SALFORD DRUG AND ALCOHOL HEALTH NEEDS ASSESSMENT

Transcription

1 2014 SALFORD DRUG AND ALCOHOL HEALTH NEEDS ASSESSMENT

2 Contents List of Graphs...5 List of Tables...6 List of Maps...6 List of Figures...7 List of Appendices...7 Executive Summary...9 Recommendations Strategy and Commissioning Ongoing Analysis and Needs Assessment Service Development Communications and Surveillance Introduction and Purpose of This Health Needs Assessment Introducing Salford City Overview Demographics Salford Health Profile at a Glance Recession, Crime and Disorder in Salford Unemployment in Salford National Policy Context and Guidance National Drugs Strategy (2010) National and Local Alcohol Strategies Targeted National Action Targeted Action at the Local Level Health as a licensing objective Promoting growth and supporting responsible businesses Salford Alcohol Harm Reduction Strategy Recovery Orientated Drug Treatment (2011) and Medications in Recovery (2012) Conceptual Framework for Promoting Recovery Assessment and Recovery Care Planning: Plan Review, Optimise The Phasing and Layering of Interventions Improve Well Being Recovery Support and Self Help Post Treatment Support Housing Support Employment support Adapting Recovery to Different Settings (Prison, Residential and non residential rehabilitation) National Institute for Health and Clinical Excellence (NICE) Guidance NICE Quality Standards Summary Quality Standard for Drug Use Disorders NICE QS Quality Standard 11 Alcohol dependence and harmful alcohol use quality standard NICE Recommendations Drug Prevalence Overview of National Drug Prevalence Estimated Drug Prevalence in Salford Opiate and Crack Cocaine (OCU) Prevalence National Prevalence Regional and Local Prevalence Recommendations Drug Treatment: Costs and Consequences National Overview Salford Cost Benefit and Value of Treatment... 55

3 Costs Avoided Investment Local Crime Recorded Local Drug Offences Local Drug Related Offences Type of Drug Offence Cannabis Farms / Plants Recommendations Drug Treatment in Salford OCU Treatment penetration Engaging the Unknown OCUs Public Health Outcomes Framework Performance National NDTMS Data First Time Entrants Local National Drug Treatment Monitoring Service (NDTMS) Referral to Specialist Services Numbers in Effective Drug Treatment Ageing Treatment Population Days in Treatment in SDAS Treatment Outcomes Profile (TOP) Data Q4 Treatment Review Treatment Exits in Treatment Map Salford Drug User Profiles: Salford Drug and Alcohol Service (SDAS) data Cannabis users Amphetamine users Cocaine Powder Users Opiate or Crack Users (OCUs) Successful Treatment versus Unsuccessful Treatment for OCUs OCU Length of treatment Opiate Success and Deprivation Injecting Drug Users Needle and Syringe Programmes HBV Prevalence and Vaccine Uptake Salford Needle Exchange Data Analysis of Individual Records Age breakdown Substances Recorded at Needle Exchange Recommendations Drug Related Mortality The National Programme on Substance Abuse Deaths (np- SAD) ONS / Public Health Mortality Files Data Recommendations Dependence on Prescription and Over the Counter Medicines National Guidance Prescription and Over the Counter Medicines Prevalence (NDTMS) Drug Related Hospital Admissions National and Regional Admissions (mental health and behavioural disorders) National and Regional Admissions (poisoning by drugs) Drug Related Hospital Admissions in Salford Employing Local Data Recommendations New Psychoactive Substances (NPS) and Legal Highs Legal Status NPS Trends Salford s Drug Early Warning System (SDEWS) Recommendations

4 12 Alcohol Use: Prevalence and Profiles National Alcohol Prevalence Regional Alcohol Prevalence Alcohol Prevalence in Salford Alcohol Prescribing Salford Alcohol Equity Audit AEA Main Findings Step Programmes The Harmful Consequences of Alcohol Use on Salford The Accessibility of Alcohol in Salford Local Offending Analysis- Alcohol Clusters Alcohol Users in Treatment with Salford Drug and Alcohol Service (SDAS) Overview Successful Treatment versus Unsuccessful Treatment for Alcohol Users Alcohol Success and Deprivation Geographical Service User Data Families and Treatment Recommendations Alcohol Related Hospital Admissions Understanding data and practice Improving our understanding of Salford s Data National Alcohol Related Hospital Admissions Alcohol Related Hospital Admissions in Salford Admitted Patient Residences: Salford Neighbourhood Liver Disease Regional Liver Disease and Mortality Liver Disease and Mortality in Salford Liver Disease and Hospital Admissions Hepatocellular Cancer: All Hepatitis C (HCV): All Future Burden of HCV: All Hepatitis B (HBV) Alcohol Deaths / Mortality Alcohol Related Mortality: England Alcohol Deaths / Mortality in Salford Alcohol Related Mortality : Salford Alcohol Attributable Deaths: Salford Alcohol Specific Deaths: Salford Appendices

5 List of Graphs Graph 1: Annual Estimates of Opiate and/or Crack Users in England Graph 2: Annual Estimates of Opiate and/or Crack Users in England by Age Group 49 Graph 3: Estimated North West OCU Prevalence Rate per year olds between Graph 4: Age Distribution of OCU prevalence in Salford between Graph 5: Estimated Percentage of OCUs that are Known to Salford Drug Treatment Services in the Last Two Years Graph 6: OCUs in Contact with DIP 2009/ Graph 7: Referral of Treatment Naïve Opiate Users in Salford between 2007/ Graph 8: OCU Treatment Population by Age Group to Graph 9: Salford Specialist Drug and Alcohol Referral Source by Age Group Graph 10: Salford OCU and All Drug Users in Effective Treatment between 2006 and Graph 11: Showing the Increase in the Proportion of Drug Users in Treatment Aged Over Graph 12: To Show Days in Treatment in Salford between 2008 and Graph 13: Age and Location Distribution for Needle Exchange Clients Graph 14: Drug Implicated Deaths in Salford during Graph 15: Age distribution of all Drug Related Deaths for Salford Graph 16: Showing Percentage of Drug Related Deaths that Were Aged 40-Plus (*Source ONS) Graph 17: Showing Total Number of Drug Related Deaths in Salford between 2003 and 2012 (*Source PHMF) Graph 18: Drug Related Mental Health Hospital Admissions between 2000/ Graph 19: Regional rates showing synthetic estimates of drinking levels Graph 20: Salford and England Population aged 16years+ who abstain from alcohol Graph 21: Levels of Harmful Drinking in Salford and England Graph 22: Number of alcohol related NHS hospital admissions where there was a primary or secondary diagnosis of a disease or condition wholly attributable to alcohol, by age 2011/12 (Source HSCIC) Graph 23: Alcohol Related NHS Hospital Admissions (ARAs 2002/03 to 2011/12 (*Source HSCIC) Graph 24: Alcohol Related Hospital Admissions by Quarter per 100,000 population Graph 25: describes the Age and Gender distribution between all Alcohol Specific admissions (adjusted for repeated admissions) Graph 26: Directly Standardised Rates for All Liver Disease by Primary Care Trust Residence in 2012 (*Source HSCIC) Graph 27: DSRs for All Liver Disease Admissions in Greater Manchester from (*Source HSCIC) Graph 28: National Admission Episodes for Alcohol Related Liver Disease by Gender and Age for 2012 (*Source HSCIC) Graph 29: Alcohol Related Mortality Rates in Salford between

6 List of Tables Table 1: Estimated number of 16 to 59 year olds in Salford using illicit drugs in the last year (2011/12) Table 2: Opiate and Crack Users in Salford: Prevalence Estimates Table 3: Reduced Crime Costs Achieved by Investing in Treatment and Recovery. 57 Table 4: Reduced Health Costs Achieved by Investing in Treatment and Recovery. 57 Table 5: Drug Related Offences in Salford between 2011/12 and 2012/ Table 6: Trafficking in Controlled Drugs in Salford (2011/12 and 2012/13) Table 7: Possession of Controlled Drugs in Salford during 2011 and Table 8: OCUs Known to Treatment by Substance Table 9: Salford OCU Successful and Unsuccessful Treatment Exits 2012/ Table 10: Length of treatment for Salford OCU s and Relevant Treatment Success 83 Table 11: Successful completion rates for opiate users in treatment with SDAS by ward Table 12: Volume of items issued in at fixed site and pharmacy based needle exchange services Table 13: Drug Related Admissions during 2011/12 (*Source HSCIC) Table 14: Estimated Salford Drinking Population (16 and above) Table 15: Crimes which hold an alcohol marker over the last 2 financial years Table 16: Salford Alcohol Users Successful and Unsuccessful Treatment Exits 2012/ Table 17: Successful completion rates for primary alcohol users in treatment with SDAS by ward Table 18: Typical admissions by alcohol admission type for England, North West and Salford Table 19: Number of admissions by alcohol admission type for England, North West and Salford Table 20: Top Ten Areas with Highest Alcohol Related Admission Rates per 100,000 population 2012/ Table 21: Directly Standardised Alcohol Specific Admission Rates for Salford Wards 2010/ Table 22: Directly Standardised Rates (95% Confidence Intervals)for Liver Cancer Mortality during Table 23: Top 10 CCGs with highest Directly Standardised Rates of Alcohol Related Liver Disease Emergency Admissions 2011/12 (*Source HSCIC) Table 24: Estimates of HCV prevalence, burden, treatment and cost of treatment by Drug and Alcohol Action Team area in the North West (*Source HPA) List of Maps Map 1: Drug Offence Clusters in Salford Map 2: Cannabis Farms in Salford during 2012/ Map 3: Distribution of Salford OCUs in treatment Map 4: Alcohol Related Crime Clusters In Salford Map 5: Geographical Location of Specialist Alcohol Users Map 6: Alcohol Specific Admissions to SRFT by Wards during 2010/ Map 7: Alcohol Attributable Admissions to SRFT by Wards for 2010/

7 List of Figures Figure 1: Boundaries and location of Salford City Figure 2: Male and Female population distribution by age, Salford and North West Figure 3: Male and Female population distribution by age, Salford and North West Figure 4: Long Term Youth Unemployment in Salford Figure 5: Drug Trends 2012: Fewer people are in treatment for drug use Figure 6: Drug Trends 2012: Drug use is down Figure 7: Drug Trends 2012: More drug users are recovering Figure 8: Drug Trends 2012: Younger people are doing better Figure 9: Drug Trends 2012: People who use heroin are getting older Figure 10: Drug Trends 2012: Crime is down Figure 11: Why Invest To Save: Treatment Services and Agency Partnerships Figure 12: Comparison between Costs of Investing in Drug Treatment and Not Investing in Drug Treatment Figure 13: Salford OCUs Known to Treatment v OCU Prevalence Rates Figure 14: Treatment System Map 2012/ Figure 15: Treatment Map for Salford 2012/ Figure 16: HBV Vaccine Coverage in Prisons in the North West List of Appendices Appendix 1: Stakeholder Consultation Appendix 2: Main components of Effective Opioid Substitution Treatment (ROTD 2011) Appendix 3: Principles and features of recovery orientated drug treatment and how to test they are being achieved - Adapted from Medications in Recovery Appendix 4: A Suggested Approach to the Phasing and Layering of Treatment (Source ROTD) Appendix 5: Suggested topics that should be covered by low intensity psychosocial interventions Appendix 6: Components of Core Key working (ROTD 2011) Appendix 7: Employment and Recovery: Good Practice Checklist (NTA 2012) Appendix 8: Public Health Outcomes Framework Appendix 9: DAAT Commissioned Services Appendix 10: England Regions and North West DAT areas Proportional use of Prescription and OTC medicines in persons known to treatment services Appendix 11: Drug and Alcohol Related Hospital Admissions- CSU Request for Data Appendix 12: Drug Use and Frequency Reported in 2011 Mixmag / Guardian Survey Appendix 13: Salford Drug Early Warning System Appendix 14: Regional Alcohol Indicators Appendix 15: Geographical Service Data Analysis

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9 Executive Summary Purpose The purpose of this Salford Drug and Alcohol Health Needs Assessment is to inform our local strategy, the commissioning of a new integrated drug and alcohol treatment system and service delivery within that system. It sets out where the gaps in our understanding are and which areas of service delivery are in need of development. It is informed by local evidence set alongside national strategies, policies, and guidance. Treatment and Recovery This needs assessment differentiates between drug use, which is common but declining, and drug addiction, which is rare but remains a significant problem. Drug treatment has been well funded over the last decade and had a measurable positive impact on individuals and society. Treatment focused on substitute prescribing has successfully reduced crime and improved health whilst declining rates of drug use have been accompanied by a decline in drug related deaths. Nationally half of those using the most serious drugs are now in treatment, more people are recovering from drug addiction and instances of young people using heroin are now very rare. Despite these evident gains the need remains to move further towards a recovery orientated treatment system that targets those with greatest problems. This is reflected in national strategic guidance which aims to both reduce illicit and harmful use and increase the numbers recovering from their dependence. Recovery aims to build on the successes brought about through substitute prescribing by increasing assets or recovery capital. This emphasis on recovery requires a more person centred approach that aims to improve wellbeing and citizenship as well as reducing dependence. Investment and Saving Salford s treatment system has managed to successfully move 10% of opiate users out of treatment in the last year, a rate higher than other areas of Greater Manchester. Investment in treatment and recovery has brought real benefits in terms of reduced crime and improved health. For Salford it has been calculated that every 1 invested in drug treatment has resulted in 4.90 being saved in terms of crime and other societal costs. 9 Comparison between Costs of Investing in Drug Comparison Treatment between and costs Not of investing Investing in drug in Drug treatment and not investing in drug treatment Treatment, Source: PHE Drug treatment investment 1M 1M Vs. Health and crime costs 1M 1M 1M 1M 1M 1M 1M 1M

10 Had there been no investment in treatment, the biggest additional cost would have come from an increase in offending. In Salford it is estimated that there would have been an additional 34,657 crimes in if no drug users had been in treatment. Recorded drug offences in Salford have fallen but there remain geographical pockets with high rates of drug offences. The majority of drug offences relate to the possession or supply of cannabis. Treatment Population Trends There are estimated 1,745 opiate and crack users (OCUs) in Salford. Local evidence suggests this official figure may be too high; in particular we are able to evidence that the prevalence of crack use is lower than estimated. Local evidence also shows that treatment penetration is much higher than official estimates suggest. In other words, our services have worked with the vast majority of OCUs in Salford with around 800 receiving treatment in 2012/13. 60% 40% 20% 0% % Salford Drug Users intreatment Aged 40-plus % England Drug Related Deaths Aged 40-plus Over half of users in Salford in receipt of Opioid Substitution Treatment (OST) are now aged 40- plus. These individuals tend to have been in treatment for several years and their likelihood of successfully completing treatment decreases the longer they remain with us. Shared Care Those ageing clients who remain in treatment tend also to be more complex with additional health and care needs. We suggest that a targeted approach delivering the best and most appropriate care on an individual level will enable even the most entrenched service users to move into recovery whilst ensuring that those that remain in treatment receive the best possible overall package of health care. In this context it should be noted that Shared Care with General Practitioners is under developed in Salford. It is therefore a priority to determine the role Shared Care is able to play in a recovery orientated treatment system in Salford. Over The Counter (OTC) and Prescription Only Medicines (POM) Nationally, one in six service users of specialist drug treatment services report using OTC or POM. Most will also use illegal drugs. However, there is a large regional variation in these figures. In Salford s treatment services there is higher than expected numbers of people who do not report use of illicit drugs but do report using prescription opiates. 10

11 The misuse of OTC and POM needs to be quantified and addressed locally with support from the Health and Wellbeing Board. Prevention should remain the focus for addressing this problem. This can be achieved through awareness raising, prescription monitoring and making alternative treatment available. Injecting Drug Users Needle exchanges have helped to prevent the spread of HIV and other blood borne viruses. Recent years have seen an increase in the number of users of image and performance enhancing drugs accessing needle exchanges. Salford has 14 needle exchange sites (three fixed and 11 in pharmacies). There is a system for collecting data of users of the service but it is not fully utilised. Half of those recorded on the systems (who name a drug) cite heroin as the reason for accessing needle exchanges, a third name performance enhancing drugs. Non-Opiate Users Although most drug users in treatment are heroin users, Salford s treatment system has worked with increasing numbers of non-opiate users. These numbered over 220 during the course of the last year and services managed to successfully move 39% of them out of treatment. This rate is similar to that of Greater Manchester but remains lower than many other areas. Drug Related Deaths The total number of deaths related to drug misuse in England and Wales was 1,496 in 2012, a decrease of 109 from 2011 which continues the downward trend seen since 2008 (ONS, 2013). Heroin/morphine is still the most common substance implicated in drug related deaths but in the last three years its involvement in overall deaths has fallen from over half to around a third. There has been a rise in deaths related to the use of New Psychoactive Substances (NPS). Salford has seen a steady rise in drug related deaths peaking in The number of deaths has since declined but there is limited understanding of the underlying trends or causes, this is a significant gap that needs addressing. Drugs Early Warning System The market for NPS also known as legal highs has grown hugely over the last five years. The UK has Europe s largest market for NPS. The internet has enabled international production and distribution. Given the scope to alter chemical structures of NPS, new formulations are outpacing efforts to impose international control. Safety is a significant issue as these drugs are untested and constantly changing to avoid legal proscription. Salford has set up a Drugs Early Warning System to help share information and disseminate warnings to professionals with regard to NPS and more traditional drug markets. 11

12 Alcohol Related Harm The significant harms caused by alcohol continue to increase for the population as whole. Nationally around a third of adults exceed the weekly recommended levels of drinking. There is currently no reliable local measure however all indicators point to Salford having amongst the worst alcohol problems in England. Relative Position of Salford for Key Alcohol Indicators, Source: HSCIC, LAPE, ONS Emergency admissions for alcohol related liver disease 2012/13 Salford NHS hospital admissions with a primary diagnosis wholly attributable to alcohol 2011/12 Salford Salford Rate of alcohol-related admissions per 100,000 population by Local Authority 2012/13 Alcohol-related deaths and agestandardised mortality rate for all persons, by local authority Salford These indicators show that Salford had the 4th highest rate of Incapacity Benefit claimants due to alcoholism, the second highest rate of alcohol related mortality amongst women and 10th highest for men. Salford also had the second highest rate of emergency admissions for alcohol related liver disease in England and the highest rate of hospital admissions for all liver disease in England. On average there were more than 60 incidents of alcohol related crime or anti-social behaviour per week in Salford. Availability of alcohol is higher in Salford than anywhere outside the capital. Alcohol related hospital admissions are of specific concern. Nationally there has been an increase of over 50% in a decade to 1.2 million admissions a year. Salford had the second highest recorded rate of alcohol related hospital admissions in England with 1 hospital admission due to alcohol for every 30 of the population in Salford also had the highest rate of admissions specifically caused by alcohol in England, with two and a half times as many as the national rate. More detailed analysis of alcohol admission data is due to take place in

13 Targeted partnership approach Alcohol problems are best tackled locally through a targeted partnership approach involving joint intelligence in line with the four priorities of the national strategy: 1. Tackling the price and availability of alcohol 2. Reducing alcohol related harms locally 3. Engaging the industry via the Responsibility Deal. 4. Supporting young people, individuals and families to change Comparing multiple datasets at ward level shows a relationship between deprivation, alcohol offending, hospital admissions, treatment and availability of alcohol. The use of alcohol also has a negative impact on the health of those that originally came into treatment for drug use. We also know that alcohol and drug misuse is linked to a risk to children. An investigation showed that in August 2011 a quarter of children on the Child Protection Register are associated with an adult with an alcohol and/or drug treatment record. A detailed analysis of data from our largest treatment service shows that there are around 300 adults in structured treatment for alcohol on any one day. There are twice as many successful treatment episodes as unsuccessful ones. The factors more common amongst those who complete successfully are: living with children, in employment, being older, being female and not using cannabis or cocaine in addition to alcohol. 13

14 Recommendations The recommendations of this needs assessment are thematically listed below. A distinction is made between those where partnership responses are key and those that will primary be addressed Public Health. Strategy and Commissioning 1 Produce one clear Vision and Strategy Document for achieving a Recovery Orientated Drug and Alcohol System in Salford. 2 Develop a more robust prevention and early intervention agenda for young people and families. 3 Ensure available national guidance is included within all current and future specialist alcohol and drug service specifications. 4 Commission appropriate services which facilitate the engagement of clients with peer role models and peer support inclusive of self help and 12 step groups (Alcoholics Anonymous and Narcotics Anonymous), provide essential support to the family and social networks of individual drug and alcohol misusing clients, engage with employment and welfare services, assist with housing need and work with housing providers. Partnership (CCG, SCC) Partnership: (Children s Service) Public Health Public Health Ongoing Analysis and Needs Assessment 5 Establish routine data sets (e.g. drugs, alcohol, crime and disorder) and ensure analytical capacity is available for future needs assessments. 6 Employ geographical mapping data to prioritise recovery assets in the neighbourhoods identified as having greatest need inclusive of youth unemployment. 7 Gain access to Salford drug and alcohol related hospital admission data, to be used for mapping trends on health needs. 8 Conduct further analysis on Salford's drug and alcohol related hospital admissions, to identify any underlying contributing factors. 9 Carry out a full information gap analysis on drug related deaths in Salford to identify underlying trends and patterns. Partnership: (CCG, CSU, Police, SCC) Public Health Partnership: (CCG, CSU) Public Health Public Health 14

15 Service Development 10 Develop and implement processes for service user involvement and client feedback to inform future service improvements. 11 Further develop specialist family support services in Salford following NICE guidance. 12 Establish protocols for information sharing and integration of case management between drug and alcohol services and Children s Services. 13 Set up routine and regular monitoring of costs and benefits of treatments in accordance with NICE guidance and where possible against other comparative DAATs. This should include a yearly review of unit costs for different treatments (e.g. new prescribing regimes or comparable aspects of services). 14 Continue to benchmark against the best performing DAATs and in addition develop internal monitoring of success rates for different interventions. 15 Conduct a review of individual needs, assets and available treatment options with the aim of developing recommendations to improve health, wellbeing and recovery potential and maximising engagement with primary health and care services. This should ensure that the associated costs to health and social care services are minimised. Particular emphasis should be placed on the needs of ageing drug users in treatment services and the development of Shared Care. 16 Collate all PHE guidance on addiction to medicine and use them to inform future recovery orientated systems. Public Health Partnership: (CCG, SCC) Partnership: (Lead Provider, SCC) Public Health Public Health Partnership: (CCG, Lead Provider) Public Health Communications and Surveillance 17 Develop a drug and alcohol communication strategy with the new service Lead Provider. 18 Review the wider primary and secondary health care services referral processes and develop a communications plan to promote consistency. 19 Further develop Salford s Early Warning System to alert partners to the health risks arising from both traditional drug use and the consumption of NPS s. 20 Produce a local strategy for surveillance of, and guidance to all stakeholders on, Novel Psychoactive Substances (NPS). This should include input from specialist drug services, A&E, Police, Trading Standards and other relevant partners. Partnership: (Lead Provider, CCG, SCC) Partnership: (CCG, SRFT, SCC, Lead Provider) Partnership: (CCG, SRFT, SCC, Lead Provider, Police) Partnership: (Trading Standards, SRFT, CCG, Lead Provider, Police) 15

16 1 Introduction and Purpose of This Health Needs Assessment Drug use is common in England with 36% population using an illegal drug at some point in their lives, yet in 2011/12 just 9% had reportedly used in the last 12 months, 1 and addiction is rare. Only 300,000 people are estimated to use heroin and/or crack cocaine and over half of those are in treatment. 2 Historic investment in drug treatment services, particularly since 2001, has resulted in access to long term high quality treatment which has substantially improved individual health and reduced the impact on wider society. Despite this drug misuse remains a major public health problem, it causes damage to both the physical and mental health of drug using individuals, an estimated 1.2 million people are affected by drug addiction in their families and it costs society an estimated 15.4 billion inclusive of its impacts on communities and crime and disorder. 3 Alcohol consumption also has major public health implications. In 2012/13, there were an estimated 1,230,510 national hospital admissions related to alcohol consumption where an alcohol-related disease, injury or condition was the primary or secondary reason for admission. This compares with 510,700 in 2002/03. Moreover, the Department of Health North West had shown that if it were not for alcohol related deaths, previous Spearhead Primary Care Trusts (PCT) such as Salford would have in all probability achieved their objective to narrow life expectancy for males and be on track to achieve the same for females. 4 The National Treatment Agency for Substance Misuse (NTA), now part of Public Health England (PHE), first published information on undertaking needs assessments in Since then significant improvements have been made to the drug and alcohol treatment system at a local level. However ongoing improvements are required for the commissioning and delivery of an integrated recovery focused approach that will enable drug users to work towards drug-free and productive lives. 5 1 Home Office. (2012) Drug misuse declared: findings from the 2011 to 2012 Crime Survey for England and Wales. 2 NTA (2012). Drug Treatment 2012: Progress made, challenges ahead. 3 NTA. (2012). Why Invest? How drug treatment and recovery services work for individuals, communities and society. 4 DoH and NWPHO 26/9/11. Where Wealth Means Health Presentation. Narrowing the English Health Inequalities Gap: What went right and what went Wrong Presentation Slides. 5 NTA (2009). Undertaking Needs Assessment Drug Treatment. 16

17 Based on validated protocols 6,7 this Health Needs Assessment (HNA) will review relevant national policy and evidence for drug and alcohol services alongside national, regional and local population health trends. The findings will inform the strategic direction, commissioning and delivery of recovery orientated drug and alcohol services throughout Salford. The local evidence base and national policy shift described in this HNA has already led to Salford proposing a new integrated alcohol and drug recovery system for adults and families. Promoting recovery and reducing the harm caused by substance misuse through effective partnership working and integrated service delivery are the overarching principles of this new service. The stakeholder consultations that informed the commissioning of the new system can be found at Appendix 1 This new system will target high risk, high need, high cost individuals, focus on the families of problematic drug users and the wide range of problematic alcohol users, seek to boost their numbers in treatment and assist as many as possible to move, with support, and greater assets to recovery. 6 Stevens A, Raferty J, (2004) Health Care Needs Assessment. Radcliffe 7 Pencheon D, (2003).Oxford Book of Public Health Practice. Oxford University Press 17

18 2 Introducing Salford The following section introduces Salford and provides a brief overview of its location and key population health characteristics. This has been informed by the NHS Salford (PCT) Legacy document 2013 and the most recent Public Health England Health Profiles Further detail on the history, background and regeneration of Salford is available on the City Council website. 9 The city Joint Strategic Needs Assessment (JSNA) 10 also provides specific insight into each neighbourhood of Salford, providing profiles on localised demographics and varying heath needs across the city. 2.1 City Overview The city of Salford covers 37 square miles and five districts (Figure 1). It is situated with the region of Greater Manchester and its closeness to Manchester city centre makes it an important part of the economy and culture that is driving England's North West forward. Figure 1: Boundaries and location of Salford City 2.2 Demographics 8 PHE. Health Profiles

19 Salford is a contrasting city, ranging from affluent to extremely deprived areas that are gradually being regenerated. Salford continues to struggle with the burden of high levels of deprivation, unemployment, teenage pregnancy, crime, smoking rates, alcohol and drug abuse and long-term chronic illness. Salford is classified by the Department for Environment, Food and Rural Affairs (DEFRA) as Major Urban. There are roughly 234,000 people living in Salford, mainly in urban areas, with around 250,000 people being registered with Salford s primary care services. Salford has a higher than average number of women of child-bearing age, which means there are more 0-4 year olds in Salford than there would typically be for the size of population. Salford also has a large Orthodox Jewish population that is estimated to contain around 10,000 people. The 2011 Census showed that 84% of the population is white British and 6% are other white (mainly Irish, Polish and other Europeans). Non-whites make up the remaining 10% of the population (mainly Black British/Black and South Asian British/South Asian). Figures 2 and 3 illustrate the distribution of Salford people by age and gender in 2010 and this is projected forward to 2035 by which time Salford s population is expected to reach 300,000. Figure 2: Male and Female population distribution by age, Salford and North West

20 Figure 3: Male and Female population distribution by age, Salford and North West 2035 Notable features of the population distribution are: A declining proportion of the population are aged under-16 and an increasing proportion are aged 65 and over. The elderly population is increasing as a result of a decline in the mortality rates and past fertility rates. Projections for the over 65s show a steady increase in all age bands for both men and women. A higher proportion of women than men in the 85 plus age band is predicted, where the ratio is expected to reach 1.5:1 by Migration between Salford and other areas within the UK accounts for the vast majority of movement in and out of the city. Population turnover between 2001 and 2006 equates to 11% of the total population of the City. 2.3 Salford Health Profile at a Glance 11 The health of people in Salford is generally worse than found nationally. Deprivation is higher than average and about 13,100 children live in poverty. 11 PHE. Health Profiles

