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Responding to drug use in Jersey Scrutiny Panel Report
Response from Health and Social Services
Ian Dyer, Adult Mental Health Service
Scrutiny Panel Report – Ian Dyer, Adult Mental Health Service
Introduction
This report has been compiled at the request of Mr Mike Haden, Lead Officer, Review of Provision of Problem Drug Users, Scrutiny Office, asking for my observations on the
addiction treatment services currently available in the island and
the way the service might develop in the future.
It incorporates responses from Mr Ian Dyer, Manager of Adult Mental Health Service whilst also coordinating responses from other areas of Health and Social Services.
The Scrutiny Panel should be aware that I am not a specialist alcohol and drug worker but have, throughout my professional career as a Mental Health Nurse and Cognitive Behaviour Therapist, worked with a number of people who have alcohol and drug related problems. Furthermore, a number of treatment options available are not specifically for people using illicit substances and should be read in context of those also receiving treatment for alcohol misuse.
Part 1 Current Treatment Options Available Definition of treatment
Firstly, at risk of sounding pedantic, we need to establish what the working definition of treatment of people with addictions is. It is in itself a complex area and differing professionals will have alternative views and opinions on how treatment should be defined. To put this into context, currently England and Wales are reviewing their mental health legislation and within their draft Mental Health Law the definition of treatment has caused much debate from within mental health professionals, the legal system, mental health charities and from service users. However, for this exercise I feel it would be useful to use the proposed definition of treatment within the English and Welsh draft mental health bill 2002. The definition reads:
"Medical treatment" means treatment for mental disorder provided under the supervision of an approved clinician; and for the purpose of "treatment" includes:-
- Nursing;
- Care;
- Habilitation (including education, and training in work, social and independent living skills); and
- Rehabilitation (read in accordance with paragraph (c)).
Identification and appropriate referral of those with substance misuse problems.
The alcohol harm reduction strategy for England (2004) states ". problems are not always identified and appropriate referral or treatment does not always occur".
Although this statement relates to alcohol misuse in England, I believe it is transferable to Jersey in relation to both alcohol and drug problems. Often substance misuse is not identified until latter stages of the problem and, once identified, the appropriate treatment option is not always sought. During my six years in Jersey I have been encouraged that identification and appropriate options have improved, through such initiatives as the community forensic mental health team, court liaison officer, alcohol and drug arrest referral worker and the increase in the adult social services team. However, these are effectively all secondary services. It can be argued that the place to identify problems is within ones home, workplace or social environment. The Jersey Health Promotion Unit do tackle some of these issues but ownership and responsibility of substance misuse needs to become everyone's issue. An analogy can be made with physical ill health, very few friends or family would watch a friend or loved one suffering with a chest infection without at least encouraging them to visit their doctor. This is not always the case when we become aware of someone suffering from substance misuse problems.
Current Treatments
It is useful to identify a treatment system and to this aim a four tier system has been identified (Models of Care 2002). Each tier identifies treatment options and from where the treatment should be delivered. The aim is for those experiencing substance misuse problems, once identified, to receive treatment within the appropriate tier according to individual need.
Tier 1 "Non-substance misuse specialist services are general health, social care and
criminal justice services accessed by substance misusers and includes referral to and from specialist services".
Local Provision.
Current local services within this tier are services provided by G.P.'s ranging from brief interventions to medical detox. The Health Promotion Unit provides information and education, examples of which include "The Mental Health resource directory" published June, 2004, "Substance" magazine, published in 2001 which is aimed at young people aged 16+. This magazine focuses on harm reduction, information, risks and first aid relating to substance abuse. The health promotion unit also provide sexual health advice. The Brook Centre offer free confidential contraceptive and counselling services for under 25s.
Other services offering information and advice include the schools educational counselling and psychology service, and Minden Base. Jersey FOCUS on mental health offer housing and advocacy and Jersey Council on Alcoholism provide housing and support. The shelter trust provides accommodation, support and counselling.
Services designed for children and young people include the Children's service and Child and Adolescent Mental Health service, both of whom will come in to contact with young people who abuse substances, and are able to offer some treatment interventions.
Probation service's locally work closely with the Alcohol and drug service and the Adult Mental Health service. The court liaison officer is a joint appointment working between the A&D service and probation. The aim is to identify people in the magistrate's court who have substance misuse problems and to either encourage voluntary access to services or, on occasions, to work with individuals through treatment orders. The AMH forensic team provide 2 sessions a week of nurse specialist time to the probation service for those clients who have a foot in both services. This may include someone with a dual diagnosis of a mental health problem and a substance misuse problem.
