referral: emerging findings from the national monitoring and evaluation programme., paper 18 DPAS/p18
5. Wool R.(2003) Health Needs Analysis, HMP La Moye, Jersey.