21 Life expectancy for both men and women is lower than the national average. Life expectancy is 12.1 years lower for men and 8.2 years lower for women in the most deprived areas of Salford than in the least deprived areas. Over the last ten years, all cause mortality rates have fallen. Early death rates from cancer and from heart disease and stroke have fallen but remain worse than the national average. The proportion of Year 6 children in Salford classified as obese is 23%, which is higher than the average for England. Levels of hospital stays among those under 18, breast feeding, teenage pregnancy, GCSE attainment, alcoholspecific initiation and smoking in pregnancy are worse than the average for England. As are estimated levels of adult 'healthy eating' and smoking, rates of hip fractures, sexually transmitted infections, smoking related deaths and hospital stays for alcohol related harm. The rate of road injuries and deaths is better than the average for England. Priorities in Salford accordingly include reducing early deaths from smoking, improving rates of breastfeeding and reducing alcohol related harm. 2.4 Recession, Crime and Disorder in Salford Crime has fallen faster in Salford than across Greater Manchester as a whole. Salford s crime rate reduced from 98 crimes per 1,000 residents to 79 crimes per 1,000 residents per quarter. Certain crime types now make up a greater percentage of all crime. Violence without injury crimes increased from 5% to 7% of all crimes (and 55% are domestic violence related) Drug offences have also increased from 10% to 13% of the total Salford crime figure. Shoplifting offences have increased proportion from 3% to 5% of Salford crimes. New Economy produced a report for the Salford Community Safety Partnership to examine the impact of the recession on crime and disorder in Salford. 12 It identifies at risk wards in Salford where unemployment and youth unemployment is high, and emerging patterns relating to crime and the recession. The main findings of the report were: 1. Increases in long term youth unemployment correlate at ward level with: 12 New Economy (2013). Examining the Impact of the recession on crime and disorder in Salford. 21

22 Areas where perceptions of Anti Social Behaviour (ASB) and of community cohesion have deteriorated for example Pendlebury, and Weaste and Seedley. Areas noted for increases in fraud and forgery crimes for example Kersal, and Walkden South. 2. Increases in long term adult unemployment correlate at ward level with: Areas most affected by increases in burglary crimes, i.e. Little Hulton and Cadishead. Areas where there have been increases in the number of veteran offenders coming to the attention of the authorities, i.e. Eccles and Little Hulton 3. Increases in short term adult unemployment correlate at ward level with: Where residents are increasingly feeling unsafe after dark in their local area, i.e. Weaste and Seedley and Little Hulton. 2.5 Unemployment in Salford The overall JSA claimant rate in Salford is high following a large increase in the first year of the recession, but has not significantly increased since then. The proportion of claimants classed as long-term has, however, increased significantly since the onset of the recession, with 45% of JSA claimants being long-term as opposed to just 20% pre-recession. Long term youth unemployment has increased dramatically between 2008 and 2012 as shown in Figure 4. 22

23 Figure 4: Long Term Youth Unemployment in Salford Long term Youth JSA Claimants in Salford October 2008 Long term Youth JSA Claimants in Salford October 2012 The New Economy report suggests a number of associations that may be in place, however no statistical correlations have been completed to reinforce these assumptions, and care must be made with any interpretations made. A specific finding to be aware of relates to the increasing proportion of domestic violence crimes recorded, alongside the levels of alcohol and drug related crimes by ward. Awareness of these trends may help to inform future delivery of services and towards the development of specific recovery assets in wards where drug and alcohol related offences and long term youth unemployment are a feature. 23

24 3 National Policy Context and Guidance 3.1 National Drugs Strategy (2010) The National Drug Strategy for England, Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life 13, outlines the Governments plans for helping people live a drug free life and addressing alcohol dependence, both of which are key causes of societal harm, including crime, family breakdown and poverty. The National Strategy represents a major policy shift, signals the development of more integrated and recovery based drug and alcohol systems, and has two overarching aims: 1. To reduce illicit and other harmful drug use; and 2. To increase the numbers recovering from their dependence. It further identifies three key themes: 1. Reducing demand creating an environment where the vast majority of people who have never taken drugs continue to resist any pressures to do so, and making it easier for those that do to stop. This is important if we are to reduce the huge societal costs, particularly the lost ambition and potential of young drug users. The UK demand for illicit drugs is contributing directly to bloodshed, corruption and instability in source and transit countries, which there is a shared international responsibility to tackle; 2. Restricting supply - drugs cost the UK 15.4 billion each year. The UK must be made an unattractive destination for drug traffickers by attacking their profits and driving up their risks; 3. Building recovery in communities - the Government wants to work with people who wish to take the necessary steps to tackle their dependency on drugs and alcohol, and will offer a route out of dependence by putting the goal of recovery in place. The Government will build on the investment that has been made in treatment to ensure more people are tackling their dependency and recovering fully. Approximately 400,000 benefit claimants (around 8% of all working age benefit claimants) in England are dependent on drugs or alcohol and generate benefit expenditure costs of approximately 1.6 billion per year. The strategy highlights an ageing heroin using population, with fewer young people becoming dependent upon the drug, and an increase in the number of young people presenting for treatment for drugs other than heroin. 13 Home Office (2010). Drug Strategy

25 The strategy acknowledges that drug treatment based around substitute prescribing has been very effective in reducing crime and preventing wider damage to the community. It also acknowledges that harm reduction initiatives like needle exchange schemes have reduced the harms caused by dependence, most notably the spread of blood-borne viruses including HIV. Importantly, the strategy highlights that disproportionate harm caused by drug and alcohol misuse among high risk groups such as those who have suffered childhood abuse, neglect, and trauma. The strategy is reviewed on an annual basis and the most recent update in 2013 highlights the following positive trends: 14 Drug use remains at its lowest level since measurement began in 1996, across all age ranges (children and young people as well as adults). Numbers of people completing drug treatment free of dependence are at a record high. Drug-related deaths have fallen over the last three years. The National Drug Strategy states that recovery involves three overarching principles: 1. Wellbeing, 2. Citizenship, 3. Freedom from dependence. Recovery is perceived to be an individual, person-centred journey rather than an end state that will also mean different things to different people. It is therefore argued that individuals must be at the heart of any recovery system with a range of commissioned services at the local level providing tailored packages of care and support. The strategy states that services must take account of diverse local needs to enable all individuals to become free from their dependence. The role of substitute prescribing in this system is still seen to play an important part in the treatment of heroin dependence by stabilising drug use and supporting detoxification. However, it recognises there are significant numbers of users who remain on substitute prescriptions as their first and only step in their recovery journey. The success of recovery can be predicted by individuals levels of recovery capital, this capital is the resources that are necessary to help start and

26 sustain drug and alcohol dependence. The strategy cites Best and Laudet (2010) 15 who identify four forms of recovery capital: 1. Social Capital - the resource a person has from their relationships. 2. Physical Capital - money and a safe place to live. 3. Human Capital - skills, mental and physical health and a job. 4. Cultural Capital values, beliefs and attitudes held by the individual. Building on recovery capital, the national strategy identifies the following areas as critical to achieving a successful recovery orientated system: A system that is locally led and locally owned All services to be outcome focused. Local areas to use a whole systems approach through pooled funding to jointly commission recovery services. Develop an inspirational recovery orientated workforce. Supported by recovery networks and recovery champions. Keeping children safe and rebuilding families. Enable reintegration into communities. Tackling housing needs. Helping people find sustained employment. Test approaches where money follows success and explore Payment by Results (PbR). 3.2 National and Local Alcohol Strategies The Government s National Alcohol Strategy 16 was launched on 23rd March 2012 and identified four key priority areas for action 5. Tackling the price and availability of alcohol 6. Reducing alcohol related harms locally 7. Engaging the industry via the Responsibility Deal. 8. Supporting young people, individuals and families to change Salford s recently completed Alcohol Equity Audit (AEA) findings were broadly in line with the new national strategic direction: There is evidence of a link between the number of venues selling alcohol in one area and levels of harm, whether this is crime, damage to health, or harm to young people. This has been evidenced locally within Salford s AEA and a key basis for this paper s recommendation to review accessibility to alcohol. 15 Best, D. and Laudet, A.B. (2010) The Potential of Recovery Capital, RSA 16 HM Government (2012). The Government s Alcohol Strategy. TSO. 26

27 The national strategy proposes to amend the Licensing Act 2003 to use Cumulative Impact Policies to apply to on and off trade premises and also control the density of premises by reducing the burden of evidence required by licensing authorities when making decisions. From 25 th April 2012, licensing authorities and local health bodies will formally become responsible authorities under the Licensing Act 2003, ensuring that they are automatically notified of an application or review, and can more easily instigate a review of a license themselves. Individuals and local communities will also have more power to input into licensing decisions locally. Supporting individuals to change behaviour through promoting sensible drinking, working with troubled families, building community support, social marketing and targeted campaigns to at risk groups. Examples include targeting those under 25 years and population approaches through Change4Life. Good information sharing is critical if local partners are to understand the scale and range of the problems locally; identifying vulnerable groups who are likely to be at a higher risk of alcohol related harm and then identify priorities for action. The strategy recommends using the College of Emergency Medicine guidance with the support of senior clinical, police and local authority leaders to enable joint intelligence to target policing and tackle problem premises. The sharing of information and joint intelligence used in the completion of the AEA demonstrates what can be achieved by multi agency working. Following the new strategy, the Home Office launched a ten week consultation on five key areas with the aim of reducing alcohol fuelled crime and anti social behaviour: A ban on multi-buy promotions. 2. A review of the existing mandatory licensing conditions. 3. Health as a licensing objective for cumulative impacts. 4. Cutting red tape for responsible business. 5. Minimum unit pricing (MUP). In July 2013 the consultation findings were produced in Next steps following the consultation on delivering the Government s alcohol strategy and have been grouped within three themes: 1. Targeted national action - including direct action from government and ambition for further voluntary commitments by the alcohol industry to tackle alcohol related crime and health harms.

28 2. Joining up at the local level - including how the government will support local areas with high levels of alcohol related harms to deliver change. 3. Promoting growth and supporting responsible businesses by removing unnecessary red tape while maintaining integrity of licensing system Targeted National Action Minimum Unit Pricing: The government has decided that the introduction of a minimum unit price for alcohol will remain a policy under consideration, but will not be taken forward at present. They also intend to monitor the legal developments and the implementation of this policy in Scotland. A ban on multi buy promotions: The government believes that the evidence for the effectiveness of a ban on multi-buy promotions in the off-trade in reducing hazardous and harmful consumption remains inconclusive, and will also not be taking this forward. The government will introduce a ban on the sale of alcohol in England and Wales below the level of alcohol duty for a product plus value added tax (VAT), to come into effect no later than Spring The Government believes this will end the sale of the very cheapest alcohol (for example a can of 4% ABV lager could not be sold for less than 40p). Mandatory Licensing Conditions: The Government intends to make existing licensing conditions more effective by: Enabling tougher action on irresponsible promotions in pubs and clubs through simplifying and tightening the law. Strengthening measures to help people drink more responsibly - requiring on trade premises to promote small measures and ensure all water is drinkable. Improve age verification requirements Challenging and Supporting Industry to Take Action The Government believes that the alcohol industry can go further to show that voluntary action can deliver the significant changes needed. It is now challenging industry to take action in other areas, increasing their level of ambition and ownership of the issues, to reduce alcohol-related crime and disorder and health harms, tackle the harmful effects of binge drinking and to support growth in local economies. This includes seeking rapid action in the following areas: supporting targeted local action; tackling the high strength or high volume products that can cause the most harm; promoting and displaying alcohol responsibly in shops; and improving education around drinking. 28

29 3.2.2 Targeted Action at the Local Level The Government wants to enable local areas to strengthen partnerships and take the right action for their community, building on Baroness Newlove s Alcohol Fund ( 1 million fund from the Department for Communities and Local Government helping 20 communities to tackle alcohol-fuelled anti-social behaviour.) Through this fund local alcohol action areas will be developed, that will benefit from advice and support from the Government, Public Health England, national industry representatives and other partner agencies with three aims: 1. Reducing alcohol related crime and disorder. 2. Reducing alcohol-related health harms. 3. Promoting growth by establishing diverse and vibrant night time economies. These areas will be encouraged to focus efforts by implementing stronger partnerships (e.g. pooled expertise/budgets), better enforcement (e.g. cumulative impact polices) and improving the evidence (e.g. data sharing) Health as a licensing objective The Government also consulted on how to introduce health as a licensing objective linked specifically to cumulative impact. This would allow licensing authorities to take wider alcohol-related health harm into account when developing cumulative impact policies. The Government has stated its continued interest in this policy since there is good international evidence that controls on premises density reduce a range of harms from alcohol, including crime and health harms. However, at present, local processes and data collection are considered insufficient and it is unclear how this proposal could be implemented in practice. The Government intends that Public Health England will support local alcohol action areas interested in developing this work Promoting growth and supporting responsible businesses The Government have stated that while the reduction of red tape should not be at the expense of safeguards against crime, irresponsible behaviour and risks to public health, there are areas where Government can reduce the burden on responsible business and community groups. There will be a number of changes to the licensing system that include: Introducing a new light touch authorisation to sell alcohol the Community and Ancillary Sellers Notice under the 2003 Act for ancillary sellers and community groups. 29

30 Increasing the annual limit for the number of Temporary Event Notices (TENs) that can apply to particular premises from 12 to 15. Freeing up businesses that provide late night refreshment by enabling licensing authorities to make local exemptions for particular locations or types of premises. Abolishing the requirement to renew personal licences every ten years. Removing the requirement to report the loss or theft of licences issued in relation to the 2003 Act to the police Consulting in due course on abolishing personal licences altogether Salford Alcohol Harm Reduction Strategy The current alcohol specific strategy Good Life with Alcohol in Salford: An Alcohol Harm Reduction Strategy For addresses five drivers to reduce alcohol related harm: 1. Investment in high quality treatment and treatment systems 2. Encouraging healthier attitudes to alcohol 3. Developing healthy alternatives to alcohol 4. Ensuring a well managed environment 5. Ensuring well managed sales of alcohol Salford s Alcohol Harm Reduction Strategy is in line with the National Alcohol Strategy The local strategy was initiated in 2007, by a Salford City Council Cabinet Working Group that had also anticipated the need for more regulation of the advertising of alcohol. This is an issue which is now being addressed by the Responsibility Deal with the alcohol industry. The strategy is also aligned with the Crime and Disorder Reduction Strategy and annual Strategic Threat Assessment Plan contributing towards Salford City Councils objectives to achieve a healthy city through increasing life expectancy, promoting positive attitudes to sexual health and wellbeing and to improve the quality of life, mental health and wellbeing. 18 The strategy has enabled key partnerships to be developed through the alcohol reference group and informs the local Health and Wellbeing board on the progress made. The development of future integrated recovery systems for drug and alcohol should continue to consider the progress through the actions already set out to reduce harm from alcohol in this strategy. This HNA recommends that consideration be given to further developing an integrated strategic approach for both alcohol and drugs. 17 Salford City Council. (2010) Salford Alcohol Harm Reduction Strategy _short_version.pdf

31 3.3 Recovery Orientated Drug Treatment (2011) and Medications in Recovery (2012) An expert group chaired by Professor Jon Strang was set up through the NTA in response to the challenges set out in the National Drug Strategy. They produced an Interim Report in that provided immediate recommendations for improving the recovery orientation of treatments inclusive of Opioid Substitution Treatment (OST). 20 OST involves the prescribing of opioid agonist medicines, most commonly oral methadone or buprenorphine, to those dependent on heroin and other opiates. The treatment, which should form part of a package of interventions, alleviates withdrawal symptoms and blocks the craving for illicit opiates. OST is generally considered for those who have difficulty in stopping their drug use and completing withdrawal. It was concluded that OST helps prevent people dropping out of treatment suppresses illicit use of heroin, reduces crime, reduces the risk of blood borne virus (BBV) transmission, and reduces the risk of death. However, there was less persuasive evidence that OST suppresses other drug use or promotes abstinence from other drugs, improves physical and mental health or improves the social integration of marginalised heroin users. It was also concluded that time limited OST is not effective and can lead to greater risks of relapse, BBVs and overdose. Moreover it was found that moving too quickly to abstinence may produce worse outcomes than treatment initially orientated to maintenance. Recovery Orientated Drug Treatment (ROTD) states that the level and quality of recovery capital plays a pivotal role in generating successful outcomes since those with good social integration and employment are more likely to leave treatment without relapse. Accordingly, a key aim of recovery orientated drug treatment is to boost recovery capital and ensure access to the resources required to protect against relapse. As part of the evidence review the ROTD identified the main components of effective OST. These outlined in Appendix 2. ROTD recommends developing Patient Placement Criteria to differentiate those who might be expected to rapidly recover with no or limited substitute prescribing from those needing long-term care. It argues that segmenting 19 NTA. (2011). Recovery-orientated drug treatment an interim report by Professor John Strang, chair of the expert group Bell J. on behalf of ROTD (2012). Medications in Recovery: Re-orientating drug dependence treatment. Appendix C- Opioid Substitution Treatment and its effectiveness: review of the evidence. 31

32 treatment and recovery populations will allow for an understanding of differential rates of recovery probability. It also calls for the development of a set of treatment and recovery indicators for use by key workers at assessment and review to identify treatments and specific interventions from which clients will be most likely to benefit. The ROTD group further maintained that the commissioning of local recovery orientated specialist drug and alcohol services should inform by informed by: Understanding the dimensions of recovery and how these fit into a conceptual framework so that treatment focuses not only on preventing immediate and longer-term harm but also on helping patients to build the resources they will need to sustain recovery: recovery capital. Determining how progress in treatment and the accumulation of positive capital can be measured in order to monitor the benefits from, and progress of, treatment. Developing an understanding of how interventions can be layered and sequenced to support and best deliver a personally-relevant and evolving journey of treatment and recovery. Optimising OST through targeted phases of treatment in line with client need. The potential wider future use of a range of medications and technologies (both existing and in development) in a range of treatment and recovery settings. In July 2012, the ROTD produced its final report Medications in Recovery. Reorientating Drug Dependence Treatment. 21 The report outlined the vision and rationale for recovery systems: The existence of an accessible, evidence-based drug treatment system in every part of England gives us an excellent opportunity to improve on the past by using international historic evidence as the floor for our ambition not its ceiling. The key findings of the report identified that: Much has been achieved by England s drug treatment system since 2001 in improving people s health. Heroin is an especially tenacious and habit forming drug and many people have not recovered. Fewer young people are now coming into treatment OST is effective but should be a platform for recovery and not an end in itself 21 NTA. (2012). Medications in Recovery. Re-Orientating Drug Dependence Treatment. 32

33 Leaving treatment is significant but is not recovery. It is important not to end treatment too early. People will recover at different rates, all need recovery support. The expert group also identified key elements of a successful treatment system that should be embedded into any current and future delivery of specialist services. A shared vision of recovery, and leadership. Organisation and staff able to support and sustain change. Staff who believe in the treatment they are delivering. A structured programme with clear treatment goals. Availability and range of OST medications. Range and quality of psychosocial interventions. Active referral to self help and mutual aid. Links to recovery orientated community organisations Conceptual Framework for Promoting Recovery ROTD s framework for promoting recovery places an emphasis on recovery assets and developing mutual aid through peer support, and harnessing the motivational momentum found at the first treatment contact. The recovery journey is then underpinned by comprehensive assessment and a recovery care plan process that is regularly reviewed and adapted as needed. The principles and features of a recovery orientated drug treatment system for both providers and commissioners are detailed in Appendix 3. A clear need is identified for appropriate leadership across all providers of care to help establish explicit recovery orientated assessment and care planning within a more visible recovery culture across all services. This must also cater for those people with mental health or physical health problems. This can require multidisciplinary coordination of care and should be implemented across all care providers and supported by clear and accountable clinical governance structures. Treatment services must create an accessible and integrated offer that is personalised and helps to promote and support wider recovery objectives for each individual. Medication to support abstinence is still a crucial part of this service, but medication or abstinence on its own is unlikely to achieve recovery. The challenge for individual drug users is changing entrenched patterns of drug using behaviour. The role of a key worker is central to providing optimism and the resources to aid the recovery through the use of: Goal setting Emphatic listening 33

34 Exploring consequences of behaviour and benefits of change Problem recognition Managing rewards and negative contingencies Involving social networks Assessment and Recovery Care Planning: Plan Review, Optimise ROTD identified the vital elements of an effective journey of treatment and recovery including: Properly assessing and regularly reviewing an individual s needs. Planning treatment to respond to these needs as they change during treatment. Optimising or adapting treatment interventions to respond to failure to benefit or to capitalise on windows of opportunities for faster recovery. The assessment process is an important part of the therapeutic process; it provides individuals in treatment with objective feedback on their situation, enabling a self assessment and evaluation of their situation. This joint assessment can then be used as a baseline to review and develop goals that enable a recovery focused care plan that is agreed in collaboration with the person and key worker. This assessment for recovery aims to deliver an informed understanding of the person s wishes, substance use, and the severity and complexity of clinical and other problems; it must identify their strengths and the obstacles to achieve their recovery. The recovery plan must consider the recovery capital that is available to the individual, including personal skills, safe accommodation, supportive relationships, personal responsibility, community engagement and positive participation in wider society. The assessment must also include methods for relieving acute distress and addressing urgent issues (e.g. minimise risk of overdose). Therefore initial stabilisation on OST, active support for detoxification and relapse prevention may be required as part of the assessment. Drug treatment services must also be able to screen, assess and identify treatment need for mental health problems since up to 70% of the drug treatment population have reported mental health problems. 22 Physical health problems can also be a persistent barrier to recovery particularly among an aging treatment population. Older service users may face particular issues in relation to recovery, which, combined with drug use 22 Weaver T., Stimson G., Tyrer P., Barnes T., and Renton A. (2004) What are the implications for clinical management and service development of prevalent co morbidity in UK mental health and substance misuse treatment populations? Drugs: Education, Prevention and Policy

35 histories measured in decades rather than years, can compound the health and social problems associated with ageing and drug use. Health issues including high blood pressure, abnormal pulmonary function, abnormal liver function, hepatitis B and C are common amongst older drug users 23 as are mobility issues, social isolation, poverty and a lack of settled housing, there is also a low level of engagement with mainstream health services. 24 Consideration should be given to how these clients are managed and monitored to improve their health, wellbeing and recovery potential thus ensuring future needs and the associated costs to health and social care services are minimised. It is essential that recovery care planning reflects the ambitions of service users and gives them space, time and support to make meaningful decisions about their futures. The plan should be a collaborative process that identifies preferred options from an attractive and flexible menu. Recovery care planning will also identify practical and staged actions that can promote progression to recovery. The recovery care plan must include regular reviews as this provides the opportunity to measure and evaluate progress towards set goals including impact of interventions and enables the setting of new goals to move individuals along in their recovery journey. The measurement of treatment and recovery capital can help to: Make effective decisions on which areas to target with adapted or optimised treatment interventions Support the person s confidence in their recovery and so further progress in treatment. The Treatment Outcomes Profile (TOP) is the national clinical instrument for monitoring outcomes in drug treatment and provides a core set of outcome measures to assess OST benefits. Specialist drug services should consider wider methods to measure recovery capital such as change motivation and engagement, support available from family and social network, skills and participation and the environment in which they are living. ROTD suggest a core recovery measure for OST would be the extent to which the person in treatment is experiencing reductions in the psychological 23 Hser Y.I., Gelberg L., Hoffman V., Grella C.E., McCarthy W., Anglin M.D. (2004) Health conditions among aging narcotics addicts: medical examination results. Journal of Behavioral Medicine.(6): Roe B., Beynon C., Pickering L. and Duffy P. (2010) Experiences of drug use and ageing: health, quality of life, relationship and service implications. Journal of Advanced Nursing 66(9), doi: /j x 35

36 aspects of dependence, such as the desire or compulsion to take heroin, difficulties in controlling heroin use and time devoted to obtaining or taking the drug or to recovering from its effects. Standardised clinical interviews can inform such measures (e.g. Composite International Diagnostic Interview (CIDI) and Subjective Opioid Withdrawal Scale (SOWS)) The Phasing and Layering of Interventions ROTD proposes phasing or sequencing progressive and dynamic recovery packages of care that are layered such that levels of intensity accord with need, choice, efficacy, and progress towards recovery. The suggested approach to phasing and layering of treatment is offered as an aid to the development of local solutions. It consists of four phases (Engagement and stabilisation; Preparation for change; Active change; Completion) with three layers of Intensity (Standard; Enhanced; Intensive). An example of how a treatment services or packages of care could be configured using this approach is given in Appendix 4. To support each phase of treatment the ROTD have suggested a number of evidence based psychosocial interventions, which are supported by Clinical Guidelines and NICE guidance on psychosocial interventions in drug misuse (2007). 25 These are outlined in Appendix 5. ROTD also provides examples of the components of core key working that should be encompassed within a recovery orientated system; these components are detailed in Appendix Improve Well Being The general population can secure improvements in mental health and well being through the embedding of the five ways to wellbeing. 26 These are a set of evidence based actions developed by the New Economics Foundation (NEF) that can often be incorporated into people s everyday lives with ease in order to promote well being. The five ways to wellbeing are; 1. Connect 2. Be Active 3. Take Notice 4. Keep Learning 5. Give ROTD acknowledge that it is unknown whether the five ways to wellbeing can be successfully adapted to the treatment population who have more complex and challenging needs than the general population. However these principles should be encouraged where possible during all recovery journeys

37 3.3.5 Recovery Support and Self Help ROTD stresses the importance of building an individual s recovery capital. Building this capital places should involve wider health and social care services (such as housing and employment) as well as family, friends and peers. The role of treatment services should adapt to enable: Initiating recovery with a clear rationale for interventions in the context of achieving self sustained recovery. Directly helping to build capital in those starting from a low base. Involving support networks in treatment through interventions such as family support and social behaviour network therapy. Referring to, and actively supporting, contact with other services and peer support group. Involving peers directly through models such as peer role-models and recovery coaching Bridge-building with peer communities of support. Peer based recovery support is an effective method of communicating to people in treatment that recovery is actually possible. It is important to make recovery visible through peer role models such as recovery champions/coaches, networks and mutual aid groups. This overt visibility will help to improve understanding and increase individual ambition and motivation to work towards recovery. These visible pathways to recovery can be a powerful motivating tool, and peers should be chosen who are further along the recovery journey. A person who has been abstinent for many years and now in employment can be a beacon of what can be achieved in the long term; however their circumstances and experiences could be very different to those at the beginning of their own recovery journey. Matching peers is an important action that should be informed by gathering service user feedback and capturing multiple recovery stories that can be visibly displayed in treatment services. Although these journeys are individual, there will be common landmarks that can be recognised at the different stages of the recovery journey such as stability of use, stable accommodation, reduced medication and detoxification. Treatment services must embrace available self help approaches and encourage the development of local community connected peer and mutual aid networks. A number of steps should be followed by local treatment services to achieve this: Identify and appoint local strategic, therapeutic and community recovery champions. 37

38 Improve the visibility of recovery by access to a recovery coach and invite representatives for the 12 step fellowships to meetings and talk to people in treatment. Improve knowledge and understanding of peer support among staff and those in treatment. Support the development of mutual aid and peer support meetings by making facilities available and maximise attendance. Promote choice through the peer support options. Facilitate access through initial contact, accompanying and explaining the offer. NICE has recognised the efficacy of self help approaches that are based on 12 step principles utilised in Narcotics and Alcoholics Anonymous (NA and AA). NICE recommends that information regarding self help groups should be routinely provided by drug treatment staff and who should also help facilitate the initial contact through accompanying clients and arranging travel. Through engaging with well developed peer support networks, people will be more likely to take greater responsibility for their own lives and thus reduce dependence on drug treatment services. The addition of just one abstinent person to a drinker s social network has been shown to increase the probability of an individual s abstinence in the following year by 27%. 27 The contribution that family and friends can make to a person s social recovery capital is significant. Families will also need support of their own and should be offered assessment, guided self help, information and advice, and facilitated contact with support groups and individual family meetings. NICE (2007) recommend behavioural couples therapy or family interventions with a non drug misusing family member, carer or partner Post Treatment Support Post treatment support is essential to identifying risk and helping prevent relapse. Local treatment services should consider regular recovery checkups and assessments. ROTD identifies that drug related aftercare may include educational, psychosocial, and pharmacological interventions. The level and intensity of this support will depend on the differences in individual recovery capital but core components should include: Mutual Aid or peer support. Recovery Coaching. Housing, employment and education support. Family and parenting support. 27 Litte M., Kadden R., Kabela-Cormeir E. and Petry. N (2009). Changing Network Support for Drinking: network Support Project. Two Year Follow Up. J Consult Clin Psychol 77 (2): Doi: /a