Vaccination and communicable diseases are provided from the microbiology service based at the general hospital. This service provides screening and treatment for people with diseases such as Hepatitis or HIV. The microbiologist visits the prison on a monthly basis providing treatment screening and pre and post screening counselling to inmates.
The accident and emergency department at the general hospital may identify someone with a substance misuse problem and can make direct referrals to the A&D service. For the past eighteen months the Adult Mental Health Service has been providing an A&E liaison service aimed at identifying those who attend A&E who have mental health problems. A number of these clients may also have substance misuse issues and will be referred to the A&D service. (See below for
more details relating to A&E)
The adult mental health service in conjunction with the occupational therapy service provides vocational opportunities. These include the job scope service at Chez Marguerite where referrals can be made for assessment of vocational ability and support into appropriate employment. The organic farm, run by the AMH service, also offer a number of people with substance misuse problems the opportunity of employment.
The Shelter Trust provides an outreach service for rough sleepers, many of whom have substance misuse problems. The majority of full time staff at the shelter have completed the alcohol and drug counselling certificate which is accredited to the university of London.
Alcoholics anonymous provide a number of groups throughout the Island for people wishing to recover from alcohol related problems.
Tier 2 "Open access substance misuse services are low threshold specialist services
that facilitate engagement with treatment services. They are less structured then tier 3 and 4 services".
Local Provision.
Tier 2 includes advice and information from the specialist alcohol and drug service. The main philosophy of this service is to provide a harm reduction service. A duty counsellor provides a drop in service Monday to Friday. The clinical team from within the A&D service provide brief interventions and are skilled in motivational interviewing techniques.
Since 2002 a needle exchange worker has been appointed and offers intravenous drug users the opportunity to obtain sterile needles and syringes to reduce the likelihood of spread of infection.
Low threshold prescribing is offered from the alcohol and drug service. This may take the form of a community alcohol and drug detox and is carried out in conjunction with a GP who provides a service to the A&D team.
Outreach services include, for example, an alcohol and drug worker providing a weekly clinic to the shelter trust residents; this allows them to discuss, in confidence, any substance misuse issues they may have. A similar service is provided to the shelter trust by a mental health professional; often the cross over of mental health issues and substance misuse can be identified at these clinics. Both clinics are self referral / drop in clinics.
Tier 3 "Structured community based substance misuse service. This tier aims to
provide treatment solely for substance misusers in a structured programme of care. Substance misusers attending these services will have agreed to a structured programme of care, which places certain requirements on attendance and behaviour. In addition to care management, treatment packages for clients with multiple needs will be co-ordinated by a care co-ordinator on behalf of all agencies and services involved".
Local Provision.
The alcohol and drug service offer structured counselling and therapeutic interventions to people with longer term substance misuse problems. They are able to refer on to the psychology service for specific treatment interventions or for clients who have more complex needs. The probation service, through the court liaison officer, offer specific treatment packages for substance abusers who have had contact with the criminal justice system.
Community based detoxification services are offered through the alcohol and drug service. This includes working with the GP or the consultant psychiatrist with a specialist responsibility to the A&D service. The nursing team within the A&D service will carry out initial assessment and implement the treatment package with clinical support and prescribing. They will then monitor the detox to ensure risks are kept to a minimum.
The methadone programme is managed from the A&D service. It aims to substitute illicit opiate use and then gradually reduce the dependence on methadone. Subutex is a newer alternative to methadone which has been successfully piloted locally and has become a treatment option in reducing the risk of opiate use.
The A&D service provides some structured aftercare for those who have completed a period of active treatment. There is also the facility of referring those people who are keen to remain abstinent to the Jersey Addiction Group.
Tier 4a "Residential substance misuse specific services include inpatient substance
misuse treatment, including inpatient detoxification, residential rehabilitation and specialist residential crisis intervention centres. They are usually abstinence- orientated programmes, which require the substance misusers to stop taking drugs either before entry or as part of a planned residential detoxification programme".
Local Provision.
The AMH service acute inpatient wards offer a hospital detoxification service. These are normally planned admissions in conjunction with the A&DS. On average the AMH service completes two in-patient detox a week. If the physical health of the client is assessed at being a high risk admission can be arranged within a medical unit at the general hospital.
Silkworth Lodge offers residential rehabilitation using the 12 step abstinence model of care. This service has demonstrated its ability and quality in providing abstinence based model of care and the ongoing audit suggests a growing evidence base for its efficacy.
