Responding to Drug Use - Director, Alcohol and Drug Service - Transcript - 16 July 2004

MR. M. GAFOOR, DIRECTOR, ALCOHOL AND DRUGS SERVICE

1. Nosingleideal solution for a recovering addict.

1. Addicts are a diverse groupneeding a diverse range oftreatments,includingcommunity-based as well asresidency-basedservices;primaryandsecondary care facilities.
2. For the size oftheIslandand its populationand size ofIslandJerseyhas a wellproportioned service.
3. Substancemisusersaremost likely torespond within a community-based service where they can learn skills neededtoliveinthe real world,including avoiding dealers and other users.
4. The majority of users (not hardened addicts) are able to stop ormoderatetheirsubstance misuseoftheirownaccord within the community.The trick is to staystopped' - users needto develop the social skills to stay offdrugs. This is where theymayneedprofessionalbackupto provide adviceandguidance.
5. ADShastheadvantageof being a singlestatutory service within easy reach of majority of users. It aims to give a promptresponseto those whoaccessservices.
6. Drug use is a covert activity but ADS believes it is in contact with 70%ofopiate users - a much higherproportionthaninUnitedKingdomwhere only 20%ofheroin users are in touch with services.
7. Jerseydoesnot yet have a full multi-disciplinary service - this would betheDirector's chief aspiration forADS.

2. Profile of drug use in Jersey

1. There are particular featuresaboutJerseyasanIslandwhichleadto a different profile inthe use ofdrugsherecompared to the UnitedKingdom.For this reason,nosingleUnitedKingdom model can beadopted for theIsland.
2. Heroin is muchmore expensive inJersey,andas a resultusers tend to take smaller quantities and injection is morecommonpractice.
3. Indications show that useof opiates hasnot increased since the ICSM report. Since that time 150 users have accessed treatment.
4. Manyheroinusers in Jerseyare still in employment,unlike in the UnitedKingdom.

3. Needle exchange programme.

1. Sharing needleswasofgreatconcern a few years agoat the time of the ICSMstudy.Levels have dropped significantly from 91 to 50%following the introduction of the NEscheme.
2. In the first yearofthescheme, there wasan escalation in theuptakeof clean needles,but this year has seen a decrease,despiteadditional availability of fitpaks throughnew outlets.

3. This suggests possibly a reduction in drug use due to recruitment to treatment as well confidence on the part of addicts that they can readily obtain fitpaks.
4. It is recognised that moreneeds to bedone to ensureequityofaccessfor the Portuguese community. Interpreters are employedbutsuspicionneedstobebrokendown.
5. The contentsof Fitpacks arebeingreviewedatpresent
6. It is recognised that the cost of fitpaks (£1.50atpharmacies)isanissueforsomebut changes would havebudgetimplications.
7. It is also recognisedthat there areissuesof confidentiality for somepeople,(namely those involved in the methadoneprogramme)whocome to collect fitpaks at Gloucester Lodgewhen clearly this meansthey are not abiding by the conditionsofthemethadoneprogramme.The presentcrampedaccommodationmeansthatthey run the riskofmeetingtheirkeyworker. Separateaccommodationfor the Needle Exchangeschemewouldbe ideal.
8. In the Director's view the establishmentof a safeinjecting room, ascurrently piloted in the United Kingdom, would not be warranted in Jersey.

4. Working with GPs.

1. ADSprovides support, training andadvice to GPswho are often the first pointofcontactfor addicts with healthservices.About30GPshavereceived training over thepast three years.
2. SomeGP'saresympathetic to drugusersbut there is a need to challenge negativeattitudesof others to ensureusershavegood primary care regardlessof the fact of their beingdrugusers.
3. There are currentlyfiveGPs licensed to prescribemethadoneandsubutex.Tobe licensed they have to undertake a certain amountof training.
4. ADSwouldliketoexpand the numberof licensed GPsbut this needstobe carefully controlled to avoid the risk of over-prescribing. In the United Kingdom, any doctor can prescribe methadone but this is difficult to monitor. As a consequence, methadone and subutex are readily diverted for sale on the street which doesn'thappen here in Jersey.
5. It is betterforsome groups of clients tobetreatedbyGPsrather than specialist drug services - for example,it is bettertokeep young naive usersaway from contactwithseasonedaddicts whoattendADS.
6. ADSisconcerned that budget cuts willpreventfurther training for GPs.

5. PrevalenceofHIVand Hepatitis C

(a) Figures presented in the ICMS report have been updated annually, although they are not currently included in the ADS Annual Report

6. Responseto people in search ofassistance

1. ADSattemptstorespondquicklywhensubstance users come for help. Theaverageresponse rate is within one or two weeks. Sometimes three weeks due to leave or sickness. This comparestoanaverageintheUnitedKingdomof three months.