39 3.3.7 Housing Support Access to stable, secure and safe housing plays an integral part in a person s recovery pathway, but is one component that drug treatment services often have less of an influence on. Treatment services can however support people s ability to access and retain housing and should actively encourage key workers to implement and advocate the following: Assess housing related need at entry to treatment and review it regularly. Optimise treatment to improve stability and ability to satisfy landlord expectations. Provide advice, information and advocacy to ensure those in treatment are receiving the appropriate welfare benefits / Universal Credit. Provide training and support in the skills needed to maintain a household and tenancy and to include financial and debt management to ensure rent is paid. Working with people to improve employment chances. Partnerships with others to provide second stage or supported accommodation. Provide housing support Employment support Routes into work whether paid or unpaid can help sustain gains made in treatment, whilst benefiting society through reduced reliance on the welfare system. Drug user s employability can be affected by their physical and mental health problems, unstable accommodation, offending history and skill base. Treatment services have an important role in raising the profile of employment as part of the recovery pathway and contributing to the introduction of work experience through local recovery networks in their own services. Treatment services should also forge closer working relationships with welfare and employment providers such as the Jobcentre plus (JCP) to help prepare individuals as early as possible in their recovery journey. These links will also help people comply with any benefit conditionality or interaction that is required with JCP services. For those people with a drug and alcohol dependency issue, guidance has been produced 28 to encourage treatment providers to work more closely with Jobcentre Plus and Work Programme providers to better support employment outcomes for this population group. From Autumn 2013, the Department for Work and Pensions will introduce tailored benefit conditionality and benefit 28 NTA (2012). Employment and Recovery A Good Practice Guide. 39

40 easement for people commencing treatment via the new Universal Credit. This action will address the National Drug Strategy commitment to offer relaxed benefit conditionality in order to encourage people to engage in treatment and to focus on recovery. A good practice checklist that specialist treatment services should incorporate when developing recovery assets and building on existing partnerships with the DWP can be found in Appendix Adapting Recovery to Different Settings (Prison, Residential and non residential rehabilitation) Recovery can be better supported in a service that provides a safe environment, daily structure, a range of psychosocial interventions and higher intensity interventions with peer support since all are beneficial to recovery. In the past, residential rehabilitative treatment was often provided for those with no or unstable housing or reserved until the later phases of a treatment journey. Aligning the ROTD approach to the phasing and layering of treatment suggests that rehabilitation services may be more cost effective when used earlier if the individual is ready for active change and higher intensity treatment. Medications in Recovery (2012) offers specific recommendations on drug treatment in prisons that take account of the correlation between drug withdrawal and suicide in the first week of custody, the high value of drugs relative to prisoners small incomes and the significant reductions in drug consumption and injecting that usually occur during incarceration, the concentration of drug users in prisons and frequency of movement between them, and the high risk of overdose on release. Based on these factors a modified approach is recommended which offers stabilisation from the first night of custody with extended prescribing reviewed every 3 months (DH 2010). Individuals with a sentence of over 26 weeks are expected to become drug free. 3.4 National Institute for Health and Clinical Excellence (NICE) Guidance As outlined by the NTA and ROTD, there are a number of NICE clinical guidance recommendations and quality standards that have been developed for specialist alcohol and drug commissioners and providers. The following section outlines the 2011 NICE quality standards and how these should be included within the delivery of specialist services NICE Quality Standards Summary Quality Standard for Drug Use Disorders NICE QS Overview

41 This quality standard covers the treatment of adults (18 years or over) who misuse opioids, cannabis, stimulants or other drugs in all settings in which care is received, in particular inpatient and specialist residential and community-based treatment settings. This includes related organisations such as prison services and the interface with other services, for example those provided by the voluntary sector Introduction Drug use disorders are defined as intoxication by, dependence on, or regular, excessive consumption of psychoactive substances leading to social, psychological, physical or legal problems. Opioid misuse is often characterised as a long-term chronic condition with periods of remission and relapse. Patterns of cannabis and stimulant misuse vary considerably and are less well understood. Patterns of drug misuse vary in England and Wales. Among people aged between 16 and 59 years, the most commonly used psychoactive substance is cannabis, followed by cocaine and ecstasy. Opioids are used less commonly 30 but present the most significant health problems. People with drug use disorders may have a range of health and social care problems. Drug misuse is more prevalent in areas characterised by social deprivation, which in turn is associated with poorer health. Many people with drug use disorders have lifestyles that are not conducive to good health. Injecting drug users are particularly vulnerable to contracting blood-borne viruses and other infections. A long-term study of people with an addiction to heroin showed they had a mortality risk 12 times greater than the general population. 31 The aim of drug treatment is to reduce such inequalities by helping people overcome their addiction and improve their quality of life. The quality standard for drug use disorders requires that services should be commissioned from and coordinated across all relevant agencies encompassing the whole drug use disorder care pathway. An integrated approach to provision of services is fundamental to the delivery of high quality care to adults with drug use disorders. Under the Health and Social Care Act 2012, the commissioning of substance misuse treatment services was transferred to local authorities in April NICE will produce a local government briefing in the first quarter of 2013/14, drawing together resources for local authorities on drug services, including this quality standard and related NICE guidance. 30 Home Office (2011) Drug misuse declared: Findings from the 2010/11 British Crime Survey England and Wales 31 Department of Health (2007) Drug misuse and dependence: UK guidelines on clinical management 41

42 The quality standard should be read in the context of national and local guidelines on training and competencies, for example competencies set out in the Drugs and Alcohol National Occupational Standards (DANOS). Implementation of this quality standard is dependent on all healthcare professionals involved in the assessment, care and treatment of adults with drug use disorders being appropriately trained, competent and supervised to deliver the actions and interventions described in the quality standard List of quality statements As per the Quality Standards for alcohol dependence and misuse, NICE have produced 10 Quality statements with associated tools to support implementation into local systems. These are described below and should also be built into the commissioning of specialist drug services in Salford. Statement 1. People who inject drugs have access to needle and syringe programmes in accordance with NICE guidance. Statement 2. People in drug treatment are offered a comprehensive assessment. Statement 3. Families and carers of people with drug use disorders are offered an assessment of their needs. Statement 4. People accessing drug treatment services are offered testing and referral for treatment for hepatitis B, hepatitis C and HIV and vaccination for hepatitis B. Statement 5. People in drug treatment are given information and advice about the following treatment options: harm-reduction, maintenance, detoxification and abstinence. Statement 6. People in drug treatment are offered appropriate psychosocial interventions by their key worker. Statement 7. People in drug treatment are offered support to access services that promote recovery and reintegration including housing, education, employment, personal finance, healthcare and mutual aid. Statement 8. People in drug treatment are offered appropriate formal psychosocial interventions and/or psychological treatments. Statement 9. People who have achieved abstinence are offered continued treatment or support for at least 6 months. Statement 10. People in drug treatment are given information and advice on the NICE eligibility criteria for residential rehabilitative treatment. 42

43 3.4.2 Quality Standard 11 Alcohol dependence and harmful alcohol use quality standard NICE Overview This quality standard covers the care of children (aged years), young people (aged years) and adults (aged 18 years and over) drinking in a harmful way and those with alcohol dependence in all NHS-funded settings. It also includes opportunistic screening and brief interventions for hazardous and harmful drinkers Introduction Alcohol dependence and harmful alcohol use are associated with increased risk of physical and mental health co-morbidities including gastrointestinal disorders (in particular liver disease), neurological and cardiovascular disease, depression and anxiety disorders and ultimately, premature death. It is estimated that 24% of people aged between 16 and 65 in England consume alcohol in a way that is potentially or actually harmful to their health or well-being. Depending on the diagnostic criteria used, alcohol dependence affects between 3% and 6% of people. Brief interventions can be effective in reducing drinking in hazardous and harmful drinkers, but people with alcohol dependence and some harmful drinkers will require more specialist alcohol services. Alcohol misuse is also an increasing problem in children and young people, with over 24,000 treated in the NHS for alcohol-related problems in 2008 and Current practice across the country is varied and access to a range of specialist alcohol services varies as a consequence. Alcohol dependence and harmful alcohol use are associated with increased risk of physical and mental health co-morbidities including gastrointestinal disorders (in particular liver disease), neurological and cardiovascular disease, depression and anxiety disorders and premature death. This quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for harmful drinkers and people with alcohol dependence in the following ways: Preventing people from dying prematurely. Enhancing quality of life for people with long-term conditions. Ensuring that people have a positive experience of care. Treating and caring for people in a safe environment and protecting them from avoidable harm

44 It is also expected that this quality standard will contribute to reducing alcoholrelated hospital admissions and readmissions to hospital. The quality standard for alcohol dependence and harmful alcohol use requires that services should be commissioned from and coordinated across all relevant agencies encompassing the whole care pathway. An integrated, multidisciplinary approach to provision of services is fundamental to the delivery of high-quality care to people who misuse alcohol. A specialist alcohol service is one in which the primary role is the assessment and management of alcohol misuse, including both psychological and physical effects. Some specialist addiction services will have this role for both drug and alcohol misuse. NICE quality standards are for use by the NHS in England and do not have formal status in the social care sector. However, the NHS will not be able to provide a comprehensive service for all without working with social care communities. In this quality standard, care has been taken to make sure that any quality statements that refer to the social care sector are relevant and evidence-based. Social care commissioners and providers may therefore wish to use them, both to improve the quality of their services and support their colleagues in the NHS List of statements NICE have recommended 13 key statements with associated evidence and tools to help achieve quality in the treatment of alcohol dependence and harmful alcohol use. These are outlined below and mechanisms should be put into place to ensure these standards are included in any Salford delivery model. Statement 1. Health and social care staff receive alcohol awareness training that promotes respectful, non-judgmental care of people who misuse alcohol. Statement 2. Health and social care staff opportunistically carry out screening and brief interventions for hazardous and harmful drinking as an integral part of practice. Statement 3. People who may benefit from specialist assessment or treatment for alcohol misuse are offered referral to specialist alcohol services and are able to access specialist alcohol treatment. Statement 4. People accessing specialist alcohol services receive assessments and interventions delivered by appropriately trained and competent specialist staff. Statement 5. Adults accessing specialist alcohol services for alcohol misuse receive a comprehensive assessment that includes the use of validated measures. Statement 6. Children and young people accessing specialist services for alcohol use receive a comprehensive assessment that includes the use of validated measures. 44

45 Statement 7. Families and carers of people who misuse alcohol have their own needs identified, including those associated with risk of harm, and are offered information and support. Statement 8. People needing medically assisted alcohol withdrawal are offered treatment within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric co-morbidities. Statement 9. People needing medically assisted alcohol withdrawal receive medication using drug regimens appropriate to the setting in which the withdrawal is managed in accordance with NICE guidance. Statement 10. People with suspected, or at high risk of developing, Wernicke's encephalopathy 33 are offered thiamine in accordance with NICE guidance. Statement 11. Adults who misuse alcohol are offered evidence-based psychological interventions, and those with alcohol dependence that is moderate or severe can in addition access relapse prevention medication in accordance with NICE guidance. Statement 12. Children and young people accessing specialist services for alcohol use are offered individual cognitive behavioural therapy, or if they have significant co-morbidities or limited social support, a multi-component programme of care including family or systems therapy. Statement 13. People receiving specialist treatment for alcohol misuse have regular treatment outcome reviews, which are used to plan subsequent care. 3.5 Recommendations Ensure available guidance is included within all current and future specialist alcohol and drug service specifications. Produce one clear Vision and Strategy Document for achieving a Recovery Orientated Drug and Alcohol System in Salford. Commission appropriate services which facilitate the engagement of clients with peer role models and peer support inclusive of self help and 12 step groups (Alcoholics Anonymous and Narcotics Anonymous), provide essential support to the family and social networks of individual drug and alcohol misusing clients, engage with employment and welfare services, assist with housing need and work with housing providers. Review the wider primary and secondary health care services referral processes and develop a communications plan to promote consistency 33 Wernicke's encephalopathy, a condition that affects the brain and nervous system, and is caused by a lack of thiamine (also called vitamin B1) in the body, are offered thiamine (either as tablets or as an injection followed by tablets, depending on the situation) to help prevent the condition developing or getting worse wernickes-encephalopathy 45

46 4 Drug Prevalence 4.1 Overview of National Drug Prevalence The European Centre for Drugs and Drug Addiction (EMCDDA) 2013 European Drug Report 34 suggests that overall drug use in the UK remains relatively high with reported lifetime prevalence of cocaine powder use ranked the highest in Europe at 10%. As is the case elsewhere, the illicit drug most commonly cited by users is cannabis. According to the Health and Social Care Information Centre (HSCIC) publication Statistics on Drug Misuse in England 35 in 2011/12 over a third (36.5%) of people aged 16 to 59 years old (around 12 million) reported having ever taken illicit drugs. Nearly three million (8.9%) said they have done so in the last year and around 1.7 million (5.2%) had reportedly taken an illicit drug in the last month. With regard to long-term trends in last year Class A drug use, among 16 to 59 year olds there was no statistically significant difference found when comparing reported rates from 2012 with those reported in 1996 (3.0% v 2.7%). However, the recorded decline in such rates among young adults (aged years) was found to be significant with a fall from 9.2% in 1996 to 6.3% in Data on reported drug use among pupils (11 to 15 years) also evidenced declines with 17% stating that they had ever used drugs in 2011 as compared with 29% in 2001, and 3% stating they used drugs at least once a month in 2011 as compared with 7% in As might be expected, older pupils were more likely to say they used drugs than younger ones with 23% of 15 year olds saying in 2011 they had used drugs in the last year as compared to 3% of 11 year olds. It worth noting that some young people are more likely to be vulnerable to drug use than others, 12% of those that had ever truanted or been excluded reported taking drugs at least once a month in 2011 but even among this vulnerable group overall declines in prevalence are reflected in the fact that in 2003 the stated figure was 21%. A significant trend that will be detailed more fully later in this assessment is the overall decline in the use of heroin and crack cocaine. That fewer young people are using heroin is indicated by the fact that in 2009/10 only 480 cited heroin as their primary drug when presenting at drug services, and by 2010/11 this had fallen to ECDDA (2013): European Drug Report HSCIC. (2012). Statistics on Drug Misuse England

47 Data from The Crime Survey for England and Wales (CSEW) 36 broadly correlates with that taken from HSCIC data cited above. Namely, that reported overall drug use in the last year was found to be highest amongst those aged 16 to 24 years old, with Class A use increasing in prevalence from the ages of 20 to 29 years old (a pattern that has been consistently observed since 1996). Other reported trends of interest include the observations that in the last year; men were more than twice as likely to have used drugs than women (12.4% vs. 5.5%), single people were more likely to use drugs than those with partners (17.4% compared to 10.3% for cohabiters and 3.2% for married people), those from White ethnics groups are more likely to use drugs than others (9.5% vs. 5.4% from non-white backgrounds) and those from the lowest income groups were more likely to use than those on higher incomes(13.6% among households with under 10,000 p.a. income vs. 7.4% among those households with incomes over 50,000 p.a.). 4.2 Estimated Drug Prevalence in Salford The following prevalence estimates are derived from matching Crime Survey for England and Wales (2011/12) data with a combination of Salford population, household and neighbourhood data (e.g. English Indices of Deprivation, Employment and Occupation, Age, Ethnicity). An average was taken from the above estimates to give Table 1. This suggests cannabis use is the most prevalent drug used in Salford followed by cocaine and ecstasy. Given the hidden nature of substance use the reported use may in fact be lower than the actual number of users. Table 1: Estimated number of 16 to 59 year olds in Salford using illicit drugs in the last year (2011/12) Class Drug Salford (16-59 years) Class A* Powder cocaine 3,240 Ecstasy 2,110 Hallucinogens 770 Class A/B Amphetamines 1,160 Class B Cannabis 10,420 Mephedrone 1,590 Ketamine 870 Not classified Amyl nitrite 1,220 Any Class A drug* 4,480 Any stimulant drug 5,090 Any drug 13,480 *only the most commonly used class A drugs (e.g. powder cocaine, ecstasy, hallucinogens) are used sufficiently frequently for a meaningful estimate to be produced for individual substances. The Any Class A drug figure includes

48 users of these named Class A substances as well as users of other substances including heroin and crack cocaine. Some individuals will use more than one substance. 4.3 Opiate and Crack Cocaine (OCU) Prevalence National Prevalence The latest official estimate of the number of heroin and crack cocaine users in England, 37 put the figure at below 300,000, this equates to 8.7 per thousand of the population aged According to the most recent estimates, the number of heroin and crack users fell to 298,752 in , from a peak of 332,090 in The number of people injecting drugs has also fallen significantly, from 129,977 in to 93,401 in Graph 1: Annual Estimates of Opiate and/or Crack Users in England The consistent decline in the estimates support the proposition of a continuing shift away from the most harmful drugs. This is particularly noticeable among younger people. Each of the last two years has seen a statistically significant decrease in the national estimate of OCUs aged and (see Graph 2 below). Each year has also seen an increase in the number of OCUs aged over 35, which is statistically significant when comparing with Taken together these figures demonstrate an aging national OCU population. 37 National Treatment Agency (2013). National and regional estimates of the prevalence of opiate and/or crack cocaine use : a summary of key findings 48

49 Graph 2: Annual Estimates of Opiate and/or Crack Users in England by Age Group Regional and Local Prevalence The regional picture looks similar to the national. Over the last three years the North West has seen a decline in the estimated number of OCUs. Graph 3: Estimated North West OCU Prevalence Rate per year olds between

50 The North West region had the highest prevalence of opiate and/or crack use at users per 1000 population aged 15-64, followed by the North East at and Yorkshire and the Humber at The South East and the East of England had the lowest prevalence of opiate and/or crack use at 5.98 and 6.30 per 1000 respectively. 38 There is a regional difference in the age breakdown of OCUs; the North West has only the 6 th (out of nine regions) highest rate of OCUs in the year age group and the year age group but the highest in the year age group. Both younger age groups have seen a statistically significant fall in the number of OCUs over two years in the North West, whilst the over 35 have increased in number although this change is not large enough to be statistically significant. Salford s rate of OCUs per 1000 population places it 14 th out of 22 areas in the North West region. The rate for Salford is similar to the regional rate of per Salford is 7 th lowest out of the 10 Greater Manchester authorities. Salford has seen a fall in the number of opiate and/or crack users (OCUs) according to the latest National Treatment Agency (NTA) estimates published in March The estimate of 1,745 is 170 (9%) less than the previous estimate. The rate of per 1000 equates to around 1 OCU for every 90 adults (aged 15-64) in Salford. Table 2: Opiate and Crack Users in Salford: Prevalence Estimates % % OCUs Estimate CI lower CI upper Increase Opiate users Estimate CI lower CI upper Increase , , , ,139 2,487 4, ,689 2,123 3, ,683 1,552 1, ,403 1,309 1, ,411 2,088 3, ,046 1,765 2, ,754 1,613 1, ,461 1,346 1, ,915 1,696 2, ,670 1,507 1, ,745 1,590 2,040-9%* ,418 1,139 1,700-15%* % % Injectors Estimate CI lower CI upper Increase Crack users Estimate CI lower CI upper Increase , ,071 1,365 3, , ,509 1,140 2, N/A N/A N/A , , , , %* ,065-22%* 38 HSCIC. (2012). Statistics on Drug Misuse England

51 Both the Year old and year old age groups saw a fall compared to whilst the year old age group remained constant (Graph 4). This is consistent with an aging local OCU population. Graph 4: Age Distribution of OCU prevalence in Salford between Recommendations Employ geographical mapping data to prioritise recovery assets in the neighbourhoods identified as having greatest need inclusive of youth unemployment. 51

52 5 Drug Treatment: Costs and Consequences 5.1 National Overview The National Treatment Agency (NTA) report Drug Treatment 2012: Progress made, challenges ahead 39 produced a range of information graphics that neatly communicate the following drug related headlines: 1. Fewer people are in treatment for drug use 2. Drug use is down 3. More drug users are recovering 4. Younger people are doing better 5. People who use heroin are getting older 6. Crime is down Figure 5: Drug Trends 2012: Fewer people are in treatment for drug use Figure 6: Drug Trends 2012: Drug use is down

53 Figure 7: Drug Trends 2012: More drug users are recovering Figure 8: Drug Trends 2012: Younger people are doing better Figure 9: Drug Trends 2012: People who use heroin are getting older 53

54 Figure 10: Drug Trends 2012: Crime is down Drug misuse is a major public health problem causing damage to both the physical and mental health of drug taking individuals and to their surrounding networks and communities. The 2012 NTA report Estimating the Crime Reduction Benefits of Drug Treatment and Recovery 40 and subsequent Why Invest 41 documents provide a summary on the estimated costs of drug addiction for individuals, communities and society. The headline estimates are that every 1 spent on drug treatment will save 2.50 in costs to society and with every 100 spent a crime is prevented. Every year drug addiction in total costs society an estimated 15.4 billion, the main component of which is the estimated 13.9billion cost of drug related crime. The annual cost of deaths related to drug misuse is estimated at 2.4billion, and every year drug misuse costs the NHS an estimated 488million. Evidence from NICE suggests drug treatment is cost effective in that it annually provides an estimated saving of 230million to the NHS and prevents over 300 drug-related deaths. A typical heroin user that remains out of treatment can spend an average of 1,400 per month on drugs (which is over two fold the average mortgage). The average annual crime cost of a dependent heroin user that is not in treatment is calculated to be 26,074 whilst conversely every offender in effective treatment results in an average of 26 offences being prevented per year. At a population level, it is argued that treatment delivers an estimated annual crime saving of 960m to the public, businesses, the criminal justice system and the NHS and a reduction of 4.9 million crimes inclusive of: ,000 fewer burglaries and robberies, saving homes and businesses 75,000 fewer car thefts and break-ins, saving motorists and businesses 40 NTA.(2012). Estimating the Crime Reduction Benefits of Drug Treatment and Recovery 41 NTA. (2012).Why invest to save?

55 350,000 fewer acts of prostitution. 1.1m fewer shoplifting thefts, saving retailers and businesses 25,000 fewer bags snatched. Figure 11: Why Invest To Save: Treatment Services and Agency Partnerships 5.2 Salford Cost Benefit and Value of Treatment The NTA Recovery Resources package 43 assists with the effective commissioning of local drug and alcohol specialist services. As part of this package a Value for Money (VfM) tool is available to allow local areas to quantify the cost effectiveness of their treatment services. The following results identify the savings and cost benefits calculated for Salford using the VfM tool to forecast future benefits covering the spending review 2010 period 2011/12 to 2014/15: The estimated total amount of harm (costs to public services) if no problem drug users were treated for their addiction would be 198.7m. The total amounts of benefits accrued are 57.8m (crime saving 30m and Health savings 27.8m). In Salford the tool calculates that in for every 1.00 spent on the local treatment system 3.42 was gained in reduced expenditure in that year. Further cost reductions have been made from those former service users now in active recovery giving a total of 4.90 avoided for every one pound invested

56 Treatment costs: 2.46M Costs avoided from effective treatment: 8.40M Total costs avoided from effective treatment and sustained recovery: 12.05M Costs Avoided The reduction in expenditure brought about by drug treatment are based on the answer to the question, what additional costs would there be if there had been no drug treatment? Drug users not in treatment spend more money on illicit drugs, and this is often funded by crime; they also have poorer health including higher rates of hospital admission and they are more likely to die early. This imposes a financial burden on individuals and the system. Figure 12: Comparison between Costs of Investing in Drug Treatment and Not Investing in Drug Treatment Drug treatment investment Vs. Health and crime costs 1M 1M 1M 1M 1M 1M 1M 1M 1M 1M Crime Had there been no investment in treatment, the biggest additional cost would have come from an increase in offending. In Salford it is estimated that there would have been an additional 34,657 crimes in if no drug users had been in treatment. It is arrived at by comparing the reduction in offending levels seen following engagement with treatment and applying that to the number of users engaged in treatment within the year. Home Office figures for the unit costs of drug related crimes were then applied to determine the financial savings from the reduction in offending. Additional costs to individual victims of certain crimes are avoided, including reduced emotional impact on victims, which are typically high for crimes such as domestic burglary or robbery. 56

57 Table 3: Reduced Crime Costs Achieved by Investing in Treatment and Recovery Treatment Recovery TOTAL Reduced Crime Costs 5,793,233 2,439,869 8,233, Health If there was no drug treatment in the knock on effects for the health service would have been significant. Users would have had many more hospital episodes and GP visits. The additional costs would have been around 1,400 per service user in treatment. The long term health gains of those who have entered recovery following treatment would not be there without that treatment, adding a further burden on to the health service. There would also have been additional demands on family carers, which have been quantified. Table 4: Reduced Health Costs Achieved by Investing in Treatment and Recovery Treatment Recovery TOTAL Reduced Health Costs 2,605,299 1,210,155 3,815, Investment The value for money tool bases its figure of 2.46M investment in drug treatment on the funding allocation for Salford and the estimated proportion of the local allocation spent on treatment, rather than harm reduction services and other lower threshold activity. It does not include the investment in alcohol treatment or young people Return on Investment The return on investment is the proportional difference between the costs had there been no treatment and the investment in treatment. In Salford the return from treatment only is 3.42 per one pound spent. Cost from no treatment = 8,398,532 = reduced cost of 3.42 for every 1 invested Cost of treatment = 2,457,484 By including the additional cost had there been no former users in recovery following treatment we see an even higher return on the investment in that treatment of 4.90 Cost from no treatment or recovery = 12.05M = reduced cost of 4.90 for every 1 invested Cost of treatment = 2.46M These figures are on par with the reduction in costs seen across Greater Manchester. 57

58 Spending and benefits for other services such as needle exchanges were not calculated as the numbers accessing such services isn t readily available centrally. These services play a very important role in reducing the harm caused by intravenous drug use including reducing the incidence of HIV and other blood borne viruses. Should future VFM analysis include the benefits accrued from this provision, the impact would certainly be higher Future There is a finite number of drug users who would benefit from treatment. The evidence suggests that in Salford most of the opiate and/or crack users (OCUs) are already known to treatment. In the future we expect the number of OCUs in treatment to decline as more move into recovery and the pool of active users out of treatment continues to shrink. Some service users require less help than others to achieve and sustain recovery; typically they have had shorter histories of drug use, fewer additional physical and mental health problems, stronger family and social networks and better housing and employment situations. As more OCUs move into recovery the decline in the number receiving treatment will slow as those with the more complex problems requiring the greatest support to move towards recovery become the majority. The consequences of this are threefold. Firstly, fewer OCUs in treatment will free up capacity to work with higher numbers of non-ocus, namely those with problems resulting from the use of drugs such as cocaine, amphetamines, cannabis or legal highs. Secondly, the more complex OCUs will require increasingly specialist services to meet their needs. Finally, the change will require a shift in resources from treatment to recovery services. The financial benefits of recovery will consequently increase and continued investment in moving people through treatment and supporting them to sustain recovery should continue to bear fruit for years to come. 5.3 Local Crime Recorded Local Drug Offences Drug offences 44 have seen a decline over the last few years. In Greater Manchester there was an 18% fall in recorded drug offences between and , with possession of cannabis falling by 21%, although this is still the single biggest drug offence accounting for more than 3 in 5 drug offences. Nationally the peak in drug offences was with a year on year decrease in offences since then, with the largest single fall occurring between and (9%). In Greater Manchester trafficking in controlled drugs accounts for 24% of recorded drug offences, nationally the figure is 14%. 44 OFFENCES RECORDED BY THE POLICE IN ENGLAND AND WALES BY OFFENCE AND POLICE FORCE AREA /03 to 2012/13, Home Office

59 The negative relationship that drug and alcohol misuse has on crime and disorder has been highlighted previously by the Crime Survey for England and Wales and the New Economy report for Salford Local Drug Related Offences Local offending analysis used police data from and to review alcohol and drug related offences in Salford. The analysis identified areas where alcohol related crime and drug related offences were highest and in future it is suggested that such analysis may assist with future targeting by partners and specialist services. Drug related offences decreased by 16.8% Salford City wide from 1,694 offences in 2011/12 to 1,410 in 2012/13. The breakdown of drug related offences by Salford ward is described in Table 5. The offences included are those which fall under Home Office codes of 092 and 093, they include possession, trafficking and supply, whereby drugs have been found on a person or in a place. The majority of wards saw a decrease in drug related offences with just four wards showing increases in 2012/2013 (Weaste and Seedley, Claremont, Swinton North, and Boothstown and Ellenbrook). The main cluster were in the ward of Langworthy where the largest number of drug related offences were recorded with 18 offences in connection with producing or trafficking, and plants or farms identified on the premises. This was also a hotspot for alcohol related crimes. Smaller clusters were also identified in Weaste and Seedley, and Barton. Weaste and Seedley recorded the highest increase in drug related offences in 2012/2013 as detailed in the table below. 59

60 Table 5: Drug Related Offences in Salford between 2011/12 and 2012/13. Ward 2011/2012 Rate per 1,000 Pop. 2012/2013 Rate per 1,000 Pop. Langworthy Broughton Little Hulton Barton Walkden North Irwell Riverside Weaste & Seedley Ordsall Kersal Pendlebury Swinton North Winton Eccles Claremont Swinton South Cadishead Walkden South Worsley Irlam Boothstown & Ellenbrook Total 1, , Diff in Statistics Map 1 displays the drug related offences by location in Salford during the 2012/2013 financial year. Map 1: Drug Offence Clusters in Salford