Although we do not have a specific crisis management service for substance misusers within Jersey there are options available dependant on the risk assessment. The Shelter Trust provide a drunk and incapable unit at their Kensington Place accommodation. This can be accessed by the Police or from within the shelters and offers a safe environment for intoxicated individuals to recover. For someone who is identified as being at risk of self harm or experiencing acute mental health problems, they can be assessed at the A&E department and if appropriate the crisis will be managed within the acute mental health in-patient wards. For people who self harm due to intoxication assessment and treatment will be offered by the general hospital and an assessment from the mental health team can be requested. The AHS are currently piloting a nurse lead psychiatric liaison service at the general hospital.
We do not offer a specific mother and child substance misuse services. However, our generic services which include children's social services, child and adolescent mental health services and the community perinatal mental health nurse will at times come into contact with mothers who have substance misuse problems. The alcohol and drug service provide training to the course run by the perinatal mental health nurse and delivered to midwives and health visitors.
Tier 4b "Highly specialised non-substance misuse specific services will have close links
with services in other tiers, but are (like tier 1) non-substance misuse specific. Tier 4b services are not substance misuse specialist services, but generally, a substantial proportion of their patients/clients are substance misusers. Many of these services tackle substance misuse related harm. These services include specialist liver disease units, specialist HIV units, vein clinics, forensic psychiatry services, specialist personality disorder or eating disorder units and so forth".
Local Provision.
The microbiology service provides specialist treatment for people with liver disease and HIV. If someone needs treatment off Island we work with Southampton in relation to Hepatitis C, with between six to ten referrals annually; and for HIV specialist treatment Guys and St Thomas's hospital is referred to, approximately 2 – 3 referrals are made each year. It should be noted that not all those treated locally or referred to specialist off Island centres have developed hepatitis or HIV from illicit drug use.
The community forensic mental health team provide input to the prison, probation service, courts and police for anyone who has or needs assessment for a mental health problem and who has been in contact with the criminal justice system. We currently have a small number of people receiving treatment in specialist secure mental health units in England. Our forensic team are actively involved in their treatment planning and assessing for treatment outcomes and risk management. The majority of service users who have received secure care in England have a dual diagnosis of mental disorder and substance misuse problems. We offer treatment for people with personality disorder through the forensic team. On rare occasions we will refer people to specialist personality disorder units in England.
Within the AMH service we have a community eating disorder team. They offer treatment and support for people with a primary diagnosis of anorexia nervosa or bulimia nervosa. A small amount of this client group may also experience difficulties with substance abuse issues.
HMP La Moye provide a detox service for any inmate who is assessed as being alcohol or drug dependant. They currently employ a substance misuse counsellor who offers counselling and education to the inmates. The A&DS provide some sessional input for prisoners nearing their release date.
Ambulance Over the last few years the Ambulance Service have identified a slight increase in Service drug related incidents, mostly involving heroin. However, it is generally felt that this is not due to any significant increase in the use of heroin but more likely due
to better relationship between the service and the drug community, who now see the service as a non-threatening point of help if they find themselves or a friend in trouble. Narcan, the antagonist to opiates which rapidly reverses the effects of an overdose even in those who's vital signs are poor, was introduced to the service in November 1999. At that time the service and the then Director of the A&D service worked hard to gain the confidence of the opiate using community encouraging them, when appropriate, to call the Ambulance service in the knowledge that the contact would be treated in confidence.
Alcohol continues to be the biggest challenge for the service and the original comments contained in the Imperial College report hold good insofar that at least 60% of work after 22-00hrs and before 07-00 is drink related. Unfortunately we do not collect these figures as part of our management information, but having spoken to ambulance personnel there is sufficient anecdotal evidence to support this. Some staff felt that the percentage could be even higher particularly at the weekends. The affect on the Service range from assaults on licensed premises or in the home, self harm, accidental injury and alcohol related illnesses i.e. fits. The service works closely with the Shelter Trust staff in Kensington Place as and with our colleagues in Police.
The table below give a breakdown of drug related call outs during 2003 Calls to heroin overdose 8
Narcan used 7
To hospital 3
To mortuary 3
Refused treatment/transport 3
Total calls for OD poisoning 215
(featuring any type of drug,
prescribed or legal, including the
above)
Total number of patients 171
transported to hospital
Accident & The accident and emergency service saw 268 people for overdose related Emergency incidents in 2003. This number includes all overdoses such as accidental
poisoning, deliberate self harm, attempted suicide, alcohol intoxication and overdose of both prescribed and non-prescribed drugs.