2. ADSgets15 referrals perweekand tries to prioritise these within the resourcesavailable.They have to be fitted into theon-goingcaseload.
3. Somevulnerablepeoplewillbeseenmore quickly, forexample a pregnantwomanor a young, chaotic teenager.
4. ADS is awareof criticism madebysome users and family memberswhosaythey have faced considerable delays in getting appointmentstogetanassessmentandseecounsellors. Their view is that the 'window of opportunity' needs to be seized when a substance misuser is motivated to make a change in their life. This opportunity may be lost without immediate response from the service.
5. Noteveryonethatpresentsforassistancewantstostoptakingtheirsubstanceofchoiceon a permanentbasis.Theymaybeseeking to alleviate a temporary crisis. Forexample,theymay want to get clean for a courtappearance;ortheymayhave visiting family. Somemaybeunder pressure from a partnerorat work.
6. It is a commonfeatureofaddiction that users wantanimmediate gratification. They cannot wait. However, if anaddicthasbeen using for a numberof years butcannotwait two weeks for an appointment, then themotivation required tomake a fundamentalchangeof lifestyle hasto be questioned.
7. Mike Gafoorundertook a study inOxfordon drop out rates from the point of referral.Theywere 20 to25%. It wasfound that thosewhowereseen promptly weremore likely todropoutof counselling andtreatment than thosewhohadtowaitformaybetwo weeks.
8. In Jersey the drop out rate is currentlyonly10%.There are a lot of factors affecting addictsand their persistence in counselling and treatment, besides the service response rate toan initial referral. Evenifadditionalresourcesallowed for a morerapidresponse, there would still be a certain dropout rate. ADS believes ithas the balanceabout right.
9. Initial appointments with ADSincludeanassessmentof the individualneedsandmotivationof the client to determine the appropriate choiceoftreatment options.
10. There is a counselloron call atGloucesterLodgeduring office hoursandon two evenings a week,butnotatweekends.

(h) There is not sufficient demand for a specific mother and child unit for drug users.

7. Harm reductionapproach

1. ADS adopts a behaviouralapproachwhichrecognisesthat they reasonswhypeoplecontinue to take drugsmaynotbe the sameas they reasonswhy they started using inthe first place.The past, with whateverproblemsmighthaveleadtoaddiction,cannotbechanged.Butpresent behaviour, andtheconsequencesofmisusingsubstancesnow,canbeaddressed.
2. Noteveryone is readytomake a decision to abstain from substancemisuse for life.Some peoplecan learn toreduceandcontroltheiruseofsubstances,despite the risks involved. This is notthecase,however, with opiate - oncesomeonebecomesaddictedtheyareunable to revert tosimplyoccasionalorrecreationaluse.
3. A harm reduction approach is notincompatible with anapproachdemandingabstinence.ADS also encourages abstinence where appropriate.

4. ADS will encouragepeopleto try the residential treatmentoptionasatSilkworth.However, not all addictsareattracted to the 12 step abstinence approach used there.Few clients can afford to take this optionwithoutsubsidisedassistance.Also those inemployment find it difficult to take thenecessarytime off toattend a residential programmeforupto three months.

8. Substitution programmes - Methadoneand Subutex

1. Methadone is a tested and effective form of substitution for heroin. It is accepted that methadone is highlyaddictive itself butcanbeusedin a managedwaytoweanpeopleaway from addiction.
2. Onethirdofpeopleon the programmesince1998havebecomedrug-freeattheir first attempt.
3. Methadone prescribing is carefully monitored inJersey in order that it doesn't leak' onto the streets.
4. A Subutex pilotschemewas successfully trialled two years agobutdoesnot suit all clients. It is a strongeropiateand can bedangerousif mixed with alcoholorotherdrugs.It is expensivebut it is usedas a treatmentoptionon the basisof client need not on the basis of cost.
5. Ibogaine has been featured recently in themedia.Thisbush' drug is largely untestedand little is knownabout its effects.
6. Criticism about the cost effectiveness of the methadoneprogramme - that long term habitual drug users play a catandmousegame with ADSseekingtousemethadonetoalleviatetheir addiction whilecontinuingto use opiateswhentheyhavethe opportunity - is unfair. ADS works with a range of substanceusers with differing motivations. It deals with them as they are and tries to work with them toreduceharm they are causingthemselves. It cannotsimply deal with those most motivated to changetheir lives whilechoosingto ignore thosewho continue tolive chaotic lives.
7. The programmeuses sanctions - a yellowandred card system - to avoid clients abusing the system so that theydon'tusemethadonesimplyas a stop gapuntil they canaccess other opiates. Clients are monitoredcloselythroughout the programme. If theylapse,theyareoffered a detox,either in hospital orathome,andloseaccess to methadone for a period.
8. In Jerseyamountsusedbyaddictsare generally small becauseof the high cost of the drug. This makes it easier to weanpeopleoffthedrugthrough the methadoneprogramme.
9. Methadoneisnotintended as a long-termmaintenanceregime.Theaim is tohelppeople to stop using opiates. It is a matterof negotiation with theclienttodecidehow long this takes.
10. Offering somepeople a maintenancemethadoneprogramme would be a recipefordisaster as manyothers would demandthesame treatment.
11. Methadonemustbe taken undersupervisionat a registeredpharmacy.Thisprocessisnot degrading in itself. Pharmaciesshouldhaveappropriateaccommodation for this purpose.
12. ADS would beconcernedtolearnofanypharmacieswhere suitably private conditionswerenot available for addictsto take methadoneunder supervision.