61 5.3.3 Type of Drug Offence The following analysis provides intelligence on the type of drug related offences that were recorded across Salford in 2011/12 and 2012/13. This includes offence type (trafficking and possession) and enables another proxy measure for local demand and trends of illicit drug use in Salford. The majority of all trafficking offences (82%) were related to cannabis. The majority of possession offences were also related to cannabis (83%). Table 6: Trafficking in Controlled Drugs in Salford (2011/12 and 2012/13) Trafficking in Controlled Drugs 2011/ /2013 Trafficking in Controlled Drugs - Amphetamine 6 5 Trafficking in Controlled Drugs - Cannabis Trafficking in Controlled Drugs - Class A 7 17 Trafficking in Controlled Drugs - Class B 6 14 Trafficking in Controlled Drugs - Class C 1 4 Trafficking in Controlled Drugs - Cocaine Trafficking in Controlled Drugs - Drug not Stated 1 1 Trafficking in Controlled Drugs - Heroin 7 11 Trafficking in Controlled Drugs - MDMA/Ecstasy 4 3 Trafficking in Controlled Drugs - Methadone 1 Trafficking in Controlled Drugs - Unspecified 4 2 Total Trafficking Table 7: Possession of Controlled Drugs in Salford during 2011 and Possession of Controlled Drugs 2011/ /13 Possession of Controlled Drugs - Amphetamine Possession of Controlled Drugs - Cannabis 1, Possession of Controlled Drugs - Class A Possession of Controlled Drugs - Class B 4 3 Possession of Controlled Drugs - Class C 1 Possession of Controlled Drugs - Cocaine Possession of Controlled Drugs - Heroin Possession of Controlled Drugs - Methadone 1 Possession of Controlled Drugs - Tablets mainly Diazepam Possession of Controlled Drugs - Tablets/Ecstasy/MDMA 9 4 Possession of Controlled Drugs - Unspecified 2 Total Possession 1,356 1, Cannabis Farms / Plants Analysis completed by the Community Safety Unit also identified the locations of those drug offences whereby the text refers to cannabis plants or farms of over 5 plants during the 2012/2013 financial year (Map 2). Langworthy had the highest number of farms recorded with the main cluster occurring in this ward. Clusters also occurred in Kersal, Pendlebury and Little Hulton. 61

62 Map 2: Cannabis Farms in Salford during 2012/ Recommendations Set up routine and regular monitoring of costs and benefits of treatments in accordance with NICE guidance and where possible against other comparative DAATs. This should include a yearly review of unit costs for different treatments (e.g. new prescribing regimes or comparable aspects of services). Establish routine data sets (e.g. drugs, alcohol, crime and disorder) and ensure analytical capacity is available for future needs assessments. 62

63 6 Drug Treatment in Salford 6.1 OCU Treatment penetration As detailed previously, official national prevalence rates for 2011/12 suggest there are in the region of 1,745 Opiate and/or Crack Cocaine Users (OCUs) in Salford. Matching this figure against National Drug Treatment Monitoring System (NDTMS) data for those in treatment enables us to produce an estimate of those unknown to treatment and thus gauge potential demand. However, as this analysis will detail, we believe that official prevalence data overstates the total of OCUs in Salford. The bull s-eye diagram (figure 13) sets the estimated number of OCUs in Salford against the local treatment data derived from NDTMS for 2012/13. The centre ring contains the 628 OCUs in effective treatment at the end of the financial year. The next ring identifies 168 OCUs who were in treatment during the year but exited before the end of it. Following this, there are 120 OCUs who were not in treatment during 2012/13 but were in the previous year. The overall number of OCUs known to treatment in Salford over the last two years is 916. Deducting this number from the official estimate of 1,745 allows us to populate the final ring and estimate that the total number of OCUs unknown to treatment in Salford in the last two years is 829. Figure 13: Salford OCUs Known to Treatment v OCU Prevalence Rates 628 On 31/3/ In 2012/ In 2011/ Unknown since 1/4/

64 In addition to estimating the total number of OCUs, national prevalence data also provides estimates of those using both heroin and crack cocaine and those using each drug in isolation. These estimates can also be matched with treatment data as shown below. Graph 5 below plots the percentage of OCUs known to treatment (treatment penetration) against prevalence estimates. The error bars relate to the prevalence estimate confidence intervals. In conducting analysis of this data it is critical to note these confidence intervals. Graph 5: Estimated Percentage of OCUs that are Known to Salford Drug Treatment Services in the Last Two Years Percentage of OCUs Known to Treatment in Last Two Years 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Opiate &/or Crack Users Opiate Users Crack Users Opiate only Both crack and opiates Crack only The data suggests that within the last two years Salford s treatment system has effectively treated over half of the estimated number of OCUs (52%, CI: 45-58%), two-in-three opiate users (64%, CI: 53-79%) and two-in-five of all crack users (42%, CI: 32-65%). When looking at those that use crack only (e.g. having never used heroin) the estimates suggest there could be 327 such individuals in Salford but the confidence interval puts the range between zero and 841. Since there were only 14 crack only users known to treatment, this could mean Salford s treatment system knows only an estimated 4% of crack only users but the true figure could be between 2% and 100%. The table below (Table 8) attempts to better put this data within the context of drug use know to treatment services and illustrate that those OCUs who use crack cocaine but do not use opiates make up a very small part of the 64

65 treatment population (but a significant proportion of the unknown to treatment population if we accept official estimates). Table 8: OCUs Known to Treatment by Substance Number Breakdown by substances of OCUs used Opiates only Both crack and opiates Crack only In treatment 31/03/ % 32% 0% In treatment in last year % 40% 5% Known to treatment in 2011/12, but not 120 treated last year 53% 43% 3% Unknown to treatment in last two years % 18% 38% Salford DAAT would argue that there are fewer crack-only users than the OCU prevalence estimate suggests. Were there a large number of crack users in the city unknown to the treatment system such individuals would be expected to have shown up within the criminal justice system given the nature of crack use and associated criminality. However, the evidence from police Mandatory Drug Test (MDT) data suggest otherwise. Salford DAAT has conducted a series of in depth analyses of this data over recent years, which showed very few individuals repeatedly testing positive for cocaine (but not opiates). Were there a significant number of crack only users in the city we would have expected contrary results. In there were almost 1,600 MDTs conducted in the police custody suite following arrest. By considering the test results in conjunction with a further 5 years historic test data Salford DAAT aimed to identify potential crack-only OCUs. By eliminating those negative tests and tests positive for opiates we found 187 individuals with a test positive for cocaine only. Only 53 of these had tested positive on more than one occasion over the six year period and there was assessment data for 49 of them. Only one individual reported the use of crack cocaine. This suggests that there are few crack users in Salford who do not also use opiates. Consequently the level of treatment penetration is unlikely to be as low as the 6% calculated from the prevalence estimates. If treatment penetration was at a similar percentage to that for opiate users, i.e. 70%, this would mean that there would be fewer than 30 crack only users in Salford. If it was only half as good as that for opiates (i.e. 35%), there would be just over 50 crack only users; a figure better supported by police drug test data. This number would see the overall OCU prevalence estimate reduce from 1,745 to 1,469 and bring the estimated total of unknown OCUs down to

66 Finally it is worth noting that treatment data from Salford Drug and Alcohol Service (SDAS) going back some 20 years, we can see that treatment penetration is much higher. Overall there are 1,794 OCUs ever known to treatment with SDAS, of which 1,470 have had a treatment episode in the last five years. To summarize, local evidence suggests the OCU prevalence estimate is too high and treatment penetration is much better than the official figures state. 6.2 Engaging the Unknown OCUs Graph 6 below shows OCU contacts with the local Drugs Intervention Programme (DIP) service in This analysis tracked attrition following arrest and a positive drug test, through to assessment by the Criminal Justice Interventions Team (CJIT) and onto numbers entering and remaining in effective treatment. The purpose of the analysis was to determine how many unknown OCUs were, in line with one of the central aims of the programme, effectively engaged as a result of the mandatory drug testing and the intervention process. Graph 6: OCUs in Contact with DIP 2009/10 Opiate and Crack Users in Contact with DIP OCU in treatment OCU not in treatment OCU status unknown Referred to CJIT (n=256) Assessed by CJIT (n=244) Not identified as in treatment (n=164) Intervention agreed (n=122) Careplan agreed (n=117) Attended triage appointment (n=81) Started treatment (n=81) Previously unknown to treatment (n=30) Retained for 12 weeks (n=23) As can be seen, the majority of those testing positive were already in treatment at the point they were arrested. Whether those out of treatment at the time of their arrest had been previously in treatment could not be determined until they were triaged by the service. 66

67 Salford only engaged 23 previously unknown OCUs into effective treatment via DIP in 2009/10. Graph 7 below looks at this question from the perspective of NDTMS data shows a steady decline in treatment-naive opiate users over the last three years. This is consistent with the narrative of there being few opiate users that remain unknown to treatment. The figures for criminal justice (including DIP) show that annually fewer than 25 have entered treatment via these routes, with fewer than 10 in Over the last five years 22% of treatment naïve referrals came into treatment via criminal justice routes compared to 50% for self referrals. Graph 7: Referral of Treatment Naïve Opiate Users in Salford between 2007/12 Figures for 2011/12 evidence 52 referrals of treatment naive opiate users in the year, of which 14 also reportedly used crack cocaine. 67

68 6.3 Public Health Outcomes Framework Performance As part of the Public Health Outcomes Framework (PHOF), 45 a specific indictor exists to measure performance of specialist drug treatment services for (i) opiate and (ii) non opiate drug users. PHOF 2.15i: Number of opiate users that left drug treatment successfully (free of drug(s) of dependence) who do not then re-present to treatment again within six months as a proportion of the total number in treatment. Salford has seen a small increase in the proportion of opiates users with a successful completion without re-presentation in the subsequent six months. The baseline period (12 months from April 11 to March 12) saw 8.1% of all opiate users leaving successfully and staying out. Since then there has been a steady increase in performance with the latest data (Jul 2012-Jun 2013) showing a 9.7% successful completion rate, currently the highest in Greater Manchester. However this percentage increase belies the fact that the number of successful individuals is the same, 78 in both periods. It was a fall in overall numbers in treatment that accounts for the improved performance. Each year one in every ten opiate users leaves treatment in Salford successfully and remains out of treatment for at least six months. Greater Manchester saw a fall from 7.7% to 6.7% over the same period. Overall there were 153 fewer successful completions between the baseline and the latest data, a 19% decline. Treatment numbers also fell in the period although by smaller 7% (n=709). Of the ten areas within Greater Manchester six saw a fall in the successful completion rate since the baseline of between 0.2 and 5.2 percentage points and four increased by between 0.3 and 2.8 percentage points. The biggest declines in the number of successful completions were seen in Bolton, Manchester and Wigan. The falls in rates seen in some areas have occurred at a time of significant change within the local treatment system. Sustaining successful completion rates of around 10% will provide challenges to services as the least complex move out of treatment into recovery and the most complex opiate users become a proportionately larger group

69 PHOF 2.15ii: Number of non-opiate users that left drug treatment successfully (free of drug(s) of dependence) who do not then re-present to treatment again within six months as a proportion of the total number in treatment. Successful completion rates are much higher for non-opiate users. Within Greater Manchester two in five non-opiate users will leave within a 12 month period and not return (38.4%). In Salford that figure is very similar (38.5%). The best performing areas in Greater Manchester manage three in five. The most significant change in Salford is the rise in the number of non-ocus in treatment (40% increase since baseline) and successfully exiting (67% increase) treatment. There has been a change in the profile of service users with non-opiate users increasing from 19% of the treatment population and 47% of successful completions in to 25% of the treatment population and 56% of successful completions 15 months later. Further detail on this indicators trend and comparison to other Greater Manchester local authorities can be found in Appendix National NDTMS Data 46 During 2012/13, there were 193,575 individuals in contact with structured drug treatment services nationally, a 1.8% decrease from the 2011/12 figures, when there were 197,110. Most of the individuals in treatment were aged (58%) and 73.4% were male. The main type of drug for which people received treatment was opiates only (primarily heroin) at 48% of all treatments with a further 32% of treatments for those who have taken both opiates and crack cocaine. Graph 8 below shows the changing age profile of the OCU treatment population nationally. There has been a fall in the age group annually since and the age group since The number of year olds has changed very little over recent year but the most significant trend has been the growth in the number of service users age 40-plus.This age group has more than doubled from 27,000 in to 59,000 in

70 Graph 8: OCU Treatment Population by Age Group to Trends in Age Groups - OCU Treatment Population First Time Entrants The total number of people entering treatment for the first time fell from 64,663 in to 25,237 in This change was due to mainly from the reduction in heroin users (47,709 new entrants in (74% of the intake) but only 9,249 in (37%). The NTA attributed this reduction to: The successful expansion of treatment services. Heroin becoming less attractive amongst younger adults given the visible damage it can do. Previous economic prosperity minimising conditions that foster drug epidemics. Disruption of the supply of Heroin. Although the population of heroin addicts has reduced significantly, the NTA reiterated the importance of ensuring recovery orientated treatment. The NTA has also identified the current long term recession as a key risk given the potential association between economic downturns and increased illicit drug use Local National Drug Treatment Monitoring Service (NDTMS) Local NDTMS data for Salford provides a detailed review of all drug and alcohol service users in treatment, their referral patterns and movement through the system, demographics and effectiveness of treatment. The following section provides analysis of their available data and also creates a profiling of local drug users that would help inform the delivery of future services. 70

71 6.4.3 Referral to Specialist Services The main referral source for specialist treatment services is self, family and friends (38%), particularly amongst year olds (64% of category). The next largest category is health and mental health accounting for 22% of the total with just over half of these age years. Criminal justice referrals are fairly evenly spread between year olds and account for 15% of the total. The spread of referral source by age group is described in more detail in Graph 9. Graph 9: Salford Specialist Drug and Alcohol Referral Source by Age Group Numbers in Effective Drug Treatment Effective treatment is defined as structured treatment that continues for at least 12 weeks or is closed in a care-planned way prior to 12 weeks. The number of Opiate and Crack Users (OCU) in effective treatment increased from around 850 in to a high of around 900 in , it then began declining in to around 750 by September The over- 18s trend (which also includes users of drugs other than heroin and crack cocaine) closely matches the shape of the OCU pattern but there was a steady a growth in the number of those primarily using other drugs from just over 100 to over 220 during the period in question. 71

72 Graph 10: Salford OCU and All Drug Users in Effective Treatment between 2006 and Ageing Treatment Population The ageing drug using treatment population is evidenced in the age breakdown of those in treatment over time. From Graph 11 below we can see that since those in their 40s and older have increase proportionately from 30% of the treatment population to 47% by In there were twice as many service users in their 30s as their 40s (47% vs. 24%), by there were fewer service uses in their 30s than 40s (36% vs. 37%). The change will in part be due to those remaining in treatment getting older but will also reflect the higher successful completion rate amongst those with shorter treatment episodes, who are typically younger. Graph 11: Showing the Increase in the Proportion of Drug Users in Treatment Aged Over-40 72

73 Percentage of Adult Treatment in Salford by Age Group ( to ) 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Under 30 24% 22% 19% 15% 15% 17% % 45% 45% 43% 39% 36% % 28% 30% 35% 37% 37% 50-plus 6% 5% 6% 7% 9% 10% Days in Treatment in SDAS Salford Drug and Alcohol Service has provided around 1,000 episodes for drug users and a similar number for alcohol user each year. Despite this the service has provided a greater total number of days of treatment for drug users (mostly OCUs), as they typically have longer treatment episodes. The number of treatment days for primary OCU episodes remained steady at around quarter of a million with 15-20,000 days dedicated to other drug users. 73

74 Graph 12: To Show Days in Treatment in Salford between 2008 and Treatment Outcomes Profile (TOP) Data 47 The Treatment Outcomes Profile (TOP) measures change and progress in key areas of the lives of people being treated in drug and alcohol services. TOP consists of 20 simple questions focusing on the areas that can make a difference to clients' lives - substance use, injecting risk behaviour, crime and health and quality of life. It produces outcomes data that can be used with individual service users, with staff, with services, across a treatment system, and nationally Q4 Treatment Review This section presents the main TOP findings for Salford at Q4 for 2012/ Opiate users (n= 127) Amongst opiate users, 50 of 92 (54%) with active use at the start of their treatment episode had become abstinent by review stage. This was towards the upper end of the expected range of 31% - 57%, based on client characteristics. Cessation of crack use was within the expected range but fewer than expected stopped using cannabis and alcohol. Of those opiate users who also cited cocaine powder as a problem (fewer than five), none were still using cocaine at review

75 Non-opiate users (n= 85) Cessation of alcohol and cannabis amongst non-opiate users was below the expected range amongst non-opiate users by review stage. A third of (non-primary) alcohol users stopped, which is toward the upper end of the expected range, and one of two crack users stopped Treatment Exits in In there were 54 successful completions for opiate users and 64 nonopiate users where there was a valid TOP record at both treatment entry and treatment exit. Fewer than five of the 54 opiate users were in employment at the start of treatment; by exit 9 were in work, giving 17% employment for an average of 4.7 days per week. Of the non-opiate users 16 (25%) were in employment at the start of treatment and 18 (28%) at exit, with an average of 4.5 days employment per week. On average there was an improvement amongst both opiate and non-opiate users in their self-reported physical health, psychological health and quality of life. Scores can range from zero (poor) to 20 (good). Both opiate users and non-opiate uses saw an average increase of 3.2 points for physical health and 4.2 for quality of life, although the non-opiate users started and ended around half a point higher. Psychological health improved more for opiate users (4.5 versus 3.6 point increase) but both groups left with an average of At treatment start 18 (15.1%) people (both opiate and non-opiate users) reported an acute housing risk, this fell to fewer than five at exit. No one was at risk of eviction by exit, down from 7 (5.9%) at the start of treatment. 75

76 Tier 4 (31) Other Tier 3 (46) SMART (51) Mona Street (53) SDAS (960) Referrals In treatment & transfers Treatment exits 6.5 Treatment Map Salford The treatment map below (Figure 14) shows the flow of services users into and out of the Salford treatment system. The blue or top section of the map shows referrals into the system by referral route and treatment service. There is also a comparison of routes with the North West region and England. Figure 14: Treatment System Map 2012/13 Self (135) Drug Services (41) CARAT (64) Other (41) Arrest Referral / DIP (2) CJS Other (9) GP (14) Probation (29) Planned (170) Referred on (84) Unplanned - Dropped out (43) Unplanned prison (1) Unplanned other (23) An overview of commissioned services is provided in Appendix 9. This overview does not include details of the drug and alcohol service for families, which is currently commissioned through Salford Children s Services. 76

77 KEY: Example: Mona Street had 53 service users in treatment in 2012/13. One referral from came from CARATs. The service had 12 transfers from SDAS and 10 planned completions. 77

78 Figure 15: Treatment Map for Salford 2012/13 KEY: 354 Number in treatment 78

79 6.6 Drug User Profiles: Salford Drug and Alcohol Service (SDAS) data The following section provides a summary profile of the drug and alcohol users in Salford Drug and Alcohol Service. The analysis was conducted with data reported to SDAS by service users. It provides local intelligence around patterns Cannabis users In SDAS saw the highest annual number of primary cannabis users entering treatment with 53 users. This compares with an average of 28 per year over the previous six years. This is due to an increase in criminal justice referrals from an average of 2.5 in to 18 in Most of this increase is due to probation referrals (n=15). Six weeks is the most common treatment length with around half ending by 3 months, successful completions tend to stay in longer. Completion rates have improved in recent years with three in four completing successfully, mostly as occasional users. Use of cannabis typically starts at age for this cohort with few starting below 11 years or above 20 years old. Around a third named a second substance, typically alcohol or cocaine whilst one in ten named three substances. Despite this, reported alcohol use is low, half are teetotal and only 1-in-20 declare use above recommended levels. The mean average age of primary cannabis users in treatment is 30 although more than half are in their 20s. A quarter are female, they are on average a couple of years older than the males. Just over half are parents (three quarters for females), with most male parent not living with their children whereas most female parent do. Only 1 in 25 is not White British. Little Hulton, Langworthy, and Weaste and Seedley are the most common wards of residence Amphetamine users Each year around 20 new service users enter treatment naming amphetamines as their primary substance. Typically, three in five will be self referrals, with GP and psychiatry services referring around 9% each. In , 29 primary amphetamine users left treatment with an average treatment length of 4 months. Most of the exits were successful (n=20), with 11 leaving drug free. Half of the primary amphetamine users do not name a second problem substance, half of the rest cite cannabis. Amphetamine is more likely to be 79

80 named as a second or third problem substance (20-40 clients per year). These non-primary amphetamine users will most likely name either opiates or alcohol as their main problem substance. Primary amphetamine users in treatment will be around 35 or 36 years old but a significant proportion will be in their 40s. A third live with some or all of their children. Half will have begun using amphetamines between 15 and 18 years old. 95% are White British and two-thirds male. Out of every 8 primary amphetamine users entering treatment Haysbrook and Acton Square have three each and King Street two. The most common ward of residence is Little Hulton. Despite these referrals rates, historically King Street has had more treatment episodes for primary amphetamine users than either of the other sites Cocaine Powder Users Relatively few service users name cocaine powder as their primary problem substance when entering treatment with SDAS each year. They typically number around each year with self referrals accounting for two-thirds of all entries over the last three years. Around three quarters are in treatment for less than six months. Only around one in twenty had a second episode of treatment. Three in five exits are successful, with the proportion increasing over the last five years. Most unplanned exits occur in months three or four, whilst successful completions are open around a month longer. Six in ten successful completions are drug free on exit. Their most commonly named secondary problem substances are alcohol (4 in 10) followed by cannabis (2 in 10), very few name three substances. Typically use begins at the age of 18, three in ten are teetotal, and one in five drinkers report drinking above recommended limits. Half of those entering treatment were aged under 30, with 23 the single most common age. Six out of seven cocaine powder users were male, just over half were parents and 98% were White British. King Street treated around half of all primary cocaine users and had a higher numbers of young users. Geographically Weaste and Seedley had the highest number of users in treatment followed by Little Hulton and Barton Opiate or Crack Users (OCUs) There are approximately OCUs in treatment in each year and around in treatment on any given day. 27% of OCUs in treatment are female. Most OCUs have multiple treatment journeys with one in ten having five or more. 80

81 Four in ten OCUs named crack cocaine as a problem substance but around ten named only crack cocaine as a problem substance (e.g. they did not report any heroin use). There were also 72 known OCUs in treatment for primary alcohol problems in with a total of 84 episodes. In half of those journeys opiates and/or crack was still named as a (secondary) problem, the rest typically had no second problem substance. The numbers of OCUs in Salford who are parents and have children living with them is 412, 37% of the total of all OCUs in treatment. This is higher than the comparator England figure of 34% but less than the North West overall 42% proportion. This highlights the importance of ensuring an effective family treatment service is in place to support the needs of these groups and to mitigate the impacts of drug misuse on vulnerable children and persons in family units. The wards with the highest rates are Langworthy, Broughton, Barton, Little Hulton and Walkden North. Those with fewest are Worsley, Boothstown and Ellenbrook, Irlam, Walkden South, Claremont and Kersal. The local areas with the high density of OCUs in treatment were central Eccles, the area around Salford Precinct (Pendleton), Weaste Lane and Bury New Road, Higher Broughton. 81

82 Map 3: Distribution of Salford OCUs in treatment Successful Treatment versus Unsuccessful Treatment for OCUs The following section provides an overview of successful and unsuccessful OCU treatment journeys in Salford. Comparing the length of treatment and associated success rates. Table 9 compares treatment exits that were successful with those that were unsuccessful. The episodes recorded in this table are only where the primary substance was opiates or crack cocaine. Table 9: Salford OCU Successful and Unsuccessful Treatment Exits 2012/13 OCU exits in Successful Unsuccessful Number of episodes Median length of episode 317 days 257 days Median Age at exit years Median age at entry % female 35% 15% Alcohol is additional problem substance 17% 10% Crack named as a problem substance 21% 23% % of parents living with all or some children 27% 14% Amphetamine named as a problem substance 3% 8% Dual diagnosis 11% 9% In regular employment 13% 4% No housing problem 89% 73% Criminal justice referrals 18% 58% 82

83 Only 15% of Criminal Justice (CJ) referrals exiting did so successfully compared to 45% of non-cj referrals. Other factors influencing success include housing issues and amphetamine use amongst CJ clients. Amongst non-cjs, parents living with children are twice as likely to successfully complete as those with no children living with them OCU Length of treatment Of the 917 OCUs in treatment for around half (485, 52%) were known to treatment five years before. One in ten entered treatment with SDAS for the first time in There were 374 episodes closed for these OCUs with a treatment length varying from 1 day to 19 years. The median length was 7½ months and a quarter had been in treatment for over 2 years. For the 709 episodes still open at the end of the year the median length in treatment was 2½ years with a quarter in treatment for almost 6 years. For OCUs in treatment on 1/4/2012 the chances of successfully completing treatment reduce the longer the client has already spent in treatment. Overall 11% of episodes open at the start of the year were successfully completed within 12 months. Those most likely to complete were the users in for 3-6 months (30% Success rate), the least likely were those with 10 or more years in treatment (3% Success rate, 4% dropped out and 6% were transferred). Table 10 clearly shows the relationship between successfulness of treatment for OCUs within the first 3 months of treatment compared to those users who are in treatment for longer periods. It is therefore important that specialist services maximise the quality of treatment and support as early as possible in order to avoid risking long term treatment and individuals who will have repeated episodes. Table 10: Length of treatment for Salford OCU s and Relevant Treatment Success Length for OCUs Number % SC within open 1/4/ months 0-12 weeks 70 21% 3-6 months 53 30% 6-12 months 79 10% 1-2 years % 2-4 years 155 9% 4-6 years 85 7% 6-10 years 93 8% 10+ years 68 3% Total % 83

84 Around a quarter of the opiate using treatment population have a continuous treatment journey of at least six years and just one in twenty results in a successful completion each year. Over a third of heroin users in treatment in began using at least 21 years ago and more than three quarters of opiate users currently in treatment are aged Half of opiate users on pharmacological interventions (primarily methadone substitute prescribing) in SDAS in are aged over 40, and 10% are 50-plus. The issues of assessing the individual needs and of managing those ageing service users with the longest treatment episodes are significant. There is a high likelihood of a number of attendant health and social issues amongst this cohort. It is a recommendation of this needs assessment that specific attention should be given to the treatment arrangements of these ageing clients in order to maximise engagement with wider health and care services Opiate Success and Deprivation It is important to consider the influence of health inequalities and deprivation on the chances of success and whether or not this could be associated with successful treatment outcomes. The following section provides a review of deprivation and successful treatment for opiate and alcohol service users. The successful completion rate for opiate users in treatment in a 12 month period varies greatly by ward from Claremont (5/17 = 29%) to Swinton North (0/26 = 0%). A statistically weak correlation (R 2 = 0.17) exists between areas of less deprivation and successful completion rates of treatment. Therefore no statistical evidence is present to suggest that opiate users from a less deprived area have an improved chance of successful treatment than those living in other areas. However there are a number of outliers to consider with Weaste and Seedley ward having a 20% successful completion rate (3 rd highest) but is the 12 th least deprived ward. Ordsall has a 17% successful completion rate but is the 5 th most deprived ward. At the other end Cadishead is 5 th least deprived ward but 19 th on the successful completion list (1/30 =3%) and Swinton North is 9 th least deprived ward but has no successful completions. The wards with the highest numbers in treatment (Langworthy, Barton and Broughton) have similar rates and are clustered around the middle of Table 11; these are some of the most deprived wards in the city. 84

85 Table 11: Successful completion rates for opiate users in treatment with SDAS by ward In treatment 2012/13 Successful completion 2012/13 % Successful completion Ward CLAREMONT % 18 WORSLEY % 19 WEASTE & SEEDLEY % 9 BOOTHSTOWN/ELLENBROOK % 20 ORDSALL % 5 IRLAM % 15 KERSAL % 11 SWINTON SOUTH % 14 BROUGHTON % 1 IRWELL RIVERSIDE % 4 LANGWORTHY % 2 PENDLEBURY % 10 BARTON % 6 WINTON % 7 WALKDEN SOUTH % 17 WALKDEN NORTH % 8 LITTLE HULTON % 3 ECCLES % 13 CADISHEAD % 16 SWINTON NORTH % 12 The absence of a successful treatment exit does not necessarily mean a treatment journey has been unsuccessful. For many service users a sustained period of treatment means greater stability and should been seen as a positive. Others will have had an unsuccessful exit from treatment. A complete understanding of the effectiveness of a treatment service or system cannot be gained solely from the number of successful completions. Weaste and Seedley have one of the highest successful completion rates but also the highest unsuccessful completion rate. Swinton North also has a zero rate for both successful and unsuccessful completions. IMD 2010 ward deprivation rank. (1=most deprived) 85