The psychiatric A&E liaison service recently completed an audit of assessments they carried out in A&E. The audit covered 2003 and the presenting problems ranged from depression, anxiety, alcohol/drug intoxication, self-harm, suicidal intent, low mood and alcohol, self-harm and alcohol, schizophrenia, bipolar disorder, personality disorder and learning disability. Below lists the numbers and gender of the alcohol and drug related assessments:
Presenting Problem Male Female
Alcohol and Drug intoxication 18 3 Low mood and alcohol 17 19 Self-harm and alcohol 10 27
These figures may not be exhaustive of all alcohol and drug related assessments as those presenting with schizophrenia, for example, may have had a secondary alcohol or drug related problem.
During 2003 the A&E liaison mental health nursing team assessed 256 people, all of whom were offered follow-up appointments with at least one of the services described below.
Follow-up service offered Numbers Liaison mental health nurse 31
Community psychiatric nurse 85 Forensic psychiatric nurse 15 Alcohol and drug service 80 Psychiatric out-patient appointment 26 Psychiatric social worker 25 Eating disorders team 16 GP 21 Other 12 Psychiatric in-patient admission 45
The numbers described above cover only those people who attended the A&E department and were specifically assessed for alcohol, drug or mental health problems, they do not contain figures for those who attended with alcohol or drug related illness or injury, these figures are not available.
Part 2 The way the services may develop
During November 2003 the A&DS came under the management of the manager of AMH. It became apparent that although a lot of good work is being achieved and a vast remit of local services are available to people with substance misuse problems (see above) more needs to be done to provide better coordination and improve pathways into and out of specific services. In collaboration with Mr Ian Rodgers, JAG, a draft paper was prepared identifying and standardising integrated care pathways. More recently the Director of the Alcohol and Drug service has taken a lead with Ian Rodgers to further develop the pathways document. Key stakeholders have will be approached for their input and support with this piece of work.
An area of need that has also been identified by the Community and Social Services management team is for those people who have long term problems due to excessive and prolonged substance misuse. Due to their cognitive functioning residential support is often required and yet the traditional suppliers of residential care find this client group challenging to manage. The proven local specialists in this field are the shelter trust. It is to this aim that the Manager of the Adult Mental Health Service has had preliminary discussions with the Manager of the Shelter Trust.
Earlier this year a prison health needs analysis was published. This piece of work was a multi agency collaboration chaired by the Manager of Adult Mental Health and carried out by Dr Rosemary Wool, former Head of Prison Medical Directorate in England and Wales and current advisor to the Council of Europe. Within her recommendations she identified the need for the prison to prepare a substance misuse strategy and a health promotion strategy. A working group will review all the recommendations and report back to respective committees.
Part 3 Financial Implications of substance misuse to Jerseys
The Imperial College report "responding to drug and alcohol use in Jersey" (2001), identifies the local challenges relating to alcohol and drug use. However, it does not identify the cost to society and it is extremely difficult to place a realistic cost to the health and social services of the Island due to substance misuse. The recent publication "Alcohol Harm Reduction Strategy for England", from the cabinet office (2004) attempts to estimate the financial cost to society in relation to alcohol misuse. It states:
"The strategy units interim analysis estimated that alcohol misuse is now
costing around £20bn a year."
"This is made up of alcohol related health disorders and disease, crime and anti-social behaviour , loss of productivity in the workplace, and problems for those who misuse alcohol and their families, including domestic violence."
It further state:
"The annual cost of alcohol misuse includes:
- 12.m violent incidents (around half of all violent crimes);
- 360,000 incidents of domestic violence (around a third) which are linked to alcohol misuse;
- increased anti-social behaviour and fear of crime – 61% of the population perceive alcohol related violence is worsening;
- expenditure of £95m on specialist alcohol treatment;
- over 30,000 hospital admissions for alcohol dependence syndrome;
- up to 22,000 premature deaths per annum;
- at peak times, up to 70% of all admissions to accident and emergency departments;
- up to 1000 suicides;
- up to 17m working days lost through alcohol-related absence;
- between 780,000 and 1.3m children affected by parental alcohol problems; and
- increased divorce– marriages where there are alcohol problems are twice as likely to end in divorce."
In 2002 the Home Office research, development and statistical directorate published "The economic and social costs of class A drug use in England and Wales, 2000". This document identifies three categories of class A drug users:
Young recreational users – defined as those taking Class A drugs aged under 25 but not in the problem user group;
Older regular users – defined as those regularly taking Class A drugs aged 25 or over but not in the problem user group; and
Problem users – users of any age whose drug use is no longer controlled or undertaken for recreational purposes and where drugs have become a more essential element of the individual's life.
The paper identifies six different groups who may bear the costs of drug use. Group – Bearer of Costs Examples of costs
Users Premature death
Loss of quality of life – mental physical health; relationships etc.
Impact on educational achievement, training opportunities etc.