9. Addictsinemployment

1. Employersshouldbe given awareness training to enable them to identify employeesatrisk and offer appropriate forms of intervention.
2. Addiction shouldbe considered as a condition requiring treatment rather than a crime - but this would involve a major changeof attitude in society.
3. ADSseekstoadviseemployers, where issues confidentiality allows,aboutwaysofsupporting employeeswhoareworkingthrough a harm reduction or abstinence programme. It would alert employers in cases ofdangertothird parties or the safetyofthecommunity.
4. Retaining employment during treatment, even through a periodof residential rehabilitation, would beenormouslyhelpful to recovering addicts.
5. The Director is currently developing Guidelines for personnel managers within Health and Social Services

10. Prison

1. ADSworksclosely with thePrison authorities in developing drug educationprogrammes.
2. A memberofADS team attends the Prisonfor ½ day a weekforpre-releasecounsellingand advice.
3. A post for a dedicated substancemisusecounsellorhasnowbeenestablishedatthePrison.
4. There is clearly lack of adequate support for all offenders on release from prison. They commonly face problems of accommodation and employment as well as difficulties in re- establishing relationships. In addition drugusers find it hard to avoid pastcontacts with other users.
5. Some form of half wayhostel would help ex prisoners tore-integrate into society.
6. A needle exchange scheme for prisoners would pose health and safety issues for the authorities. IntheDirector's view, attentionshouldbefocussedonpreventingdrugs from getting into the prison rather than acceptingdruguseas a norminsidetheprisonwalls.
7. The Director wouldfavourtheprovisionofcondoms for prisoners.

11. Arrest referral worker

1. This post wasestablished last yearas a pilotschemeasanattempt to break the cycleofcrime and substancemisuse. It enablescontact with offenders at the point ofarrestwhenmotivation to seekassistancemaybe high.
2. There havebeensome initial hiccoughs with custodystaffbutisgrowing successfully

12. Court Liaison Officer

1. This officer has reported thatcourtsarebecomingmorefavourable to the useoftreatment orders for those addicted to drugs (those charged with possessionasopposedtodealersand traffickers)

2. The courtsrecognise that it'smorecost effective andbeneficial to givetreatmentrather than incarcerate addicts.

13. Inter-agency collaboration

1. Relevantagencies were involved last yearinworkshops in the developmentof the new Crime andSubstanceMisuse strategy.
2. There have beenimprovements in communicationanddata collection includingthepinklist for GPs.There is also a meeting every twomonthsofthe Drug DependencyAdvisoryGroup, including the involvement of Employment and Social Security Department to advise on prescriptions.
3. There are data protection issues regarding sharing of information about clients with other agencies, suchasRoseneath. This can beovercomeproviding the client consents.
4. ADShas recently received a sourceoffunding from the Proceeds of Drug Trafficking to enable referrals to localresidential rehabilitation facilities likeSilkworthLodge.Seven referral have been made in the last sixmonths.
5. ADS is working with Silkworthonadmissions criteria andhas started to evaluatetheoutcomeof placements at Silkworth to ensure value formoney.
6. Workhasbegunon developing a documentoutlininganintegratedcarepathwaysapproach.

14. Clientuser group

1. Anattempthasbeenmade to form a usergroupbutit failed largelybecauseof clients fears that meetings would bemonitoredby the police.
2. Similarly a group calledParentsAgainstDrug Addiction foldedaspeople did notwantto be identified.