86 7 Injecting Drug Users 7.1 Needle and Syringe Programmes The Advisory Council on the Misuse of Drugs recommends that a combination of opiate substitute therapy and needle and syringe programmes are the most effective way of reducing the spread of HCV among those who inject drugs. 49 Needle and syringe programmes (NSP) were introduced to the UK in 1986 as a response to the then HIV epidemic because injecting drug users commonly shared used and infected injecting equipment, thereby spreading blood borne viruses such as HIV and HCV. Through the 1990s, needle and syringe programmes witnessed a rise in the number of people accessing services who injected performance and image enhancing drugs, and a decline in the number of attendees who were injecting other drugs. The Burden of Liver Disease 50 report states that the trend has continued with regard to increasing numbers of performance and image enhancing drugs users accessing needle exchanges. The report reinforces the need for all drug injectors to be protected against the risk of the transmission of blood borne viruses through the provision of clean injecting equipment. Performance and image enhancing drug injectors should not be excluded from efforts to prevent the spread of blood borne viruses regardless of the fact that they tend to inject intramuscularly rather than intravenously. 7.2 HBV Prevalence and Vaccine Uptake In the UK, the HBV vaccine is not a routinely administered vaccine, but is targeted for those people that are at increased risk of being infected with HBV or could be at risk of serious complications inclusive of injecting drug users (IDUs). The proportion of IDUs ever infected with HBV has fallen both nationally and regionally since HBV vaccine uptake in IDUs in the North West has increased significantly from 43% to 75% between 2000 and However, the results of anonymous monitoring suggest transmission of HBV among IDUs is proportionally higher in the North West than nationally. There has also been a proportional increase in coverage for the North West prison population as described in Figure 16. However, reported coverage for HMP Forest Bank in Salford shows significant decline between 2008 and This decline warrants further investigation. 49 Advisory Council on the Misuse of Drugs (2009). The primary prevention of hepatitis C among injecting drug users. London: Home Office. 50 NWPHO. (2012). The Burden of Liver Disease and Inequalities in the North West of England. 86

87 Figure 16: HBV Vaccine Coverage in Prisons in the North West Salford Needle Exchange Data There are 14 needle exchange sites across Salford including three fixed site exchanges based within SDAS treatment services. All sites report stock distributed, estimates of returns and number of clients using the service. A data base is also used to record client details however this is not used consistently across the city. There are around 40 syringes issued for every client per month. There is around 1 return for every 5 syringes issued. Over half (57%) of records do not name a main substance and thus the analysis of individual records shown below should be considered indicative. 87

88 Table 12: Volume of items issued in at fixed site and pharmacy based needle exchange services Item Pharmacy Fixed Site Needle Syringes 81,670 28,378 Barrels 57,750 36,707 Needle Heads 90,603 62,895 Swabs 84,340 33,920 Filters 125,973 29,705 Water 2, Condoms 332 1,470 Acidifier 105,045 11,910 Preparation Utensils 21,844 9,004 Estimated no of syringe returns 34,519 22, Analysis of Individual Records The Needle Exchange database (NEO) had 1676 unique users recorded for , however it is likely that this figure is an over estimate as the data suggests some needle exchange users are recorded multiple times. The actual number may be up to 20% lower, however for this analysis each unique identifier was treated as a separate client. Five out of every six needle exchange users was male (84%). Female clients were on average three years older than male clients (38 years vs. 35 years). Only 65 client records (4%) have a structured treatment status recorded, of these 90% state the user is not in structured treatment. Only one person is recorded as being of no fixed abode. There was a great deal of variation across the sites in terms of client profile. These gaps in data recording will need to be rectified in the future in order to better understand our injecting populations Age breakdown Graph 13 shows the age distribution for each needle exchange for those clients where age was recorded. The sites are ordered from those with the youngest age profile on the left to the oldest on the right. Two of the three fixed site needle exchanges are amongst those with the youngest age profile, reflecting the profile of the performance enhancing drug users who reportedly represent the vast majority of their clients. The two sites with the youngest age profile are both located in Eccles with over 70% aged under-30 in each; however Church Street Pharmacy, also in Eccles, has amongst the oldest profile. Three-quarters of the clients from the Alliance Pharmacy in Seedley were aged 40-plus. 88

89 Graph 13: Age and Location Distribution for Needle Exchange Clients *fixed site needle exchange Substances Recorded at Needle Exchange Over half (57%) of records do not name a main substance. Of the rest, heroin is the most commonly named substance (43%) followed by performance enhancing drugs (33%) and amphetamines (14%). Others mostly used various combinations of amphetamines/crack/heroin Opiates There were 363 individuals recorded as opiate users (mostly heroin), 85% were aged years, with a median age of 36 years. Of these, 19% were female and they tended to be a little older. Opiate users only accounted for 10% of fixed site clients (where substances were named), but over half of pharmacy sites (56%). The reason for this may be that the fixed site needle exchanges are within structured treatment services. Some of those in structured treatment may be reluctant to use needle exchanges within fixed sites. Postcode data was recorded in 264 cases, 104 (39%) were in M8 (Manchester) and 96 were in Salford postcode districts (36%). The most common Salford postcodes were M7 (Broughton, n=60) and M6 (Weaste and Langworthy, n=27). Half of all recorded opiate users access Boots Pharmacy in Cheetham Hill (n= 156) which borders Manchester Performance enhancing drugs Seven out of eight clients of fixed site needle exchanges are recorded as using the service for performance enhancing drugs (where substances were named). Over 90% of this group use steroids (n=231) with some using human growth hormone (n=21). Almost all are male (97%) and they are typically aged 89

90 For other sites only one in four reportedly use performance enhancing drugs. Around a third of records had no postcode area. Of the rest around two thirds were in Salford. The postcode areas with the highest number of users are M7 (Broughton n=26), M8 (Manchester, n=20), M30 (Eccles, n=21) Other Drugs There were 110 reported users of amphetamine either alone (103) or in combination with heroin (7). The median age was 38 years with half of users aged There were some older users with 13 (12%) aged 50-plus. One in five users was female. Over half of users gave no postcode, with 44% of the remainder living in M6. Most of this geographical cohort used the Lloyds Pharmacy in Salford Precinct (Pendleton), which accounted for over a third of all activity for amphetamine users. The second highest usage was of the Church Street Pharmacy in Eccles with just under a quarter of users. There was also recorded use of Melanotan Recommendations Develop and implement processes for service user involvement and client feedback to inform future service improvements. Conduct a review of individual needs, assets and available treatment options with the aim of developing recommendations to improve health, wellbeing and recovery potential and maximising engagement with primary health and care services. This should ensure that the associated costs to health and social care services are minimised. Particular emphasis should be placed on the needs of ageing drug users in treatment services and the development of Shared Care. Continue to benchmark against the best performing DAATs and in addition develop internal monitoring of success rates for different interventions. 51 Melanotan is a synthetic hormone and is injected under the skin to encourage it to darken. The drug increases the levels of the pigment melanin in the skin. This pigment is part of the body s natural response to the sun, and increasing levels of melanin results in skin darkening or tanning. There are two forms available, Melanotan I and II, which are diluted in water before being injected. 90

91 8 Drug Related Mortality 8.1 The National Programme on Substance Abuse Deaths (np- SAD) The International Centre for Drug Policy (ICDP) produces annual reports on drug related deaths in the UK. The most recently considered Drug Related Deaths in the UK- Annual Report includes deaths of addicts and non addicts that occurred during 2012 and for which coronial inquests have been completed. Its main purpose is to provide an analytical summary of data received, provide surveillance, and to detect and identify emerging trends. There were 1,613 notifications of drug-related deaths occurring in 2012 in the UK. This represents a decrease of 144 (8.4%) over the same reporting period in Data was provided by 87 of the 111 Coroners jurisdictions in England and Wales; a response rate of about 78%. The demographic characteristics of the deceased have remained consistent over recent years. For the UK as a whole, the majority were males (72%), under the age of 45 years (68%), and White (97%). Most deaths (71%) occurred at a private residential address. The main underlying cause(s) of death were: accidental poisoning (63%); intentional self-poisoning (14%); and poisoning of undetermined intent (12%). This pattern represents a decrease in accidental overdoses compared to the previous year with consequent rises in other types of overdose deaths. A greater proportion of older females died of intentional self-poisoning than males. This pattern has remained consistent across the years. The slight increase in deaths reported in 2011 s data in which stimulants such as cocaine and ecstasy were implicated has continued into 2012 (accounting for 1.7% and 1.2% respectively, up from 1.2% and 0.7%), whilst deaths involving amphetamines stabilised. As in 2011, 2012 saw a substantial number of deaths reported involving New Psychoactive Substances (NPS), again dominated by methcathinones such as mephedrone. However, the number of NPS-attributed deaths has been questioned, 53 as some are reported to be linked to substances that are either not new (e.g. PMA), or not psychoactive (e.g. anabolic steroids). Heroin/morphine remained the principal substance implicated in UK deaths. However the proportion of deaths in which the drug was implicated rose from its lowest level in 2011 to 36.4% in This increase of 4.5% from last year contrasts with the steady decline that was seen between 2009 (52.5%) and 52 International Centre for Drug Policy.(2013). Drug Related Deaths in the UK Annual Report programmes/pdfs/national%20programme%20on%20substance%20abuse%20deaths%20- %20Annual%20Report%202013%20on%20Drug-related%20Deaths%20in%20the%20UK%20January- December%202012%20PDF.pdf 53 Nutt, DJ & King, LA, Deaths from legal highs : a problem of definitions, Letter to The Lancet, Vol 383 March 15, 2014: 91

92 2011 (31.9%) for deaths involving this drug. Another change in the drugrelated death trends witnessed in recent years was seen in the proportion of cases involving methadone: deaths in 2012 involving this substance fell to 27.6%, which is in contrast to the steady rise seen from 2008 to 2011 (from 22.4% to 30.8%). Deaths involving hypnotics/sedatives, such as benzodiazepines, continued the consistent rise seen in previous years from 21.8% in 2008 to 30.3% in The involvement of multiple substances in drug-related deaths is both a national and international phenomena. This underlines the risks associated with the co-ingestion of substances, especially central nervous system depressants such as opiates/opioid analgesics, alcohol and benzodiazepine. Salford follows a similar trend in the types of drug implicated in deaths during As illustrated below heroin/morphine and methadone were the most commonly implicated drugs recorded by the coroner followed by hypnotics/sedatives. Graph 14: Drug Implicated Deaths in Salford during Salford Substance Misuse Deaths by Drug Implicated Heroin/morphine Methadone Hypnotics/sedatives Cocaine Amphetamines Ecstasy -type Total The pattern of deaths within Salford also follows the national and overall North West trend in terms of age distribution with around 50% of all reported drug related deaths occurring within the year age group for the last three years, see Graph 15 overleaf. 92

93 Graph 15: Age distribution of all Drug Related Deaths for Salford & under & over The highest rates of drug-related deaths per 100,000 population aged 16 and over in 2012 were in the following DAAT areas: Liverpool (12.57); Blackburn with Darwen (11.45); Hammersmith and Fulham (11.34); Sunderland (10.55); and Manchester (8.79). Following 3 years of drug related death rates that were amongst the lowest in Greater Manchester, in 2011 Salford had the fourth highest rate (11.64 per 100,000) in England. This fell back to 3.14 per 100,000 in 2012, the fifth highest out of ten Greater Manchester DAAT areas. 8.2 ONS / Public Health Mortality Files Data The total number of deaths related to drug misuse in England and Wales was 1,496 in 2012, 54 decrease of 109 from 2011 when there were 1,605 such deaths. This continues the downward trend seen since ONS (2013), Deaths related to drug poisoning in England and Wales,

94 Graph 16: Showing Percentage of Drug Related Deaths that Were Aged 40-Plus (*Source ONS) Percentage of Drug Related Deaths Aged 40-Plus in England 60% 50% 40% 30% 20% 10% 0% It should be noted that the overall increase in np-sad reported drug related deaths in Salford during 2011 is reflected in locally available information from the Public Health Mortality Files (PHMF). 55 However, the totals recorded are different. The graph below illustrates an increase in deaths between 2003 (6) and 2011 (29). The most recent data, covering 2012, shows a decrease to 19 drug related deaths. Graph 17: Showing Total Number of Drug Related Deaths in Salford between 2003 and 2012 (*Source PHMF) 55 ONS. Public Health Mortality Files. Source: 94

95 Ongoing coroner investigations may cause a significant data lag and as such the latest PHMF may be incomplete. It can also be hypothesised that changes and differences in processes of recording and reporting deaths may account for differences within and between the two data sets considered. A clear recommendation from the HNA is the need to improve our understanding of these datasets and the events and processes that sit behind them. Consideration should also be given to local confidential enquiry. 8.3 Recommendations Gain access to Salford drug and alcohol related hospital admission data, to be used for mapping trends on health needs. Carry out a full information gap analysis on drug related deaths in Salford to identify underlying trends and patterns. 95

96 9 Dependence on Prescription and Over the Counter Medicines 9.1 National Guidance The 2010 Drug Strategy makes specific reference to the expectation that local responses to drug misuse should address the needs of those dependent on prescription and over-the-counter medicines (OTCs). Dependence such substances is often summarised under the title of addiction to medicines (ATM)). PHE have produced guidance 56,57 for the commissioning of treatment for dependence on prescription and OTC medicines such as: Benzodiazepines and z-drugs, prescribed mainly for anxiety and insomnia. Opioid and some other pain medicines, both prescribed and OTC. Stimulants prescribed for ADHD or slimming. OTC cough and cold medicines, antihistamines and stimulants. The guidance outlines overlapping populations who are susceptible to misuse but stresses that distinct treatment approaches may be required for those: Who use prescription and OTC medicines as a supplement or alternative to illicit drugs or as a commodity to sell. Who overuse prescription or OTC medicines to cope with genuine or perceived physical or psychological symptoms. Who s us of a prescribed medicine inadvertently led to dependence, (sometimes called involuntary or iatrogenic addiction). PHE stress the importance of identifying local need arising from the misuse of prescription and OTC medications. They recommend that local Health and Wellbeing Boards support this process which entails reviewing NDTMS and prescription data, engaging with CCGs about the prescribing patterns of their GPs, working with Controlled Drugs Accountable Officers (CDAO) in NHS England Local Area Teams, and consulting service users, those affected by addiction, and those that work in the field. As part of identifying and responding to local need, PHE recommend a focus on prevention with primary and secondary healthcare, public health and social care working together to: Ensure psychological and other treatments are available as alternatives to prescribing medicines e.g. Increasing Access to Psychological Therapies (IAPT). Ensure public and patients are aware of the problems that can arise with these medicines and understand why availability is limited in duration and quantity

97 Ensure doctors, pharmacists, social care staff and others are aware of current guidance on these medicines and are alert to developing problems in patients. Monitor and responding to prescribing and purchasing patterns Primary care is likely to be the first point of call for patients dependent on prescription or OTC medicines but specialist responses should be developed to support and advise GPs in providing treatment and recognising when patients require more specialist care. These specialised services will need to adapt to such individuals who may need long term support and be mindful of the fact that they may be uncomfortable sharing space with illicit drug users. PHE also identify the importance of ensuring that all commissioned services include appropriate clinical governance mechanisms to ensure safe and effective prescribing of medicines. The guidance states that Primary Care practices will be expected to respond to ATM problems as part of regular patient care within the terms of the General Medical Services (GMS) contract. Any specialist responses should be commissioned as part of local drug and alcohol misuse treatment system from one or more of- Primary Care (providing an enhanced service) A provider of integrated drug and alcohol treatment services A dedicated ATM provider. The system should also ensure that pain management, mental health, drug and alcohol treatment services and voluntary sector organisations all work and communicate closely together to enable an integrated approach to meet individual patients needs. 9.2 Prescription and Over the Counter Medicines Prevalence (NDTMS) NDTMS data for details those in specialist drug treatment recorded as using prescription or OTC medicines during their latest treatment journey. Nationally there were 27,842 or one in every six (16.7%) service users in specialist treatment who cited use of over the counter or prescription medication. The majority (85.8%) of this cohort also used illegal drugs. However, it noteworthy that NDTMS records 4,603 individuals (2.4% of the total treatment population) as being in treatment solely for OTC or prescription drugs. Benzodiazepines were the most commonly used prescription drug, used by three-quarters of all users of OTC/prescription drugs. For those with no additional illegal drug use the most commonly used OTC/prescription drugs were prescribed opioids. 97

98 NDTMS data for on OTC/prescribed drug use within treatment services shows a great deal of regional variation, ranging from 32% in the North East to 11% in the West Midlands and the East Midlands. The North West had 4,905 (15.8%) service users in specialist treatment that cited use of over the counter or prescription medication, similar to the national rate. The majority (85%) of this cohort also used illegal drugs, with 878 (2.4%) in treatment solely for OTC or prescription drugs, again this is similar to the national picture. In Salford 123 illicit drug users (15.2%) cited use of prescription or OTC medicines, which is just below the regional rate. However, 36 (3.4%) individuals cited use of prescription or OTC medicines with no additional illicit drug use, and in percentage terms this cohort is 45% larger than found both regionally and nationally. In contrast to national and regional data very few of these individuals are recorded as using benzodiazepines but recorded rates of prescribed opioid use are much higher. The above data is given in full in Appendix

99 10 Drug Related Hospital Admissions 10.1 National and Regional Admissions (mental health and behavioural disorders) In 2011/12, there were 6,173 admissions to hospital with a primary diagnosis of a drug-related mental health and behavioural disorder. This is 7% (467) less than 2010/11 when there were 6,640 such admissions. Overall, between 2000/01 and 2011/12 admissions have decreased by 23% (1854) from 8,027 to 6,173. In 2011/12 almost three times as many males were admitted to hospital with a primary diagnosis of drug-related mental health and behavioural disorders than females (4,558 and 1,615 respectively). In 2011/12 more people aged were admitted with a primary diagnosis of drug related mental health and behaviour disorders than any other age group, accounting for 33.8% (2,084 out of 6,173) admissions. The Strategic Health Authority (SHA) with the most admissions for drug related mental health and behaviour disorders as the primary diagnosis was North West SHA (20 admissions per 100,000 population). The SHA with the lowest admissions was East of England SHA (6 admissions per 100,000 population). Where primary and secondary diagnosis was recorded there were 57,733 admissions in 2011/12, this is a 12.4% (6,380) increase from 2010/11 when there were 51,353 such admissions (Graph 18). Figures from this type of admission have continued to increase year on year and are now almost twice as high as there were eleven years ago as they stood at 25,683 in 2000/

100 Graph 18: Drug Related Mental Health Hospital Admissions between 2000/ National and Regional Admissions (poisoning by drugs) In 2011/12 there were 12,344 admissions to hospital with a primary diagnosis of poisoning by drugs. This is a 1.9% (242) decrease compared to 2010/11 when there were 12,586 such admissions. Since 2000/01 there has been a long term increase of 58% (4,530) when there were 7,814 such admissions. Adults in the age groups reported the highest number of admissions (2,924) with a primary diagnosis of poisoning by drugs in 2011/12. Those in the age groups reported the lowest number (361). In 2011/12 more males were admitted to hospital with a primary diagnosis of poisoning by drugs than females (6,336 compared to 6,008). The SHA with the most admissions for primary diagnosis of poisoning by drugs was North East SHA (with 41 admissions per 100,000). London SHA had the lowest (13 admissions per 100,000) Drug Related Hospital Admissions in Salford Table 13 below shows the number of NHS hospital admissions for drug use in The ICD codes used are: F11-F16, F18, F19 (drug related mental health and behavioural disorders) and T T40.9, T43.6 (poisoning by drugs) 59. The relatively low numbers mean that standardised rates have not been produced at a local level. Crude rates indicate that Salford has higher see for full definitions of diseases. 100

101 rates than Greater Manchester and the North West and double the national rate. Table 13: Drug Related Admissions during 2011/12 (*Source HSCIC 60 ) Admission Type Salford GM North England West Diagnosis of drug related mental Primary ,392 6,173 health and behavioural disorders Secondary 358 4,591 12,165 51,560 Primary diagnosis of poisoning by drugs ,531 12,344 Salford also has a lower proportion of admissions that are secondary diagnoses of mental and behavioural disorders than regional or national admissions. These secondary admissions would be admissions for any reason other than drug use but where drug use is also diagnosed. Those with a primary diagnosis are admissions where drug use is the main reason for the admission. Salford had the 16 th highest national level of hospital admissions due to substance misuse for young people age years in the period There were 43 admissions, a rate of per 100,000. The corresponding rate for Greater Manchester was and the national rate was Salford was significantly higher than both the region and the country. Two other areas of Greater Manchester, Wigan (8 th ) and Tameside (13 th ) were also within the 20 highest areas nationally Employing Local Data An information request for all drug and alcohol related admissions were submitted to the new Greater Manchester Commissioning Support Unit (CSU). This information can be used to identify drug and alcohol related admissions for 2012/2013 and provide insight on the characteristics of patients admitted and help identify patterns of drug or alcohol use. However due to the NHS reform, and current national policy on data sharing requirements with local authorities, this information was not made available to inform this HNA. A recommendation from this HNA is to ensure intelligence and data sharing systems are in place to allow for future analysis of all drug and alcohol related admissions. The relevant ICD-10 codes and data sharing request is detailed in Appendix Recommendations Carry out further analysis on Salford's drug and alcohol related hospital admissions, to identify any underlying contributing factors

102 11 New Psychoactive Substances (NPS) and Legal Highs 11.1 Legal Status The United Nations Office on Drugs and Crime (UNODC) - World Drug Report has defined NPS s as psychoactive substances not under international control that pose unforeseen public health challenges, in a market that has grown rapidly over the last decade. Producing and marketing these legal highs can achieve high profits without penalty. When brought under control in one country, production and/or the distribution centres of these substances are then shifted to another country so that sales (mainly internet) continue. UNODC have reported cases, where substances are modified slightly so that they are not covered by the respective country s legislation. The number of NPS reported by Member States to UNODC rose from 166 at the end of 2009 to 251 by mid This actually exceeds the total number of psychoactive substances currently controlled by international drug conventions (234 substances). NPS, which have not been tested for safety, may be far more dangerous than traditional drugs. Street names, such as "spice", "meow-meow" and "bath salts" can mislead young people into believing that they are indulging in lowrisk fun. Given the scope to alter chemical structures of NPS, new formulations are outpacing efforts to impose international control. The adverse effects and addictive potential of most of these uncontrolled substances are at best poorly understood. These synthetic drugs fall into three broad categories: synthetic cathinones (often marketed commercially as bath salts), synthetic cannabinoids (known as spice or incense), and synthetic amphetamine-like drugs. The cathinones and amphetamines are both stimulants and have similar effects. The most common signs of use are dilated pupils, hypertension, hyperventilation, paranoia, agitation, and hyperthermia. Synthetic cannabinoids have many of the same signs, as well as tremors and seizures. 63 The Misuse of Drugs Act 1971, which controls and classifies drugs that are dangerous or otherwise harmful when misused, has been amended several times since 2010 in an attempt to control the emergence of a number of new psychoactive substances in the UK. These include a range of synthetic cannabinoids, methoxetamine (and other related compounds), O- desmethyltramadol desoxypipradrol (2-DPMP), its related compounds and 62 UNODC (2013). World Drug Report Vol 382 July 6,

103 phenazepam naphyrone and other synthetic cathinones, tapentadol and amineptine, NBOMe and benzofuran compounds NPS Trends The World Drug Report identifies the United Kingdom as Europe s largest market for NPS. The UK had a reported lifetime prevalence rate of 8.2% among those aged 15 to 24. For 2010/11, the British Crime Survey found that the most widespread NPS was mephedrone, with an annual prevalence rate of 1.4% among the population aged 16 to 59 in England and Wales. This was higher than use of more established drugs such as ketamine (0.6%), khat (0.2%), as well as other NPS such as Spice (0.1%) and BZP (0.1%). Mephedrone was reportedly the third most used substance after cocaine, and level with ecstasy. Among those aged 16 to 24, the reported use of mephedrone (4.4%) was on a par with that of cocaine powder, and the second most widely misused substance in 2010/11. Mephedrone use was found to decline in response to an import ban and its classification as a Class B substance under the Misuse of Drugs Act in Reported annual prevalence fell by a fifth between 2010/11 and 2011/12, to 1.1%, ranking fourth after cannabis (6.9%), cocaine (2.2%) and ecstasy (1.4%) among the general population (aged 16 to 59). Findings from the 2012 Mixmag / Guardian drugs survey 65 (UK sample of 7700) also provided insight into risks, symptoms experienced, cost, access and consumption of NPS. For an overview of drug use and frequency among respondents to this survey see Appendix Salford s Drug Early Warning System (SDEWS) These trends highlight the need for local systems to be aware of changing drug taking behaviours and consider how services may address the consequences of NPS misuse. A number of national and European wide drug warning systems exist, but none of these systems are designed to identify, risk assess or respond to localized outbreaks of NPS use or risks associated with other more established forms of drug use. The current situation in the UK varies by region, with some areas already reporting significant NPS use within a variety of drug markets including the existing population of injectors. Currently in Salford there appears to be minimal reported incidence of NPS however, keeping up to date with this rapidly changing market, even knowing

104 which substances are legal, presents a considerable challenge for already busy services. In 2012 Salford DAAT commissioned Michael Linnell to develop a drug early warning system. The purpose of Salford s Drug Early Warning System (SDEWS) is to respond to the information needs and concerns of all members across a range of agencies. This includes the facilitation and cascading of information or warnings to appropriate staff and when deemed necessary the sending of alerts to specific target audiences of service users and/or the media. The SDEWS also enables the DAAT to formally report where necessary to the PHE. Given the scale of emerging NPS challenges, the SDEWS is an essential component of the local specialist system and its use should be promoted with all appropriate professionals. Further details on the function and implementation of the SDEWS can be found in Appendix Recommendations Further develop Salford s Early Warning System to alert partners to the health risks arising from both traditional drug use and the consumption of NPS s. Produce a local strategy for surveillance of, and guidance to all stakeholders on, Novel Psychoactive Substances (NPS). This should include input from specialist drug services, A&E, Police, Trading Standards and other relevant partners. Collate all PHE guidance on addiction to medicine and use them to inform future recovery orientated systems. Develop a drug and alcohol communication strategy with the new service Lead Provider. 104

105 12 Alcohol Use: Prevalence and Profiles 12.1 National Alcohol Prevalence The following section provides the most recent available statistics on alcohol consumption and its health related consequences. Current government recommendations 66 state that adult men should not regularly drink more than 3-4 units of alcohol a day and adult women should not regularly drink more than 2-3 units a day. After an episode of heavy drinking, it is also advisable to refrain from drinking for 48 hours to allow tissues to recover. The recent report by Health and Social Care Information Centre, Statistics on Alcohol; England 67 has shown the following drinking behaviours amongst adults and children in England for 2011: 61% of men and 72% of women had either drunk no alcohol in the last week, or had drunk within the recommended levels on the day they drank the most alcohol. This was most common among men and women aged 65 or over. 64% of men drank no more than 21 units weekly, and 63% of women drank no more than 14 units weekly. 12% of school pupils had drunk alcohol in the last week. This continues a decline from 26% in 2001, and is at a similar level to 2010, when 13% of pupils reported drinking in the last week Regional Alcohol Prevalence The North West region has some of the highest levels of alcohol related harm in England. The North West Public Health Authority (NWPHO) publishes data on a range of alcohol indicators annually via the Local Alcohol Profiles for England (LAPE) website. 68 The North West has the highest regional rates for the following indicators: Months of Life Lost due to alcohol: Males aged less than 75 years Months of Life Lost due to alcohol: Females aged less than 75 years Alcohol-Specific Mortality: Males, all ages Alcohol-Specific Mortality: Females, all ages Mortality from Chronic Liver Disease: Male, all ages Mortality from Chronic Liver Disease: Females, all ages Alcohol-Attributable Mortality: Females, all ages Admitted to hospital with alcohol specific conditions: Males, all ages Admitted to hospital with alcohol specific conditions: Females, all ages For the following indicators the North West has the second highest regional rate, in each case the North East has the highest rate: Health and Social Care Information Centre (2013). Statistics on Alcohol: England

106 Alcohol-Attributable Mortality: Males, all ages Under 18s admitted to hospital with alcohol specific conditions: Persons Admitted to hospital with alcohol attributable conditions: Males, all ages Admitted to hospital with alcohol attributable conditions: Females, all ages Admission episodes for alcohol-attributable conditions (previously NI39): All ages See Appendix 14 for details. Despite this level of harm linked to alcohol, the North West does not have the highest estimates for higher risk, increased risk or binge drinkers, see Graph 19 below. However, these are synthetic estimates that have very wide and overlapping confidence intervals. Graph 19: Regional rates showing synthetic estimates of drinking levels. 80% 70% 60% 50% 40% 30% 20% 10% 0% lower risk drinking higher risk drinking increasing risk drinking binge drinking 12.3 Alcohol Prevalence in Salford Prevalence estimates for alcohol use show that Salford has a lower proportion of adults who abstain from drinking than the country as a whole, although the difference is not significant given the wide confidence intervals shown in Graph

107 Graph 20: Salford and England Population aged 16years+ who abstain from alcohol When applying these proportions to the local adult population, Salford has 29,127 (95% CI 19,454-36,796) abstainers and 159,653 (151, ,326) drinkers. Salford has a significantly higher proportion of binge drinkers than England (at least 27% higher, possibly as much as 64% higher) but other categories are not significantly different (Graph 21) Graph 21: Levels of Harmful Drinking in Salford and England Applying the estimated number of drinkers in Salford s adult population to estimates for each drinking category give the following figure in Table