Excess unemployment and loss of lifetime earnings
Families/carers Impact on children of drug users'
dependants
Transmission of infection
Intergeneration impact on drug use
Financial problems
Concern/worry for users
Caring for drug users and drug users dependants
Other individuals directly affected
Wider community effects Industry
Public sector
Victims of drug driving; drug related violence; drug related crime.
Transmission of infections from drug use.
Fear of crime
Environmental aspects of drug markets – needles, effects of drug dealing in the community.
Sickness absence
Theft in the workplace
Security expenditure to prevent drug related crime
Productivity losses
Impact of illicit markets on legitimate markets.
Health care expenditure
Criminal justice expenditure
Social care services
Social security benefits
The study then attempts to estimate the economic and social costs of Class A drug misuse from each of the three identified groups. Its summary states:
"A total of £6 million a year health service and criminal justice costs was associated with young recreational users. This translates to a cost of £7.75 to £15 per user depending on whether the lower or higher estimate of the number of young recreational users is used (lowest estimate 399,000 – highest estimate 798,000). Total social costs for this group was estimated at £28.8 million a year, a cost per user between £36 and £72. These social costs include an estimate of the full costs of premature deaths from ecstasy use. Older regular users were estimated to cost around £6.3 million each year, a cost per user between £3 and £6 (1,091,000 lowest estimate – 2,182,000 highest estimate of users in this group). Estimates for young recreational and older regular users exclude any allowance for productivity effects and effects from driving and drug taking".
"For problem drug users, total economic costs range from £2.9bn to £5.3bn, based on low to high estimates of the number of problem drug users (the medium estimate is £3.5bn) - £10,402 per user per annum. Total economic and social costs for this group increase the range of figures to between £10.1bn and £17.4bn - £35,455 per user per annum. Problem drug users account for almost all economic and social costs (99%), and drug-related crime accounts for around 88 per cent of total economic and social costs".
By using the same estimates of total economic costs along with the mean numbers of each of the three users groups we can provide a rough estimate of local cost. The estimated number of Class A drug users in Jersey would equate to 3,050 (estimated number of Class A drug users in England and Wales, divided by population of 52 million = 3.51%. 3.51 % of Jerseys population of 87,000 = 3,050). Of the 3,050 Class A drug users in Jersey 702 (23%) would fall into the category of young recreational users with an estimated annual cost of £65.75 per person, an annual total of £46,156. 1,952 (64%) would be classified as older regular users costing an estimated £6 per person, an annual cost of £11,712. The remaining 396 (13%) of problem users would be costing £35,455 per user per annum in total economic cost. This equates to an annual cost to the Island of £14 million.
It must be stressed that the figures for Jersey are a rough estimation based on the percentage of population of Class A drug users in England and Wales, and directly comparing the equivalent percentage to the Jersey population. This is based on the assumption that the figures estimated in England and Wales in relation to class A drug users can be directly assimilated to Jersey by percentage.
By using the same assumption we can attempt to identify the cost to the Island of alcohol misuse. The estimated total economic cost to England through alcohol misuse is £20 billion per year. By dividing this number with the population of England (46 million) the cost per person equates to £434.80 per annum. By multiplying the population of Jersey (87,000) by the £434.80 we can estimate the total cost of alcohol misuse to the Island at £37.8 million.
Conclusion
It is a difficult and complex task when trying to place figures on the cost to society of substance misuse. How accurate the above figures are will be open to interpretation, what can not be doubted is the fact that substance misuse is costly.
Within Jersey, statuary and voluntary services provide a wide and comprehensive number of treatment services. Whilst completing this paper it was pleasing to identify the majority of national recommendations within each of the service tiers are being provided in some form locally. Obviously some of the more specialist services have to be accessed off Island due to economies of scale. However, there is a need to improve the coordination of services and this piece of work is underway.
The majority of money related to substance misuse is geared towards providing reactive services. It could be argued that the best way to tackle the issues of substance misuse is through investment into proactive interventions.
References
Cabinet Office. (2004); alcohol harm reduction strategy for England. www.strategy.gov.uk Department of Health. (2002); Models of Care for substance misuse treatment. www.doh.gov.uk/nta
Home Office Research, Development and Statistics Directorate. (2002); The economic and social costs of Class A drugs in England and Wales, 2000. www.homeoffice.gov.uk/rds/index.html
Imperial College School of Medicine. (2001); responding to drug and alcohol use in Jersey: key findings report.
Jersey Health Promotion Department. (2004); the mental health resource directory.
States of Jersey Health and Social Services (2004) Substance misuse treatment service specification (draft proposal)