108 Table 14: Estimated Salford Drinking Population (16 and above) Category % of Drinking Population aged % Confidence Interval Lower risk drinkers 117,930 82, ,012 Increasing risk 30,651 17,366 59,052 drinking Higher risk drinking 11,072 3,974 36,770 Binge drinking 46,459 42,148 50,929 These figures suggest between 40,000 and 54,000 adults in Salford engage in binge drinking. There are an estimated 11,000 higher risk drinkers in the city although the true figure could be as low as 4,000 or as high as 39,000. However given the width of the estimate for abstainers the above confidence intervals may be wider. The below figures provide the widest confidence interval range for each category. Lower Risk Drinking: 78, , 313 Increasing Risk Drinking: 16, , 629 Higher Risk Drinking: 3,783 38,998 Binge Drinking: 40,124-54, Alcohol Prescribing The two main drugs prescribed for the treatment of alcohol dependence in primary care settings and in NHS hospitals in England are Acamprosate Calcium (Campral) and Disulfiram (Antabuse). Acamprosate Calcium helps restore chemical balance in the brain and prevents the feeling of discomfort that can be associated with not drinking, therefore reducing the desire or craving to consume alcohol. It accounted for two-thirds of prescribed items. Disulfiram can produce an acute sensitivity to alcohol resulting in a highly unpleasant reaction when the patient under treatment ingests even small amounts of alcohol. The Health and Social Care Information Centre (HSCIC) have compiled data on these prescription items and the Net Ingredient Costs (NIC) for treating alcohol dependence. In 2012, there were 180,000 prescription items for the treatment of alcohol dependence, mostly issued in primary care settings. This is an increase of 6% on the 2011 figure and an increase of 73% on the 2003 figure. The Net Ingredient Cost (NIC) of these prescription items in 2012 was 2.93m, an increase of 18% compared with 2011 and a 70% increase compared with In 2012 nationally, 315 prescription items per 100,000 population were dispensed for alcohol dependency. The North West SHA had the highest 108

109 number of prescription items per 100,000 population (541) and London SHA had the lowest (143). The North West also had the highest number of prescription items per 100,000 population for Acamprosate Calcium (403). In 2009/10 Salford PCT issued 703 prescriptions for Disulfiram with a NIC of 9,470 and 1,284 Acamprosate Calcium with a NIC of 15, Salford Alcohol Equity Audit As part of the Alcohol Harm Reduction Strategy an Alcohol Equity Audit (AEA) 70 was completed for Salford in At the same time findings from the One on Every Corner 71 study were published that looked at the association between off licence density and alcohol harm amongst young people. The findings from this described Salford as having the highest density of off licences in England (excluding London) with 136 per 100,000 population. This led to questioning of the relationship between alcohol availability and alcohol misuse. The AEA was therefore commissioned to review the current demand and use of alcohol services across Salford. It clearly identified how accessible alcohol is in Salford and examined the relationship this had with alcohol related crime and other harmful alcohol-related consequences within different communities. The AEA reviewed multiple datasets including alcohol related hospital admissions, specialist alcohol service use; alcohol related crime and licensed premises. This information was analysed to identify the demand for alcohol services, the associated health needs and the risks of alcohol consumption and how this is dispersed across different communities in Salford. The following section provides a detailed analysis of alcohol related hospital admissions and service user demographics. Further statistical analysis and mapping relating to access and service use is available in the full AEA document AEA Main Findings The AEA looked at three main topics, the key findings of which are summarised below: 1. Specialist alcohol service provision 2. The harmful consequences that alcohol has on individuals and communities in (hospital and crime data) 3. The accessibility of alcohol and its association with levels of specialist service use, crime and hospital admissions NHS Salford/ Salford City Council. (2012). Salford Alcohol Equity Audit 71 One on every corner: The relationship between off-licence density and alcohol harms in young people. Alcohol Concern (July 2011) 109

110 Specialist Alcohol Services Overall access to Tier 3 specialist alcohol services is in the main, equitably distributed according to need. Increased rates of adults in alcohol treatment are found in areas of greatest deprivation these include: Little Hulton, Walkden North, Swinton North, Barton, Weaste and Seedley, Irwell Riverside and Broughton. More recent data (see section ) shows the level of association between deprivation and treatment numbers. Approximately one in four children on the child protection register were associated with an adult who has an alcohol or drug treatment record. Of those adults, half were in treatment solely for alcohol and are associated with one in ten children currently on the register. See section 13.3 for further details. There is a strong local association between density of alcohol licensed premises and numbers in treatment. Salford Tier 2 alcohol services have recently been redesigned but require further support from primary care and wider community partners to establish local assets and interventions in areas facing increasing demand Step Programmes As described by ROTD, 12 step programmes play an important part of a recovery orientated system and specialist services should actively engage with their 12 step partners encouraging participation and hosting of sessions where possible. Current Salford provision of Alcoholics Anonymous (AA) includes 10 regular weekly meetings of AA held at eight different locations, covering every day of the week. Narcotics Anonymous (NA) have three weekly meetings, these are located in central/west areas of Salford The Harmful Consequences of Alcohol Use on Salford Alcohol causes major economic losses to Salford by considerably contributing to increased worklessness and substantial costs for welfare and treatment services in the area. Salford has a significantly higher rate of Incapacity Claimants, (297 per 100,000) whose main medical reason is alcoholism compared with Greater Manchester (201), North West (173) and England (104). Salford is ranked the 4 th worst area for this nationally. Salford consistently displays some of the highest levels of alcohol related mortality in Greater Manchester, the North West and England. Salford is nationally ranked as the second highest area for female and tenth highest for male alcohol specific mortality. 110

111 Increased rates of alcohol specific hospital admissions are found in areas of greatest deprivation: Broughton, Langworthy, Weaste and Seedley and Winton. In 2009/10 Salford s young population of drinkers had the highest rate of alcohol specific hospital admissions in Greater Manchester (126 per 100,000 population) significantly greater than both the North West and England rates. Increased rates of alcohol related crimes are also found in areas of greatest deprivation: Little Hulton, Barton, Langworthy and Broughton. There is a strong association between the number and location of alcohol related crimes and adults in treatment. The highest incidence rates (per 1000 population) of alcohol related crime occurred in Little Hulton (14.5) Walkden North (12.6), Langworthy (12.3), Eccles (12), Barton (11.9) and Swinton North (10.2). In 2010/11 Salford recorded 7,258 incidents of domestic violence, with 1,961 alcohol related crimes and a further 1,239 anti social behaviour incidents due to alcohol. Alcohol related crimes are occurring more in areas where there are greater numbers of premises selling alcohol The Accessibility of Alcohol in Salford From Salford s 537 alcohol licensed premises included in AEA analysis; the location and greatest numbers of premises are strongly associated with: Areas of increased alcohol related crimes such as domestic violence and anti social behaviour. Areas where increased service users in alcohol treatment live Areas of increased alcohol related admissions Areas of greatest deprivation This analysis has shown that alcohol related crimes are occurring more in areas where there are greater numbers of alcohol related premises. Reducing the ease of access to alcohol should be considered as an intervention for reducing crime in areas where alcohol related crime is rife Local Offending Analysis- Alcohol Alcohol related crime includes any crime which has been assigned an alcohol related marker by the police. During 2011/12 there were a total of 18,888 crimes in Salford of which 1,665 (8.8%) had an alcohol marker. In 2012/13 total crimes reduced to 16, 508 with 111

112 1,393 (8.4%) having an alcohol marker. The breakdown of all alcohol related crimes by Salford ward is described in Table 15. Table 15: Crimes which hold an alcohol marker over the last 2 financial years. Ward 2011/2012 Rate per 1,000 Pop. 2012/2013 Rate per 1,000 Pop. Diff in Statistics Langworthy Barton Ordsall Eccles Walkden North Irwell Riverside Weaste & Seedley Winton Broughton Little Hulton Swinton North Pendlebury Cadishead Swinton South Irlam Walkden South Kersal Claremont Worsley Boothstown & Ellenbrook Total 1, , The number of crimes with an alcohol marker has decreased in the last financial year. The actual percentage of alcohol related crimes against all crime remains at a similar figure to the last financial year. During 2012/2013 Langworthy was the ward with the highest rate per 1,000 population, followed closely by Barton. There were small increases of offences in 2012/2013 for the wards of Weaste & Seedley, Ordsall and Walkden South. All other wards have seen decreases Clusters Map 3 displays the alcohol related clusters for the 2012/2013 financial year for the City of Salford. 112

113 Map 4: Alcohol Related Crime Clusters In Salford Clusters for alcohol related crimes have occurred in Barton/Eccles border, Weaste and Seedley, Langworthy and Ordsall. Smaller clusters have occurred in Barton and Eccles specifically along Liverpool Road. A brief overview and profile of these clusters are described. Barton/Eccles This is a large area covering Eccles Town Centre and Liverpool Road. 87 alcohol related crimes were recorded here in 2012/2013. Offences were mainly related to assaults and public fear alarm and distress. There was a 65% detection rate for all alcohol related offences in the area. Church Street was the main repeat location with a total of 45 recorded offences There were a similar number of crimes recorded here in 2011/2012 with a total of 93. Weaste & Seedley The Weaste & Seedley cluster of 36 offences related mainly to the Hospital on Stott Lane. 25 offences were recorded at the Hospital in 2012/2013 compared to the 20 offences recorded in 2011/2012. There has been a small increase. Offences included assault, affray and public fear alarm and distress. Langworthy Pendleton has created a cluster of 67 offences with an alcohol marker. This is the same figure as in 2011/

114 Again offences were mainly related to assaults and public fear alarm and distress. There were also a small number of shoplifting offences. Ordsall The Trinity cluster in Ordsall contained 39 offences up from 20 offences in 2011/2012. Offences included assault, and public fear alarm and distress. 11 offences related to the Hotel on Victoria Bridge Street although they were all multi victim offences whereby guests have verbally abused or assaulted staff members, therefore only 4 actual incidents. Smaller clusters One cluster was in Peel Green/Patricroft around Liverpool Road in the Florence Street/Atherton Way area. There were 34 offences (12 domestic related). The supermarket on Liverpool Road was targeted on 5 occasions. The other cluster mainly features around Liverpool Road between Patricroft Bridge and Shakespeare Road. 114

115 13 Alcohol Users in Treatment with Salford Drug and Alcohol Service (SDAS) 13.1 Overview This section provides an analysis of alcohol users in treatment with Salford Drug and Alcohol Service. There were 2,909 primary alcohol users in treatment at some point in the last five years (1 April 2008 to 31 March 2013). Two thirds of alcohol users have had just one journey within the last five years, whilst one in eight has had three or more journeys. The number of primary alcohol users in treatment on any given day, over the five year period, ranged between 402 (Sep 2011) and 212 (Jan 2013), the average was 333. Most primary alcohol users in treatment were aged in their 30s or 40s (median 42 years), almost all (97%) were White British and a third were female. Around seven in every thousand Salford adults aged are in treatment with SDAS for alcohol problems in any given year. The wards with the highest rates are Langworthy, Broughton, Little Hulton, Walkden North and Barton. Those with fewest are Worsley, Boothstown & Ellenbrook, Walkden South, Claremont and Pendlebury The areas with the highest density of resident users are: Salford Precinct (Pendleton), Peel Green / Brookhouse (Barton), and Bury New Road, Higher Broughton. Previous analysis (Salford Alcohol Equity Audit 2012) shows that there was a strong correlation (r 2 =0.66) between the wards with the highest number of adults in treatment with SDAS and young people in treatment for alcohol problems with Lifeline SMART Successful Treatment versus Unsuccessful Treatment for Alcohol Users Table 16 below provides an overview of the key characteristics of clients in specialist alcohol treatment and compares the differences between successful and unsuccessful treatment exits in

116 Table 16: Salford Alcohol Users Successful and Unsuccessful Treatment Exits 2012/13 Primary alcohol exits in Successful Unsuccessful Number of episodes Median length of episode 122 days 90 days Median Age at exit years Median age at entry % female 30% 25% Opiate is additional problem substance 2.9% 2.5% Cocaine named as a problem substance 4.7% 8.9% % of parents living with all or some children 30% 17% Cannabis named as a problem substance 8% 15% Dual diagnosis 13% 17% In regular employment 15% 9% No housing problem 87% 84% Criminal justice referrals 12% 19% The factors more common amongst those who complete successfully are: living with children, employment, being older, being female and not using cannabis or cocaine in addition to alcohol. Alcohol users have a successful completion rate of 67% with little variation by length of treatment. The neighbourhood area with the best ratio of successful completions compared to unsuccessful completions is Walkden and Little Hulton neighbourhood, with the Swinton neighbourhood also performing well. Each of these neighbourhoods has a ratio of 3:1 (i.e. three successful completions for every one unsuccessful completion). Eccles neighbourhood has the poorest ratio at just better than 1:1. However Eccles neighbourhood has a low representation rate. The section below considers the rates for Salford s wards and compares them to deprivation levels Alcohol Success and Deprivation There is minimal correlation between deprivation and successful completion of alcohol treatment (R 2 = 0.01). As with drug treatment Claremont ward has the highest success rate (16/23 = 70%). Despite this there is little similarity between the success of opiate and alcohol treatments by locality. Ordsall, Boothstown and Ellenbrook have high rates for opiate treatment but low for alcohol, whereas Little Hulton and Swinton North have low opiate but high alcohol rates. 116

117 Table 17: Successful completion rates for primary alcohol users in treatment with SDAS by ward Ward In treatment 2012/13 Successful completion 2012/13 % Successful completion CLAREMONT % 18 SWINTON SOUTH % 14 LITTLE HULTON % 3 SWINTON NORTH % 12 WEASTE & SEEDLEY % 9 WALKDEN NORTH % 8 IRWELL RIVERSIDE % 4 WINTON % 7 CADISHEAD % 16 WORSLEY % 19 PENDLEBURY % 10 ECCLES % 13 LANGWORTHY % 2 KERSAL % 11 IRLAM % 15 BROUGHTON % 1 BARTON % 6 ORDSALL % 5 BOOTHSTOWN/ELLENBROOK % 20 WALKDEN SOUTH % 17 IMD 2010 ward deprivation rank (1=most deprived) Geographical Service User Data There has been little change in the distribution of both OCUs and primary alcohol clients over the last four years across Salford. Appendix 15 provides further detail on the geographical correlations found between specialist drug and alcohol service users in Salford. The conclusions may be employed to inform future targeted interventions and where successful rates of treatment completions could be improved. The main findings of the geographical analysis are summarised here covering a four year period 2008/2012: Irwell Riverside and Walkden North neighbourhoods each saw a 40% increase in alcohol clients over the 4 years. The increase in Walkden North occurred between and after which there has been a small decrease. The largest fall was seen in Walkden South. Irwell Riverside meanwhile has seen a steady year on year increase. 117 The wards with the highest numbers of both OCUs and alcohol clients are Langworthy, Barton, Broughton and Little Hulton.

118 The located numbers of OCUs and alcohol clients show a very strong correlation, suggesting that drug problems and alcohol problems tend to occur in the same areas. DSRs for successful completions by alcohol users were compared to areas with unsuccessful rates. This showed Walkden and Little Hulton actually have the best ratio for successfully completing treatment given they were the worst areas for OCU success. Walkden, Little Hulton and Swinton have a ratio of 3:1 i.e. three successful completions for every 1 unsuccessful treatment episode. Compared to the worst area which was Eccles with a 1:1 ratio. Alcohol service user location is shown in Map 2. Map 5: Geographical Location of Specialist Alcohol Users 13.3 Families and Treatment Alcohol misuse impacts not only on the individual but also on wider society as previously shown by treatment service data and local crime figures. It can also impact directly on their immediate family. A data matching exercise was conducted by Salford Children s Services, Salford DAAT and SDAS to investigate the number of adults who have a treatment record that also have an associated child on the Child Protection Register. 118

119 The data matching exercise was conducted using data taken from the Child Protection Register on 9 th August 2011 and SDAS records on 10 th August A total of 419 children were on the register. These children were associated with 756 adults (parents / main carers) however 19 were excluded from the exercise because no date of birth was recorded. Of the 419 children, 92 were found to be associated with 53 adults that had a treatment record. These 92 children were associated with 48 households. The main findings of the analysis were; Just under one in four children on the Child Protection Register are associated with an adult with an alcohol and/or drug treatment record (92 out of 419). Just over two thirds of these children (n=65) are associated with adults currently in alcohol and/or drug treatment. Half of the adults currently in treatment are in treatment for alcohol (17 out of 34). These are associated with around one in ten children currently on the register (39 out of 419). Most of those with a history of opiate / crack use are currently in treatment (13 out of 16). These are associated with 18 children currently on the register. This data matching exercise has identified the wider consequences that alcohol and drug use can have on families, ultimately contributing to children being placed at risk. This creates greater health and social care needs that require subsequent support for children and troubled families were alcohol and drugs having a major negative influence. The analysis also demonstrates the importance of sharing information between partners to help identify potential at risk service users and their families. It also demonstrates the importance of record linkage between differing organisation such as social care and specialist drug and alcohol services in order to integrate case management and to demonstrate changes in performance and outcomes related to drug and alcohol misuse. The findings from the data matching exercise also underline the need, as identified previously in the DAAT Review of Under 25s Substance Misuse Services (2011), for targeting those young people most at risk of developing substance misuse problems in the future. In particular the children of problematic drug and alcohol users are a key cohort. 119

120 13.4 Recommendations Develop a more robust prevention and early intervention agenda for young people and families. Develop Further develop specialist family support services in Salford following NICE guidance. Establish protocols for information sharing and integration of case management between drug and alcohol services and Children s Services. 120

121 14 Alcohol Related Hospital Admissions 14.1 Understanding data and practice Salford has consistently seen admission rates that place it within the top two or three areas in the country despite the presence of services specifically designed to help those most at need and those who repeatedly present at A&E with alcohol issues. The indicator used to measure the alcohol related hospital admissions is based on 2 key factors: 1. All the ICD-10 codes attached to every hospital admission in an area. 2. The likelihood that the conditions diagnosed are caused by alcohol use. All the AAFs for all admissions are added up to give a total for each local authority area. A standardised rate per 100,000 population is also calculated. The likelihoods have been calculated by the NWPHO at Liverpool JMU and are expressed as a number between 0 and 1, with 1 meaning certainly caused by alcohol (e.g. alcoholic liver disease or alcohol poisoning). These likelihoods are called alcohol attributable fractions (AAF). Each 10-year age band has different AAF for each condition, the AAF are also differentiated by gender. The ICD-10 codes attached to each admission can be given either as diagnoses by clinicians or automatically if a patient s records indicate an underlying condition or co-morbidity not recorded by a clinician. Each admission will typically have a number of different ICD-10 codes, up to 14 in some cases. An AAF will be matched to each of these codes. From this list the highest AAF will be used for the admission. For example, a 28 year old male admitted to hospital with acute appendicitis (ICD-10 code K35) has high blood pressure (I10) and also suffers from epilepsy (G40). The AAFs for these three codes for a male aged are: K35 = 0, I10 = 0.24, G40 = 0.64 The highest of these is 0.64 so this would be the AAF for this admission even though the admission only occurred because of the appendicitis which is not caused by alcohol consumption. It is possible that that many more admissions are counted as alcohol related than is truly accurate and have contributed to a greater increase in the number of recorded alcohol related admissions in Salford. Salford Royal Foundation Trust employs an Electronic Patient Record (EPR) system that automatically searches all previous records to pick out comorbidities of which alcohol abuse has been considered one since April The guidance around this has been interpreted strictly in Salford. 121

122 Therefore these patients will always receive an alcohol specific code attached to their future admissions, meaning they ll always attract an AAF of 1. Salford has high levels of alcohol use. To help to combat this, alcohol screening takes place routinely in Salford Royal Foundation Hospital Trust (SRFT). Whilst screening and subsequent brief interventions does reduce consumption and improve health, the consequence is that those patients reporting above recommended levels will have this recorded as a diagnosis attached to their admission. Therefore admission data will show a large number of admissions where secondary diagnoses are counted as alcohol specific. The latest alcohol admission data release from HSCIC (31 May 2013) allows Salford DAAT to separate out primary and secondary diagnoses and alcohol specific from alcohol related. Table 18 separates admissions into four categories by primary and secondary diagnoses and by wholly and partly attributable conditions. Primary diagnoses are the reason for the admission, secondary are other conditions the patient has that may or may not be related to the reason for admission. Wholly attributable admissions are those involving alcohol specific diagnoses, partly attributable involve a diagnosis that may be alcohol related. Table 18: Typical admissions by alcohol admission type for England, North West and Salford Wholly Primary Admissions specifically due to alcohol issues e.g. drunk people (acute intoxication) or alcoholic liver disease Secondary Admissions for patients with conditions not caused directly by alcohol who also have other alcohol specific issues e.g. injuries occurring whilst intoxicated or elective procedures where screening shows increased alcohol consumption (harmful use). Partly Admissions due to conditions, some of which may in part be due to alcohol consumption e.g. some cancers or cardiac arrhythmia Admissions due to particular conditions unrelated to alcohol use but who also have other issues, some of which may in part be due to alcohol consumption e.g. hypertension. The national regional and Salford figures for admissions in each of these categories are highlighted in Table 19 overleaf. Salford has two and a half times as many people whose admission to hospital was directly caused by alcohol than the country overall. Salford had 338 primary diagnoses per 100,000 population that were wholly alcohol attributable compared to 132 in England and 200 in the North West. This figure is the highest in the country and 15% higher than the second highest (Wirral, 293 per 100,000). 122

123 Table 19: Number of admissions by alcohol admission type for England, North West and Salford ENGLAND Wholly Partly Total ENGLAND Wholly Partly Total Primary Primary 6% 11% 16% Secondary 441 1,479 1,920 Secondary 19% 64% 84% Total ,298 Total 25% 75% 100% North West Wholly Partly Total North West Wholly Partly Total Primary Primary 7% 10% 17% Secondary 676 1,651 2,327 Secondary 24% 59% 83% Total 876 1,918 2,794 Total 31% 69% 100% Salford Wholly Partly Total Salford Wholly Partly Total Primary Primary 8% 7% 16% Secondary 1,416 1,948 3,364 Secondary 35% 49% 84% Total 1,754 2,243 3,997 Total 44% 56% 100% The figures also show that around 1 in 5 admissions are wholly attributable secondary diagnoses in England. In the North West that rises to one in four but for Salford it s higher than 1 in 3. This category makes up a higher proportion of the total alcohol admissions for Salford than it does for any of the other 151 PCT areas in England Improving our understanding of Salford s Data Salford DAAT suggests that additional alcohol specific (wholly attributable) diagnoses are attached to Salford admissions to a much greater extent than in other areas. As discussed above, potentially this turns admissions that may have been partly attributable into wholly attributable. The fact that Salford has the higher level of alcohol specific primary diagnoses than anywhere else suggests the city s problem with alcohol is very real. To understand and help address this problem we require routine access to admissions data. An information request to this end was submitted to the new Greater Manchester Commissioning Support Unit (CSU). However due to the NHS reform, and current national policy on data sharing requirements with local authorities, this information was not made available to inform this HNA. Instead we have employed 2010/11 admissions data alongside the current Local Alcohol Profiles for England (LAPE) resources will provide insight into Salford alcohol related hospital admissions. A recommendation from this HNA is therefore to ensure intelligence and data sharing systems are in place to allow for future analysis of all drug and alcohol related admissions. The relevant ICD-10 codes and data sharing request is detailed in Appendix

124 Access to this data will enable routine analysis that provides evidence of health need and developing trends and at a minimum answers to the following key questions What are the biggest contributing conditions? Who are the people admitted (age, gender, and repeat admissions)? Are the admissions planned or unplanned? 14.3 National Alcohol Related Hospital Admissions In 2011/12, there were an estimated 1,220,300 admissions related to alcohol consumption where an alcohol-related disease, injury or condition was either the primary reason for hospital admission or a secondary diagnosis (broad measure). This is an increase of 4% on the 2010/11 figure (1,168,300) and more than twice as many as in 2002/03 (510,700). Of the estimated 1,220,300 alcohol related admissions in 2011/12, 75% (919,200) were due to conditions which were categorised as chronic, 8% (94,300) were for conditions categorised as acute and 17% (206,800) were for mental and behavioural disorders due to alcohol. Males were more likely to be admitted to hospital accounting for 63% of overall alcohol related admissions. Among different age groups, those aged 75 and over had the lowest number of admissions of all adults where the primary or secondary diagnosis was wholly attributable to alcohol. There was a peak in admissions among those aged 45 to 54 (Graph 22, overleaf). 124

125 Graph 22: Number of alcohol related NHS hospital admissions where there was a primary or secondary diagnosis of a disease or condition wholly attributable to alcohol, by age 2011/12 (Source HSCIC) For 2011/12, the England alcohol related admission directly standardised rate (based on primary and secondary diagnosis recorded) was 2,298 per 100,000 population. In comparison the North West was 2,795 with Salford ranked with the largest alcohol related admissions in the country at 3,997 per 100,000 population 72 Caveats exist regarding the data used to analyse and calculate alcohol related admissions that need to be considered when interpreting trend data, 73 these are linked to the methods of coding previous years alcohol related hospital admissions and adjusting to allow for comparison in the future trends. Adjusted figures show a 51% increase from an estimated 807,700 alcohol related admissions in 2002/03 and a 1% increase from 1,205,500 in 2010/11. The proportional difference in this increase over time is described in Graph 23. Further breakdowns of admissions and demographics by analysis type can be found in Statistics on Alcohol: England Local Alcohol Profiles for England Health and Social Care Information Centre (2013). Statistics on Alcohol: England

126 Graph 23: Alcohol Related NHS Hospital Admissions (ARAs 2002/03 to 2011/12 (*Source HSCIC) 14.4 Alcohol Related Hospital Admissions in Salford Salford s alcohol related hospital admissions are currently the second highest in the country according to the most recently available data. 74 There were 815 admissions per 100,000 population in during quarter 4 (Jan - Mar 2013). Salford s rate equates to 1 admission per 123 of the population in 3 months. Despite the high rate, this represents a decrease from the last quarter of 63 (7.2%) with Q seeing the lowest rate since April- June Graph 24 compares Salford s admission rate with the regional and national rates. Graph 24: Alcohol Related Hospital Admissions by Quarter per 100,000 population

127 1, Alcohol Related Hospital Admissions By Quarter per 100,000 Salford North West England Salford target Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Salford had the second highest admission rate of any Local Authority over the last 4 quarters (Table 20) for which data is available, with 3,365 per 100,000 or 1 admission for every 30 of the population over 12 months. Although there was a fall of 9% in the number of alcohol related hospital admissions in 2012/13, Salford missed the annual target for the third year running. Table 20: Top Ten Areas with Highest Alcohol Related Admission Rates per 100,000 population 2012/13 Area Q4 Area Middlesbrough 819 Middlesbrough 3,471 Salford 815 Salford 3,365 Islington 748 Blackpool 2,980 Kingston upon Hull, City of 745 Manchester 2,972 Knowsley 743 Burnley 2,953 South Tyneside 734 Blackburn with Darwen 2,950 Sunderland 727 Liverpool 2,940 Blackpool 714 Wigan 2,933 Wigan 712 Knowsley 2,923 Blackburn with Darwen 711 South Tyneside 2,912 North West 586 North West 2,402 England 476 England 1,951 Local NHS Salford resident data has been provided through the NHS Commissioning Business Support Unit. Using local admission data from the Secondary Use Service dataset, detailed demographic data on Salford residents whose admission can be linked wholly or partially to alcohol consumption can be obtained. Characteristics include: 127

128 Post code Age Gender Repeated Admissions ( Frequent Flyers ) Ethnicity Given the complexities that can exist in identifying patients with an alcohol attributable fraction (AAF), the dataset used describes patients who have had an alcohol specific admission (AAF=1). This allows the results to be confident that all patients included have an admission wholly related to alcohol; it covers the period April March The dataset is also split to describe the impact of repeat admissions made by the same patient during this 12 month period, these patients can also be referred to as frequent flyers. Graph 25: describes the Age and Gender distribution between all Alcohol Specific admissions (adjusted for repeated admissions). In 2010/11 Salford recorded 1778 Alcohol specific admissions. Accounting for any repeated admissions by the same patient, there was a total of 1141 alcohol specific patients in 2010/11 resident in Salford. Of these, 68% were male and the age range most at risk of an alcohol specific admission ranged between year olds (median 46yrs Inter quartile range (IQR) 10yrs). The ethnicity recorded for these alcohol specific patients was pre-dominantly White British (95%) with a further 1% Irish and another 1% from other white backgrounds. 128

129 Admitted Patient Residences: Salford Neighbourhood Using patient post code data and the assigned alcohol attributable fractions, directly age-sex standardised rates of admission by ward level have been calculated for both alcohol attributable and alcohol specific admissions across Salford wards and neighbourhoods. The data from NHS Commissioned Business Services (CBS) covers all hospital admissions by those patient s resident in Salford. These rates can then be compared with existing knowledge of different localities; such as levels of deprivation, social marketing descriptions, access to potential services and the availability of alcohol in that area. Table 21 describes the Directly Age-Sex standardised rates (DSR) across Salford wards. For admissions wholly related to alcohol, Langworthy, Weaste and Seedley, Winton and Broughton wards all have significantly greater rates than Salford. When comparing the DSR for Alcohol Attributable admissions Langworthy, Broughton, Weaste and Seedley, Barton, Ordsall, Winton and Swinton North wards all have significantly greater rates of admission than would be expected for Salford. Table 21: Directly Standardised Alcohol Specific Admission Rates for Salford Wards 2010/11 Rank for Highest Admission in Salford Ward Name Alcohol specific (DSR per 100,000) Confidence Interval Lower Confidence Interval Upper Significantl y Higher / Lower 1 Langworthy Higher 2 Weaste and Seedley Higher 3 Winton Higher 4 Broughton Higher 5 Barton Eccles Swinton North Little Hulton Cadishead Irwell Riverside Walkden North Ordsall Pendlebury Swinton South Claremont Lower 16 Irlam Lower 17 Kersal Lower 18 Worsley Lower 19 Walkden South Lower 20 Boothstown and Ellenbrook Lower Salford (RESIDENT) Salford (REGISTERED) Salford Crude rate (all records)

130 Salford Royal Foundation Trust (SRFT) alcohol admission data is also available, and as the main secondary care provider, its findings mirror those for admissions made to all Hospitals in Greater Manchester by a Salford Resident. Map 6 illustrates that rates of alcohol specific admissions to SRFT are significantly greater in Broughton, Langworthy, Weaste and Seedley and Winton localities when compared to Salford average. However we must also remember that Salford overall has significantly higher alcohol specific admissions than England for both males and females. Map 6: Alcohol Specific Admissions to SRFT by Wards during 2010/11 As expected Alcohol Attributable admissions made solely to SRFT also mirror the overall DSR findings for Salford residents. Map 7 shows significantly greater rates of admissions come from Langworthy, Broughton, Weaste and Seedley, Barton Ordsall, Winton and Swinton North wards. Map 7 demonstrates those most affected wards when compared to Salford overall. However those areas that are not statistically different to the Salford average still have high levels of admissions given Salford is significantly worse when compared to England. 130

131 Map 7: Alcohol Attributable Admissions to SRFT by Wards for 2010/11 131

132 15 Liver Disease The North West Public Health Observatory (NWPHO) and Health Protection Agency (HPA) produced the Burden of Liver Disease 2012 report 75 that collates routinely available data on the burden of liver disease and describes its relationship with inequalities in the North West of England. The report identifies a number of negative consequences of alcohol misuse in the North West that include: Alcohol-related cirrhosis is the leading cause of registrations for liver transplants in the North West. North West adults continue to be more likely than average to drink over the recommended limits. There are more deaths from alcohol-related liver disease in the most deprived local authorities of the North West than the least deprived. Alcohol-related liver disease refers to damage to the liver caused by alcohol misuse. One of the liver s functions is filtering alcohol and when this occurs some cells die but subsequently are capable of regeneration. However, prolonged alcohol misuse can prevent regeneration. The final stage of alcoholrelated liver disease is cirrhosis of the liver Regional Liver Disease and Mortality The rate of liver disease deaths in the North West increased among males from 27.0 per 100,000 in 2005 to 30.9 per 100,000 in 2010; deaths in males are markedly higher around the ages of 55 to 64 years whereas for females over the age of 40, they are more evenly spread across age categories. The second largest contributor to liver mortality in the North West during 2010 was hepatocellular cancer with 15% of males and 5% of females dying from this. Liver disease mortality is highest in Blackpool (42.7 per 100,000 population) and lowest in Eden (8.2 per 100,000); over two thirds of the variability can be explained by deprivation. Salford had the 3 rd worst mortality rate in the North West (30.0) for all liver disease (underlying cause) between , behind Manchester (34.4) and Blackpool. Alcohol-related liver disease accounts for the greatest proportion of all liver disease deaths for both males (47%) and females (43%) in the North West. In England, for males this was 45% and females 35%. 75 NWPHO. (2012). The Burden of Liver Disease and Inequalities in the North West of England

133 15.2 Liver Disease and Mortality in Salford In the North West between 2005 and 2010 mortality rates for alcohol-related liver disease were stable for both males and females. The mortality rate among males was approximately twice the rate of mortality among females with deaths in the North West highest among men aged 45 to 64 years. Rates of alcohol-related liver disease among females were more evenly distributed across a wider range (40 to 64 years). In 2011 Salford CCG had a rate of 22 per 100,000 population for under 75 mortality rate from Liver Cancer. This was the 36th highest nationally (out of 211) compared to a national rate of 14.9 and North West regional rate of 21.1 per 100,000. The directly standardised rates (DSRs) for the top ten areas of liver cancer mortality in are described in Table 22. Table 22: Directly Standardised Rates (95% Confidence Intervals)for Liver Cancer Mortality during CCG Name DSR CI Lower CI Upper Population Observed Rank NHS BLACKPOOL CCG NHS SOUTH SEFTON CCG NHS BRADFORD CITY CCG NHS WOLVERHAMPTON CCG NHS SOUTHPORT AND FORMBY CCG NHS WIGAN BOROUGH CCG NHS CAMDEN CCG NHS NORTH MANCHESTER CCG NHS BLACKBURN WITH DARWEN CCG NHS CALDERDALE CCG NHS SALFORD CCG Salford also had the 6 th highest rate of years of life lost due to mortality from chronic liver disease including cirrhosis 77 ( ) with years lost per 10,000 pop. For females the rate was (6 th highest) and males (14 th highest). Salford has a statistically significant higher rate for years of life lost than England males (29.24), England females (14.8) and England all persons (22.03) Salford also has a higher rate than North West males (45.11), females (25.85) and all North West persons (35.48), although this is not statistically significant when comparing 95% confidence intervals. 76 GP registered population counts from NHAIS (Exeter), the Primary Care Mortality Database (PCMD) and ONS mid-year England population estimates 77 NHS Information Centre indicators, Years of life lost due to mortality from chronic liver disease including cirrhosis: directly standardised rate, <75 years, 3-year average, MFP, 133

134 As highlighted by the Burden of Liver Disease report, both the misuse of drugs and alcohol can be causally related to the incidence of liver disease, and it is important to review available data regarding the impact and burden of liver disease in the Salford population Liver Disease and Hospital Admissions In 2012 the North East region had the highest rate of all liver disease admissions per 100,000 population (92.5), followed by the North West (87.1). In each region the age group with the highest admission rate was year olds. The North West had the highest admissions amongst year olds however the nationally peak age for liver disease is years for both males and females. Salford had the highest rate of hospital admissions for all liver disease in England in 2012, with 171 admissions per 100,000 population. This is an increase of 13% from 151 admissions per 100,000 in 2011 (2 nd highest nationally). This rate is almost double the regional rate (87 per 100,000) and more than two and a half times the national rate (65 per 100,000). The actual number of admissions in each calendar year were 329 (2011) and 372 (2012). Directly Standardised Hospital Admission Rates for Liver Disease are summarised in Graph 26. Graph 26: Directly Standardised Rates for All Liver Disease by Primary Care Trust Residence in 2012 (*Source HSCIC) 134

135 Two other Greater Manchester areas feature in the graph above; Manchester (3 rd ) and Heywood, Middleton & Rochdale (4 th ). Within Greater Manchester all but two PCT areas (Bury and Tameside & Glossop) saw an increase in admissions with the largest increase occurring in Oldham (50% increase, from 71 to 106) (Graph 27). Graph 27: DSRs for All Liver Disease Admissions in Greater Manchester from (*Source HSCIC). Alcohol Related Liver Disease and Hospital Admissions Hospital Admissions (per 100,000 population) for alcohol-related liver disease in 2010/11 were significantly higher in the North West ( %CI: ) than England (93.8 (95%CI: )). Salford had a significant higher rate of (95%CI: ) than both the North West and England. Approximately half of all liver hospital admissions are alcohol related, with the national peak age for alcoholic liver disease being years for males and years for females. However there are a significantly greater proportion of males than females within these age groups as demonstrated by Graph Data source: health & social care information centre 135

136 Graph 28: National Admission Episodes for Alcohol Related Liver Disease by Gender and Age for 2012 (*Source HSCIC) Updated analysis for this HNA has shown Salford CCG to have the second highest (out of 211) national rate of emergency admissions for alcohol related liver disease in 2011/12 at 69.8 per 100,000. The national median CCG rate is 22.3 with a weighted average of 24.6 per 100,000. Data from the 10 localities with the highest rates for alcohol related liver disease emergency admissions are summarised in Table Hospital Episode Statistics (HES), ONS mid-year population estimates and GP registered population counts from NHAIS (Exeter) Released March

137 Table 23: Top 10 CCGs with highest Directly Standardised Rates of Alcohol Related Liver Disease Emergency Admissions 2011/12 (*Source HSCIC) CCG Name DSR CI Lower CI Upper Population Observed rank NHS NORTH MANCHESTER CCG NHS SALFORD CCG NHS SUNDERLAND CCG NHS SOUTH TYNESIDE CCG NHS HEYWOOD, MIDDLETON AND ROCHDALE CCG NHS TAMESIDE AND GLOSSOP CCG NHS LEEDS SOUTH AND EAST CCG NHS SOUTH MANCHESTER CCG NHS CENTRAL MANCHESTER CCG NHS BLACKPOOL CCG Hepatocellular Cancer: All Most cancers that occur in the liver are tumours that have spread from other parts of the body and are termed secondary cancers. Cancers that arise from the liver are termed primary liver cancers and are relatively uncommon in the UK, making up about 1% of all cancers. The most common primary liver cancer is hepatocellular cancer which is causally related to hepatitis and alcohol misuse. The main cause of hepatocellular cancer is cirrhosis of the liver where the tissue has become scarred as a result of damage over a long period of time. Certain causes of cirrhosis have a strong link with hepatocellular cancer: alcohol misuse, fatty liver disease and hepatitis C. On average, there are 212 new cases and 165 deaths attributed to hepatocellular cancer in the North West every year, this figure may be a minimum given possible underreporting to the local cancer registry. During , Salford had the fourth worst mortality rate 2.8 (95%CI: ) per 100,000 population for hepatocellular cancer in the North West (1.8 (95%CI: )), which is also significantly higher than for England at 1.6 (95%CI: )). During , Salford also had the 10 th worst incidence rate of hepatocellular cancer in the North West, with 2.7 (95%CI: ) per 100,000 population. This was slightly higher than the North West (2.4) and England 137

138 (2.3) but not statistically significant due to the overlapping confidence interval ranges Hepatitis C (HCV): All Hepatitis means inflammation of the liver. The most common causes of hepatitis are viral infections such as hepatitis B (HBV) and C (HCV). HCV in particular can persist and cause cirrhosis of the liver. HCV is a blood borne virus which is transmitted via infected blood or less commonly via body fluid. Estimates suggest that there are approximately 216,000 people chronically infected with HCV in the UK. The main risk factor for HCV is sharing or use of contaminated equipment by injecting drug users. Acute HCV is normally asymptomatic and if left untreated up to 25% of people clear the virus naturally. Those who remain infected after the first six months of infection are described as having chronic HCV; the virus remains in the body for many years and may progress to cirrhosis, liver failure or cancer. Progression of liver disease is more likely in those who drink alcohol or are over the age of 40 years. In most cases HCV infection has no symptoms and therefore many people can be unaware they are infected. Therefore the incidence and prevalence of hepatitis C are not precisely known, it is estimated that in England, 0.4% (1 in 250) of the adult population are living with chronic infection. The Burden of Liver Disease report provided the following key findings related to HCV infection: The number of deaths attributed to HCV in the North West is relatively low compared to other liver disease. Hospital admissions for HCV (all diagnoses) have risen since 2005 and are higher among males than females. The rate of admission for HCV is significantly higher in the North West compared to England. The rate of hospital admissions varies considerably between local authorities dependent on whether only primary diagnosis or all diagnoses is analysed. This may be due to differences in primary care/outpatient service provision. Approximately 5% of people undergoing diagnostic testing for HCV were positive between 2005 and 2010 with the highest proportion of positive tests in males aged 35 to 44 years. There has been a decline in the proportion of young people testing positive since Estimates of the population prevalence of HCV by DAAT area show the highest levels in Lancashire, Manchester and Liverpool, reflecting the higher prevalence of injecting drug use in these areas. Injecting drug use is by far the main risk exposure accounting for over 70% of positive individuals; 65% of injecting drug users tested in the 138

139 North West were HCV positive compared to the national average of 49%. Reported sharing of needles and other drug use equipment has decreased since 2000 and there has been an increase in the proportion of drug users aware of their HCV infection. The North West has a significantly higher rate of admission for both HCV as a primary diagnosis (11.9 per 100,000 population) and all diagnoses (78.9 per 100,000 population) than the England average (8.6 and 49.3 per 100,000 population respectively). During , Salford had the 5 th worst hospital admission rate for HCV (primary diagnosis) behind four other Greater Manchester local authorities Future Burden of HCV: All The HPA has used statistical modelling to estimate the future burden and the cost of treatment for HCV. The North West contributes an estimated 39,992 (20%) of the total 200,000 number of people with HCV in England. It is estimated that Salford has 1,345 HCV infected persons costing 976,875 in annual treatment. Using the modelling tool outlined in Table 24, by 2015 it is also estimated that Salford DAAT area HCV population requiring treatment will increase by 14, leading to an increase in costs of 133,158 and a further 91 people would have died by 2015 with 42 at cirrhotic or end stage liver disease. The total cost of treating individuals already infected with HCV is estimated at 29 million for the North West and 121 million for England. Additionally there is an estimated cost of 4 million for the North West and 20 million for England for treating cases that are not already receiving care. 139

140 Table 24: Estimates of HCV prevalence, burden, treatment and cost of treatment by Drug and Alcohol Action Team area in the North West (*Source HPA) 15.7 Hepatitis B (HBV) Hepatitis B (HBV) is a blood borne viral infection which causes inflammation of the liver. It is transmitted through infected blood or body fluids by sharing needles or contaminated equipment during injecting drug use, by sexual contact with an infected person, by mother to baby (perinatal) transmission, by needle-stick injuries or by tattooing or body piercing 80. The first six months of infection is known as acute HBV infection; failure to clear the virus after this leads to chronic infection. Most adults infected with HBV fully recover and develop life-long immunity. However, infection in babies 80 PHE /HPA website (cited 5/8/13) tisb/hepbgeneralinfo/ 140

141 and young children is likely to result in chronic infection (90% of infants infected in the first year of life and 30% to 50% of children infected between one and four years of age). Chronic infection can lead to liver cirrhosis and hepatocellular carcinoma. People with HBV can often be asymptomatic and may therefore be unaware of their infection. HBV is relatively uncommon in England but prevalence is higher in those born in certain countries (South East Asia, China and Africa) many of whom will have acquired infection at birth or in early childhood. In the UK, the HBV vaccine is not a routinely administered vaccine, but is targeted for those people that are at increased risk of being infected with HBV or could be at risk of serious complications. Examples of these groups include: injecting drug users (IDUs), people who change their sexual partners frequently, men who have sex with men, babies born to infected mothers, prisoners and family contacts of an individual with HBV infection. The Burden of Liver Disease report combines a range of data sources to identify the burden of HBV in the North West including injecting drug users and needle exchanges. No data on HBV deaths are provided due to small numbers. The North West in 2010 only had 11 deaths reported with an underlying cause of HBV. The main findings of the report relating to HBV are: Hospital admissions for HBV in the North West have declined since 2006/7. Laboratory reports of acute infection declined between 2008 and 2010; most acute cases were among men aged years. Limited data on risk factors suggest that sexual exposure accounts for most transmission of acute infection. Approximately 1.7% of people tested in the North West were HBV positive between 2005 and 2010; the proportion of antenatal women tested who were positive has remained stable since 2005; the highest proportion of those positive was in Greater Manchester. The proportion of those tested who were positive in the North West between 2005 and 2010 were higher in people who were Other and/or Mixed Ethnicity (11.8%), Black or Black British ethnicity (8.5%) and Asian or Asian British ethnicity (2.8%) compared to White or White British ethnicity (0.9%). 141

142 16 Alcohol Deaths / Mortality Alcohol related deaths are measured by both alcohol attributable and alcohol specific indicators in line with methodology for calculating alcohol related hospital admissions (Alcohol Attributable Fractions) Alcohol Related Mortality: England In England, in 2011 there were 6,923 deaths directly related to alcohol. This is a 26% increase since 2001 when there were 5,476 alcohol related deaths and a 3.8% increase from 2010 when there were 6,669 such deaths. The number of male deaths increased from 4,439 in 2010 to 4,518 in 2011 and the number of female deaths increased from 2,230 in 2010 to 2,405 in More men than women died from each of the causes directly related to alcohol, except for chronic hepatitis, where the reverse was true. Alcoholic liver disease was the most common cause of death and accounted for 64% (4,441) of all alcohol-related deaths in LAPE have estimated that in 2009 there were 15,401 deaths that were attributable to alcohol consumption (10,289 for men and 5,111 for women) Alcohol Deaths / Mortality in Salford Alcohol Related Mortality : Salford Following the same methodology for calculating alcohol related hospital admissions (the use of Alcohol Attributable Fractions); alcohol related deaths are measured by both alcohol attributable and alcohol specific indicators. Salford consistently displays some of the highest levels of alcohol related mortality in Greater Manchester, the North West and England Alcohol Attributable Deaths: Salford The rate of alcohol attributable deaths for Salford males was 53.2 per 100,000 in 2009/10 having risen 31% since 2005/06, the highest increase in Greater Manchester. Female alcohol attributable deaths (21.1) also recorded an 11.9% increase during the same period. This data illustrates the rising influence alcohol has on mortality in Salford. The Directly Standardised Rate (DSR) of alcohol attributable deaths for Salford males in 2010 was ((95%CI: ) per 100,000 population. This ranked Salford as the 15 th highest area nationally, with a significantly higher rate than England (35.48 (95%CI: )) and a higher than the North West (43.42 (95%CI: )).However this attributable mortality rate for males continues to reduce year on year since the 2006 rate of per 100,000 population. Salford female attributable mortality rate is ranked 59 th nationally at (95%CI: ) per 100, 00 population. It is less than the North West 142

143 regional rate of (95% CI: ) but higher than the England rate (14.7 (95%CI: )). Similar to the Salford male trend, female alcohol attributable mortality rates have reduced overall since 2006 from per 100,000 population Alcohol Specific Deaths: Salford Salford females recorded the highest rate of alcohol specific deaths in Greater Manchester for 2007/09 (15.6 per 100,000) and ranked second worst nationally behind Blackpool. This was significantly greater than the female alcohol specific mortality rates for both the North West (9.9) and England (6.1) and represents a 78% increase when compared with 2003/05 records. Salford males also recorded a statistically greater alcohol specific rate of mortality (25 per 100,000) than both the Greater Manchester (25) and England (13) level; it was ranked tenth worst area nationally. This was a 25% increase from 2003/05 records and alongside both female alcohol specific and alcohol attributable mortality figures. The DHNW 81 have highlighted the impact alcohol related mortality has had on spearhead areas such as Salford, with proportionately greater mortality in spearhead areas compared to non spearhead. From population surveys between 1998 and 2008, spearhead and nonspearhead populations have experienced very similar rates of increase in average alcohol consumption and in binge drinking. Surveys of drinking tend to show consumption increases in all income groups except the very poorest. DHNW ongoing clinical studies show that the better off in our society drink more but in ways that harm them less and the less well off drink less but in ways that harm them more. The major components of the mortality increases are in alcoholic liver disease between 45-64yrs, digestive cancers and alcoholrelated dementia in 60-74yrs. The DSR for alcohol specific mortality per 100,000 population for Salford males in is (95% CI: ), higher than the North West (18.51 (95%CI: )) and significantly higher than England (13.16 (95%CI: )). This places it as the 22 nd nationally for alcohol specific male mortality. Salford male alcohol specific mortality has seen an increase since 2006 (18.04), however this most recent figure for is a reduction from (25.05). 81 DoH and NWPHO 26/9/11. Where Wealth Means Health Presentation. Narrowing the English Health Inequalities Gap: What went right and what went Wrong Presentation Slides. 143

144 Alcohol specific mortality for Salford females is ranked 6 th highest nationally. With a rate of (95% CI: ) it is higher than the North West (9.82 (95% CI: )) and significantly higher than England (6.04 (95%CI: )) for Although this rate has improved since (15.63) it is greater than 2006 rate of per 100,000 population. The alcohol specific and attributable mortality trends are depicted in Graph 29. Graph 29: Alcohol Related Mortality Rates in Salford between

145 145 Appendices

146 Appendix 1: Stakeholder Consultation Following the policy shift towards Building Recovery in Communities -Salford Drug and Alcohol team has completed extensive stakeholder consultation on this model and how local services should be shaped to meet the identified needs of key stakeholders. Whilst undertaking consultation regarding the recovery model, further consultation was also required as part of the public health reform. This reform has led to the National Treatment Agency become part of Public Health England and Public Health in local areas is now part of local authorities. Further reform has also seen the introduction of Police and Crime Commissioners and Clinical Commissioning Groups, and wider changes to regional and national NHS commissioning structures. With the public health move to local authorities and changes to the allocation of spending from the Department of Health, a Salford City Council Community Impact Assessment was also completed. This required assessments of the needs of vulnerable people and how changes to the recovery model would impact on service users. A summary of all stakeholder feedback, expressed need, and actions for implementation is provided in this section. Consultation Events and Feedback From January to March 2012, Salford DAAT undertook a series of stakeholder, public and service user consultations as part of the consultation phase of the re-specification of the drug and alcohol treatment system. Below is a summary of the key findings that emerged from this work: A Provider Briefing Event took place on 19 January 2012, attended by 68 people from a range of agencies. The main points raised by participants were: The need to develop peer recovery focused support including recovery champions and peer based assertive outreach. The development of a visible and accessible recovery community. Greater integration and co-ordination across the system with a single point of entry and effective and integrated information systems. Community development and links between the services and the community. Development of employment related activity, linking into the local business economy. Fast entry and re-entry to prevent people disengaging and dropping out. 146

147 Focus on families including the most vulnerable young people, adult carers, parents in recovery and identifying families and parents who are not in treatment. Need to develop accessible opening times, evening and weekends, drop-in sessions. Need for women specific services, especially women leaving prison. Recovery to be integrated into the model, as a guiding principle not as a service at the end of the model. Need to have more detail within pathways and methods of achieving outcomes. All of the responses from the exercise were input into a database and used to create Figure xxx (the size of the word represents the number of times the word was mentioned): Consultation Wordle 82 -(the size of the word represents the number of times the word was mentioned) Service User Consultations 1. Eccles 27th February 2012 The main points raised were: Lack of after-care support once finished treatment and the need for support to continue when people are in recovery The need for recovery mentoring The need for help with methadone reductions 2. Mona Street 28th February 2012 The main points raised were: The need for services in the evenings and at weekend and in local areas

148 The need for provision for women i.e. residential rehabilitation and mental health provision. Greater involvement in the community including voluntary work, recovery talks in local community, schools, and churches. Experience of stigma. The need for relapse prevention and residential support for people who relapse. Support for families i.e. childcare, weekend provision. Support tailored to the person. Not enough groups i.e. need to be longer, more confidence / self esteem related, more peer led. 3. Little Hulton 12th March 2012 The main points raised were: The need for more aftercare and changing social circles Social isolation and lack of provision in Little Hulton i.e. youth clubs, recovery activities. The need for more support for women i.e. residential rehabilitation. The need for more publicity about personal budgets. The need for more support for families i.e. childcare, support and information for children, keeping families together. Importance of support from key-worker, having continuity of care, phone calls to remind of appointments and follow up calls. Drugs education in local schools and in community. Transport issues. More ex users working in services. Public Consultation 1. Eccles Gateway 5th March 2012 Alcohol was recognised as a key issue with particular points made about home drinking, social acceptability, and accessibility. The need of for a social life for people who abstain from drugs and alcohol. Women s needs were recognised, in particular the need for childcare. Support for the separation of prescribing from co-ordination, brief interventions and outreach. Workforce issues were raised with the need to ensure the right people are doing the right jobs and to avoid the loss of talent, skill and existing expertise during the re-organisation process. The need for strategic coordination of resources was highlighted. DAAT representatives also attended the Ordsall and Langworthy Community Committee and held public events in Broughton and Pendleton. The recommendations from stakeholder consultation and the community impact assessment that should be incorporated into the local design. 148

149 Summary of Recommendations for Improvement The following key points were identified as specific recommendations for improving future drug and alcohol services: Diversity and equality to be central to specifications and potential providers to demonstrate understanding of the councils diversity and equality policies. Equality monitoring to be included in the specifications for the new contracts. To develop a system of prioritising that accounts for older people, mental health, physical disability, sensory/visual impairment and ill health, sexual identity and gender re-assignment, race / ethnicity / religion. To specify providers responsibilities for the provision of translation and interpretation in all contracts. Communications and assertive outreach strategy to include how diversity issues will be addressed. Development of protocols relating to information sharing and informed consent. Specialist residential rehabilitation project for women to be included in the specifications. To include families and carers and recovery in the development of the integrated commissioning approach in children s services. Strategy to be developed for young people, families and carers. To support the commissioning of the In Focus Project. Childcare to be included in the criteria for personalisation. Specifications to include provision of palliative care for people with severe and enduring mental health problems dual diagnosis. To develop pathways between drug and alcohol and mental health / counselling services. Fair Access to Care to be included in all specifications. Deprivation index included in the personalisation project. Integrated commissioning between Supporting People and DAAT. To develop wet and dry housing provision. To include a system of prioritisation for housing specifications. Asset Based Community Development to be included in the specifications. Domestic violence to trigger priority status within the recovery system. 149

150 Appendix 2: Main components of Effective Opioid Substitution Treatment (ROTD 2011) Engaged, stable clinical leadership that provides clear goals and maintains cohesion, focus and engagement of clinicians to sustain therapeutic settings in which to optimise recovery. Organisation and staff able to support and sustain change, including motivated staff with appropriate qualifications, confidence in their skills and supervised by competent clinicians /management. Longer retention in OST and initial orientation to maintenance for up to one year or more, yet with encouragement for those doing well to move on from treatment if sufficient recovery capital is in place to sustain long term abstinence Staff who believe in the treatment they are delivering and are emphatic to their treatment users. A structured programme for recovery that sets out treatment goals for OST that provides direction and structure for people in treatment and clinicians. Quality psychosocial interventions Contingency Management as per NICE 2007c recommendations Behavioural couple and family interventions and Cognitive Behavioural Therapy (CBT) for common mental health problems Active referral to 12 step self help groups Sufficient dose of OST to prevent withdrawals and high enough to increase tolerance and attenuate any response to injected heroin A range of OST medications, supervised consumption, tailor treatment to different needs, incentivise participation, maximise retention in structured treatment to ensure safety. Links to local recovery orientated community organisations Continued treatment, support and monitoring to maintain abstinence for at least 6 months following detoxification as per NICE 2007a Availability of naltrexone, with supervision and a programme of care as a treatment option for detoxified persons who are highly motivated to remain in abstinence programmes. 150

151 Appendix 3: Principles and features of recovery orientated drug treatment and how to test they are being achieved - Adapted from Medications in Recovery Principles and features of recovery orientated drug treatment For Commissioners Integrated recovery orientated systems of care are needed to build and maintain recovery Arbitrarily curtailing or limiting the use of OST does not achieve sustainable recovery and is not in the interests of people in treatment or the wider community Drug treatment is not expected to deliver recovery on its own but should integrate with and benefit from the providers of other services. For Services Closer adherence to the compelling evidence for effective OST, and the existing guidance based upon it, will deliver many of the improvements needed but more can and should be done. Some people entering treatment have a level of personal and other resources (often called recovery capital) that will enable them to stabilise and leave treatment more quickly than others as long as they are provided with the support they need. 151 Prompts to test whether they are being achieved Is a full range of treatment options commissioned, including residential rehabilitation, so there is the necessary flexibility to build a range of treatment and recovery pathways for different needs: from brief interventions for those not needing structured treatment to full packages of care-managed pharmacological, psychosocial and recovery interventions for those with complex needs? Do contracts avoid imposing arbitrary time limits on treatment or elements of it, such as prescribing? Are services expected to set clear and ambitious goals for each individuals treatment, with planned timescales for action, and expected targets for general improvements in treatment and recovery such as: Increased psychosocial interventions? Hosting of 12-step meetings? Development of aftercare functions and peer support? Is an integrated recovery-orientated system of care being created involving other health and social care services to provide recovery support, including mental health, employment, housing, mutual aid, recovery communities etc? Is practice audited (and where needed improved) against recommendations in the NICE 2007 suite of drug misuse guidance (up-to-date quality standards)? Do supervisors have the appropriate competences to supervise all the techniques or interventions being used by the practitioners they are supervising? Is recovery capital assessed and individual treatment plans designed to utilise the strengths and aspirations of each service user?

152 Many others have long term problems and complex needs- their recovery may take longer and require long term treatment to build their recovery capital Arbitrarily curtailing or limiting the use of OST does not achieve sustainable recovery and is not in the interests of people in treatment or the wider community Are arbitrary time limits for treatment or elements of it avoided but clear and ambitious treatment goals set, with planned timescales for action and regular reviews? Are service users, peer support and recovery champions involved at all levels of organisations and where appropriate in delivery of peer based interventions and service promotion, (e.g. peer support available at assessment)? Recovery is made visible, including the hand and footholds at each stage of recovery through access to peers who are perhaps just a little further along their recovery journey. Mutual identification through mutual aid and peer support is important Are pathways through and out of treatment made visible (for example involving service users in promotion of services, developing peer support services, involving service users in delivery of groups, promoting recovery events, hosting 12 step meetings)? Are opportunities promoted for contact between people in treatment and others further in their recovery journeys? Is access to mutual aid facilitated by advocating for it, accompanying service users, providing meeting space, attending open meetings, providing or arranging transport? Features of Recovery Orientated Drug Treatment Systems and Services A clear and coherent vision and framework for recovery that is visible to people in treatment, owned by all staff and maintained by strong clinical leadership service users? Purposeful treatment interventions that are properly assessed, planned, measured, reviewed and adapted Phased and Layered interventions that reflect the different needs of people at different times Does the service participate in the building of communities of recovery that overlap with treatment, advocating for mutual aid, utilising peer supporters, ensuring recovery is visible to Are assessment, planning, review, and optimisation processes all arranged so that treatment is active, individualised, and based on proper understanding (and regular reviews) of an individual s changing problems, needs and strengths? Is the service developing a local solution to phasing and layering interventions so that, at every point in a treatment journey, they can be offered in a way that is appropriate to an individual s stage of recovery and how much intervention they need? 152 Is a range of treatment interventions available to meet the needs of a range of clients including those with more complex needs that may require

153 Treatment that creates the therapeutic conditions and optimism in which the challenge of initiating and maintaining change can be met, especially by those with few internal and external resources OST programmes that optimise the medication aspect of the treatment according to the evidence and guidance. Recovery measured by assessing and then tracking improvements in severity, complexity and recovery capital, and by using this information to better understand how to tailor interventions and support to improve an individual s chances of and progress in achieving recovery Drug treatment not expected to deliver recovery on its own but integrated with and benefitting from other support such as mutual aid, employment support and housing. Drug treatment-alongside peers and families- that provides direct access, signposts and or facilitated support to opportunities for reducing and stopping drug use, improving physical and mental health, engaging with others in recovery, improving relationships (including with children), findings meaningful work, building key life skills and securing housing. high intensity interventions? Do managers ensure key workers understand how and when to use a range of techniques and tools, including goal, setting empathetic listening, exploring the impact and negative consequences of current behaviour and the benefits of change, strategic use of problem recognition to amplify ambivalence about the status quo, managing rewards and negative contingencies, and involving social networks? Are OST programmes audited to ensure: Effective doses of OST are being prescribed as recommended in clinical guidance and tailored to the individual? Supervised consumption is used as recommended in clinical guidance and tailored to the individual to minimise risk while enabling opportunities for recovery such as self directed medication, employment, childcare? Is progress in treatment regularly measured, and responded to, through intelligent use of the Treatment Outcomes Profile (TOP), drug testing and measures of dependence, change motivation and engagement, skills and participation, environment, personality and relationships, risk and safeguarding, financial support? Has the service developed partnerships, joint working protocols and other ways of working with others able to provide recovery support, including mental health, employment, housing, mutual aid, recovery communities? Are arrangements in place for access to a broad range of recovery supports? 153

154 Appendix 4: A Suggested Approach to the Phasing and Layering of Treatment (Source ROTD) 154

155 Appendix 5: Suggested topics that should be covered by low intensity psychosocial interventions 155

156 Appendix 6: Components of Core Key working (ROTD 2011) Comprehensive assessment including: o Safeguarding o Family support needs o Risk Assessment/ reassessment of recovery capital Recovery / care planning Multiagency work, including: o Safeguarding o Family support service o Mental Health Care coordination (if applicable) Risk Management Crisis Management Health monitoring Advocacy Pro-active engagement / re-engagement Harm reduction Appropriate supported / facilitated referrals to: o Healthcare o Mutual aid o Financial and legal advice o Housing, employment, education and training. 156

157 Appendix 7: Employment and Recovery: Good Practice Checklist (NTA 2012) Is there high-level strategic commitment to the agenda within the local authority as well as strong operational leadership via the drug and alcohol partnership? What operational links are in place between treatment and recovery providers, service user groups, Jobcentre Plus and Work Programme providers? Are there named champions or operational leads within Jobcentre Plus and Work Programme providers? Are contacts shared with local drug and alcohol partnerships? Are the local Jobcentre Plus and Work Programme champions facilitating joint working between the agencies, including agency visits, mutual training and outreach provision? Does Jobcentre Plus have a district-level named champion identified by group partnership manager? Have the functions of the previous district drug coordinator been retained? Are Jobcentre Plus and/or Work Programme providers represented at local joint commissioning meetings? Has a joint-working process been agreed between the local treatment system, Jobcentre Plus and the Work Programme? 157

158 Appendix 8: Public Health Outcomes Framework 83 PHOF 2.15i Number of opiate users that left drug treatment successfully (free of drug(s) of dependence) who do not then re-present to treatment again within six months as a proportion of the total number in treatment. GM Rank Monthly Rank Change Local Authority Baseline Current Performance Growth since Performance Apr11 baseline Jul12 Jun13 Mar12 1st Salford [77 from 797] 8.1% 9.7% 1.6% 2nd Stockport [67 from 697] 6.8% 9.6% 2.8% 3rd Bury [49 from 552] 9.1% 8.9% -0.2% 4th Trafford [34 from 397] 10.2% 8.6% -1.6% 5th Tameside [73 from 869] 9.1% 8.4% -0.7% 6th Oldham [61 from 797] 6.8% 7.7% 0.9% 7th Rochdale [72 from 973] 7.1% 7.4% 0.3% 8th Manchester [136 from 2,482] 6.9% 5.5% -1.4% 9th Wigan [49 from 1,103] 6.6% 4.4% -2.1% 10th Bolton [51 from 1,381] 8.9% 3.7% -5.2% Greater Mcr [669 from 10,048] 7.7% 6.7% -1.0% Source: NDTMS Please note: Numbers in Parentheses represent the Number of Successful Completions Remaining Out of Treatment for 6 Months from the Number in Treatment % 8.0% 8.0% 8.3% 8.3% 8.6% 8.6% 8.7% Aug11 - Jul12 Sep11 - Aug12 Oct11 - Sep12 Nov11 - Oct12 Dec11 - Nov12 Jan12 - Dec12 Feb12 - Jan13 Mar12 - Feb13 9.3% 9.1% Apr12 - Mar13 9.8% 9.7% May12 Jun Apr13 May13 In treatment Completions Jul12 - Jun13 % completing 8.1% 8.0% 8.0% 8.3% 8.3% 8.6% 8.6% 8.7% 9.3% 9.1% 9.8% 9.7%

159 PHOF 2.15ii Number of non-opiate users that left drug treatment successfully (free of drug(s) of dependence) who do not then re-present to treatment again within six months as a proportion of the total number in treatment. GM Rank Monthly Rank Change Local Authority Baseline Performance Apr11 - Mar12 Current Performance Jul12 - Jun13 Growth since baseline 1st Bury [82 from 144] 50.4% 56.9% 6.5% 2nd Oldham [120 from 237] 40.9% 50.6% 9.7% 3rd Tameside [91 from 186] 45.7% 48.9% 3.3% 4th Trafford [92 from 193] 49.1% 47.7% -1.4% 5th Rochdale [112 from 283] 40.3% 39.6% -0.8% 6th Salford [100 from 261] 30.8% 38.3% 7.5% 7th Wigan [115 from 304] 42.9% 37.8% -5.0% 8th Stockport [94 from 305] 33.3% 30.8% -2.5% 9th Manchester [60 from 225] 36.6% 26.7% -10.0% 10th Bolton [49 from 243] 25.1% 20.2% -4.9% Greater Mcr [915 from 2,381] 38.5% 38.4% 0.0% Source: NDTMS Please note: Numbers in Parentheses represent the Number of Successful Completions Remaining Out of Treatment for 6 Months from the Number in Treatment % 30.4% 33.6% 33.8% 36.5% 39.8% 39.8% 38.6% 39.2% 38.9% 38.3% 38.3% Aug11 - Jul12 Sep11 - Aug12 Oct11 - Sep12 Nov11 - Oct12 Dec11 - Nov12 Jan12 - Dec12 Feb12 - Jan13 Mar12 - Feb13 Apr12 - Mar13 May12 - Apr13 Jun12 - May13 In treatment Completions Jul12 - Jun13 % completing 30.5% 30.4% 33.6% 33.8% 36.5% 39.8% 39.8% 38.6% 39.2% 38.9% 38.3% 38.3% 159

160 Appendix 9: DAAT Commissioned Services Salford Drug and Alcohol Service (SDAS) Description SDAS is an integrated drug and alcohol service provided by Greater Manchester West NHS Trust (GMW). It offers specialist drug and alcohol advice, support and treatment to adults aged over 18 who are experiencing problems with their drug and alcohol use including care planning, prescribing services, naloxone provision, counselling and psychological services, motivational interviewing, needle exchanges, GP liaison, group work, BBV testing and vaccination, recovery support, community detoxification, housing and employment support, criminal justice services, aftercare, mental health and pregnancy services. SDAS provides services from a number of locations across the city with bases in Eccles, Little Hulton and Salford Crescent. Performance SDAS underwent a significant restructure in Following this, in September 2013 the service moved from four NDTMS agency codes (one for primary alcohol clients and three for drugs, one at each of the above locations) to one single agency code for all clients. The performance data below relates to , prior to the restructure. OCUS in Effective Treatment Over 18s in Effective Treatment 160

161 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Measure Period Acton Square King Street Haysbrook Representation (opiate users) Planned exits Apr 12- Sep 12 67% 79% 100% Representation (non-opiate users) Planned exits Apr 12- Sep 12 90% 100% 100% Planned exits as % of all exits (OCUs) Exits Apr 12- Mar 13 67% 68% 60% Planned exits as % of all exits Exits Apr 12- Mar 13 88% 74% 95% (non-ocus) TOP completion (start) Jan 13- Mar % 100% 100% TOP completion (review) Jan 13- Mar % 100% 92% TOP completion (exit) Jan 13- Mar 13 89% 100% 100% Waiting times under 3 weeks (first modality) Jan 13- Mar 13 94% 100% 100% Waiting times under 3 weeks Jan 13- Mar % 100% 93% (subsequent modality) Hep C testing rate (injectors) In treatment Mar % 95% 88% Hep B vaccination rate New treatment journeys 77% 84% 59% (of offered and accepted) Apr 12- Mar 13 Naloxone prescriptions issued (YTD) Apr 12- Mar DIP referrals entering treatment Jan 13- Mar 13 96% Salford Alcohol Service Performance Measure Definition Performance Chart Criminal Justice Tier 2 Service and Dedicated Clinic - Tier 2: Reduced alcohol consumption for harmful / high risk alcohol drinking offenders Reduced alcohol consumption from 50+ units for men and 35+ units for women per week to under 21 units for men and 14 units for women Actual Plan Criminal Justice Tier 2 Service and Dedicated Clinic - Tier 2: Improved social functioning for harmful / high risk alcohol drinking offenders Reduced CISS score by more than 1 point (improved functioning) Actual Plan Criminal Justice Tier 2 Service and Dedicated Clinic - Tier 2: Reduced offending for harmful / high risk alcohol drinking offenders Complete Order / Licence without Re- Offending Actual Plan 161

162 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Criminal Justice Tier 3 Service and Dedicated Clinic - Tier 3: Reduced alcohol consumption for dependent alcohol drinkers Reduced alcohol consumption from 50+ units for men and 35+ units for women per week to under 21 units for men and 14 units for women at discharge Actual Plan Criminal Justice Tier 3 Service and Dedicated Clinic - Tier 3: Improved social functioning for dependent alcohol drinkers Reduced CISS score by more than 1 point (improved functioning) Actual Plan Criminal Justice Tier 3 Service and Dedicated Clinic - Tier 3: Reduced offending for dependent alcohol drinkers Complete Order / Licence without Re- Offending Actual Plan Dedicated General Practice Tier 2 Service - Tier 2: Reduced alcohol consumption for harmful / high risk alcohol drinkers Reduced alcohol consumption from 50+ units for men and 35+ units for women per week to under 21 units for men and 14 units for women on discharge Actual Plan Dedicated General Practice Tier 2 Service - Tier 2: Reduced alcohol consumption for harmful / high risk alcohol drinkers Reduced CISS score by more than 1 point (improved functioning) Actual Plan Community Alcohol Team Tier 3 Complex Case Management Service - Tier 3: Discharged alcohol free for dependent alcohol drinkers Reduced alcohol consumption from 50+ units for men and 35+ units for women per week to 0 units for men and 0 units for women on discharge Actual Plan 162

163 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Community Alcohol Team Tier 3 Complex Case Management Service - Tier 3: Reduced alcohol consumption for dependent alcohol drinkers Reduce consumption 50+ units men and 35+ units women per week to > 21 units men >14 units women discharge Actual Plan Community Alcohol Team Tier 3 Complex Case Management Service - Tier 3: Improved social functioning for dependent alcohol drinkers Reduced CISS score by more than 1 point (improved functioning) Actual Plan Community Alcohol Team Tier 3 Detoxification Service - Tier 3: Complete Alcohol Detoxification Complete Community Detoxification Actual Plan Community Alcohol Team Tier 3 Detoxification Service - Tier 3: Improved social functioning for dependent alcohol drinkers Reduced CISS score from range to 0-11 range on discharge (improved functioning) Actual Plan Service Representations - Tier 2&3: Sustained recovery Clients of GMW leaving treatment in a planned way remaining out of treatment 12 months after completion 100% 80% 60% 40% 20% 0% Actual Plan Community Recovery Services (formerly The Mona Street Project) Description Community Recovery Services is a Salford City Council community based recovery support service for people with long term, complex drug and alcohol problems. The service provides a range of centre based well being support and sessions, group based peer support and community development and outreach activity. The service provides a range of holistic and person centred support to members along the continuum of their recovery journey. Members receive co- 163

164 ordinated support as they move between the areas of the service including breakfast club, drop-in, group work, development and community work, sport and recreational activities, peer support, personal budgets, recovery and aftercare support, education and employment services, Citizens Advice Bureau welfare rights, outreach and case management. The service will maintain regular telephone contact with people who have left the service for up to 5 years. The service works with clients who may or may not be in structured treatment saw 36 alcohol clients and 60 drug users (including 56 OCUs) recorded on NDTMS as being in effective treatment. Many of those accessing the service will have recently had a treatment episode within other services. The service has around 20 active clients receiving structured treatment (as recorded by NDTMS). The service is also working with a further 70 individuals, who access some of the other parts of the provision. Performance Engage with the community and encourage positive participation with wider society Number engaged in regular community-based and inhouse wellbeing activities Target Qtr 1 Qtr 2 Qtr 3 Qtr 4 Cumulativ e clients 58 sessions 27 clients 65 sessions 37 clients 122 sessions 73 clients 245 sessions Support participants into education, training and employment Number of clients referred to Skills and Work Number of clients undertaking accredited courses Number of clients entering voluntary work Number of clients entering employment Targe t Qtr 1 Qtr 2 Qtr 3 Qtr (8 courses) Cumulativ e Personalisation Number of clients accessing personal budgets and activities funded by personalisation Number of clients who have improved their CISS scores by 2 or more points Targe t Qtr 1 Qtr 2 Qtr 3 Qtr 4 Cumulativ e

165 THOMAS Description THOMAS in Salford offers a full treatment and recovery journey. The service includes a residential rehabilitation project at THOMAS House, semiindependent accommodation with floating support and a personalised budgets project. THOMAS is actively supporting the development of a visible recovery community in Salford including a recovery café. Performance Bed occupancy rates Period Days No Total Days Occupancy Target Days OCU Target of bed occupied rate occupied occupancy beds days by OCUs rate [B] [B]/[A] [C] [C]/[A] [A] Q % 90% % 60% Q % 90% % 60% Planned discharges Period Number discharged [A] Planned discharge [B] % planned [B]/[A] Target Q % 80% Q % 80% Numbers achieving qualification, entering education, training or employment: 12 achieved qualifications in maths, English, it with the Broughton Trust and/or Adult Learning Centre. Recovery events Number of events and participants: 1 NA meeting a week since May approx. 20 attendees Peer led 12 step group Big Book read 3 mornings per week, includes 1st and 2nd stage, attendees Outdoor activities twice a month attendees Soulford recovery band, 2 gigs at recovery events a month across NW Camping once a month 10 attendees. 165

166 Turning Point Smithfield Description Smithfield is a 22 bedded unit providing 24 hours nurse-led care providing a range of alcohol and drugs detoxification. The service includes: 24-hour a day nursing, and medical care with a leading consultant six days a week Alcohol, heroin, methadone / buprenorphine, or stimulant detoxification programmes Comprehensive link node mapping group programme (Include a PDF of the groups) Evening activities Access to local NA groups in the local community Peer and family support groups / mentorship Salford purchases alcohol detoxification provision from Smithfield. Performance The annual target for the number of successful alcohol detoxifications completed at Smithfield is a maximum of 88 and a minimum of 80. Year-todate performance against this target as at Q2 is shown below. Successful Alcohol Detoxification Annual NDTMS performance data Annual OCU Non-OCU Alcohol TOTAL Treatment start Planned exit % Planned exit 0% 50% 86% 84% 166

167 SRFT Assertive Outreach Team Description The Assertive Outreach Service works over a six month period with a cohort of around 30 individuals who are frequently attending Salford Royal Foundation Trust (SRFT) for alcohol-related reasons, looking at the causes, such as relationship problems or poor mental health, and helping them get the support to overcome their problems, for example housing support, psychological therapy or detoxification programmes. The team includes a range of multidisciplinary staff, including an Emergency Medicine Consultant, social worker, alcohol worker, support worker, nurse, psychiatrist and psychologist. The service also relies on a close working relationship with the hospital Alcohol Specialist Nurses and the expertise of other colleagues across the city, including the police, GPs, mental health services and housing organisations. Performance The service is measured on the overall reduction of A&E attendance and hospital ward admissions for the cohort. These measure compare, for example, the total number of A&E attendance the cohort has in the 3 months prior to the service engaging with them with the number seen in the second half of the six month programme. Individually service users reductions of CISS scores are also measured. Performance for the first cohort of is shown in the box below. Indicator Performance Target Reduced CISS Score 2+ Points (individuals) Reduction in A+E attendance (cohort total) 21% 20% Reduction in ward admission (cohort total) 44% 35% SRFT Alcohol Specialist Nurse Service Description The service based with Salford Royal Foundation Trust consists of two nurses, one highly specialist alcohol nurse and one specialist alcohol nurse. The service delivers high volumes of short alcohol interventions, including motivational interviewing and alcohol identification and brief advice (alcohol IBA) as well as detoxifications (predominantly inpatient). Performance The table below shows the volume for the first half of Measure 6 month output Motivational Interviewing (MI) 454 Alcohol Identification and Brief Advice (IBA) 260 Outpatient Detox 3 Repeat MI (SA) 35 Lifestyle IBA 3564 Inpatient detox completed 152 Referral to RADAR unit 34 bed days saved

168 SRFT Vulnerable Young People Nurse Service Description This service offers a dedicated health service to vulnerable children and young people including those who are looked after and young offenders as well as those with substance misuse issues in contact with Lifeline SMART. The service provides initial health assessments which identify and address the health needs of the children and young people. Performance The annual percentage of young people in substance misuse treatment in receipt of a specialist healthcare assessment is shown in the chart below. Note: figures for are for the first two quarters only. Percentage Receiving a Specialist Healthcare Assessment 80% 70% 60% 50% 40% 30% 20% 10% 0% Salford Under 18s 12% 4% 23% 48% 35% 50% SMART (all ages) 21% 8% 27% 47% 29% 20% National (under 18s) 60% 60% 70% 72% 71% 72% 168

169 Lifeline SMART Description Lifeline SMART is the specialist young people's substance misuse service for children and young people up to 21 years old (and on exception up to 24 years old) who are experiencing difficulties with alcohol or drugs. The service aims to support abstinence and recovery, reduce the harms associated with drug and alcohol use and promote wellbeing. Lifeline SMART offers specialist treatment and targeted provision to Salford young people and offers support to parents where capacity allows. Lifeline SMART provides training to partner agency professionals and volunteers working with young people in Salford including teachers, learning mentors, teaching assistants, school nurses and Connexions personal advisers and hosts community awareness raising events regarding young people and substance use and misuse. The service offers the following: specialist assessment specialist care/recovery planning case management planned individual programmes therapeutic interventions substitute prescribing access to detoxification substitute prescribing targeted provision to Salford Youth Offending Service Performance saw the following performance: Information Source <18 Over 18 New Episodes Total In Treatment during Quarter Carried Over Total Exits Number exiting treatment in (planned) Number exiting treatment in (unplanned) % of planned exits met their goals by exit. Measure SMART National % waiting under 3 weeks 100% 99% Received a Care Plan within 2 weeks 93% 99% Offered a Hepatitis B vaccination 98% 83% Offered a Hepatitis C Test 75% 78% Average treatment length (weeks) Planned discharges 81% 79% Met goals agreed on care plan at planned discharge 91% 88% Onward referral of planned discharges 97% 65% TOP compliance averaged 91% for treatment starts, 92% for reviews and 97% for planned exits. 169

170 NDTMS data completion rates were as follows: Data item SMART National % % Units of Alcohol Frequency (Days) of Alcohol Accommodation Need Age of onset of Drug Looked After Child status Parental Status YP Education Status (Tx Start) YP Involved in Offending (Tx Start) YP Involved in Self Harm (Tx Start) Met goals agreed on care plan YP Involved in Offending (Tx End) YP Involved in Self Harm (Tx End) Hepatitis B Status Hepatitis B Vaccination n/a 12 Lifeline SMART measure outcomes for all young people in treatment using a locally devised tool which measures change in ten domains on a scale from one to ten between treatment start and discharge. The two charts below show the average scores for young people leaving treatment in Q4 at start and discharge separated by age group Q4 Under 18s Child Protection Alcohol 8 6 Drugs Offending 4 2 Risky Behaviours Initial 0 Discharge Education, Employment & Money Physical Health Identity & Social Relationships Mental Health Family, Care & Accommodation 170

171 Q4 Over 18s Child Protection Alcohol 8 6 Drugs Offending Education, Employment & Money Risky Behaviours Physical Health Initial Discharge Identity & Social Relationships Mental Health Family, Care & Accommodation Next Step Description Next Step is a Salford City Council service which supports young people aged 15 to 21 who have been in care and who may need support. The service works with Young people who have lived with foster carers or in residential care, providing support to develop all the skills they will need to move on towards independence. The service has a worker who is 50% funded by the DAAT to undertake drug and alcohol work with this group of young people including screening, harm reduction, targeted group work, targeted substance misuse interventions, awareness raising and prevention work, skills and employment services and diversionary activities including partnership work with a range of sports and arts based organisations. Performance saw 100% (n=208) of all year olds in care and leaving care, which is completed as part of a transfer meeting between the Looked After Children s Team and After Care (Next Step). All young people have to have been in care for 13 weeks or more to be eligible for a substance misuse service from Next Step. The following sessions were held throughout the year working with 105 unique individuals: Smoking Cessation) with 7 young people (5 males; 2 females), Streetdance: ongoing weekly sessions, 12 young people, all female with Rio Ferdinand Foundation Lowry showcase for dance and drama course. 15 young people; 5 male; 10 female. All young people will work towards a GCSE or BTEC level 2 Urbanathlon 5K fun run 24 YP Help for Heroes football match 11 YP male

172 5 young people involved in 30 hour BBC/media Trust film project looking at hopes and aspirations which included an ASDAN qualification in Film & Media Studies. Boxing: ongoing weekly sessions, 4 young people, 2 male 2 female Chlamydia Screening: 15 young people screened, 8 female, 7 male. Drama and Film Group: over 16 weeks; 12 young people; 2 male, 10 female. This was on a Friday evening to reduce episodes of Missing From Home, and included targeted sessions on substance misuse, alcohol awareness, and sexual health. All working towards a GCSE or BTEC level 2 Tier 2 substance misuse interventions delivered to a total of 87 individuals. GADDUM: Salford Carers Centre Description Salford Carers Centre provides a range of services to enhance the lives of unpaid carers of all ages. The Centre helps carers access a wide range of services including specialist one-to-one advice, support and information plus regular carers' newsletters, activities and events. Salford Carers Centre also has Young Carers for children and young people under the age of 18 and Adult Young Carers services for those aged

173 Appendix 10: England Regions and North West DAT areas Proportional use of Prescription and OTC medicines in persons known to treatment services (*source NDTMS) All clients in treatment Location Individuals in treatment Proportion of all clients citing Prescription or over the counter drugs (any use) Proportion of clients citing Prescription or over the counter drugs (no illicit use) Region North East % 3.7% South East % 3.7% South West % 2.8% Eastern % 2.4% Yorkshire and Humberside % 2.2% North West % 2.4% London % 1.7% East Midlands % 2.1% West Midlands % 1.3% DAT Cheshire % 15.4% Cumbria % 6.0% Blackburn with Darwen % 1.6% Tameside % 3.9% Blackpool % 0.7% Lancashire % 2.9% Warrington % 3.6% Bolton % 1.7% Rochdale % 3.2% Bury % 6.2% St Helens % 2.0% Wirral % 2.5% Salford % 3.4% Oldham % 1.4% Cheshire West and Chester UA % 2.9% Cheshire East UA % 3.4% Wigan % 1.8% Stockport % 3.3% Sefton % 2.2% Trafford % 4.3% Halton % 2.9% Liverpool % 0.8% Manchester % 0.9% Knowsley % 1.5% 173

174 Over the Counter Opiates Prescription drugs Barbiturates Z-drugs Benzodiazepines Analgesics Prescribed opioids Over the Counter Opiates Prescription drugs Barbiturates Z-drugs Benzodiazepines Analgesics Prescribed opioids Prescribed / over the counter drugs, cited no illicit drug use Individuals citing prescribed or over the counter drugs Salford 81% 0% * 0% 0% * 14% 36 North West 65% 1% 24% 3% 0% 2% 17% 878 England 64% 2% 27% 4% 0% 3% 17% 4603 Prescribed / over the counter drugs, cited illicit drug use Individuals citing prescribed or over the counter drugs Salford 26% 0% 76% * 0% 0% * 123 North West 16% 0% 84% 1% 0% 2% 2% 4905 England 23% 0% 77% 1% 0% 2% 3%

175 Appendix 11: Drug and Alcohol Related Hospital Admissions- CSU Request for Data Aim- To inform the Salford Drugs and Alcohol Health Needs Assessment 2013 Rationale To demonstrate need and demand for specialist drug and alcohol services by analysing population level admission data for any Salford residents in 2012/2013. By providing aggregated population data to identify epidemiological trends, this in turn would inform the new Lead Provider commissioning model and service delivery. This will improve the future quality of services provided to Salford patients. This information will not be used to identify or provide intervention with individual patients. Previous requests have used Patient Unique identifiers that were generated by the previous Greater Manchester NHS Commissioning Business Support Unit instead of providing actual NHS numbers. Post code data is requested along with key patient demographics that will be aggregated to inform future service delivery. Details of Data Requested- All resident population from Salford with a hospital attendance or admission with the following ICD10 codes within a primary AND/OR any other additional 13 diagnoses fields between April 2012 and March Alcohol Specific A+E attendances and admissions- with an Alcohol Attributable Fraction of 1 (Taken from LAPE and attached on page 3). ICD10 Code Description E24.4 Alcohol-induced pseudo-cushing s syndrome F10 Mental and Behavioural disorders due to the use of alcohol G31.2 Degeneration of nervous system due to alcohol G62.1 Alcoholic polyneuropathy G72.1 Alcoholic myopathy I42.6 Alcoholic cardiomyopathy K29.2 Alcoholic gastritis K70 Alcoholic Liver Disease K86.0 Chronic Pancreatitis T51.0 Ethanol Poisoning T51.1 Methanol Poisoning T51.9 Toxic effect of alcohol, unspecified X45 Accidental poisoning by and exposure to alcohol 175

176 Drug related A+E Attendances and Admissions (Taken from NHS Information Centre Statistics on Drug Misuse: England 2012) ICD10 Code Description F11 F16, F18 F19 Mental and behavioural disorders due to drug use (excluding alcohol and tobacco) T40 (T40.0- T40.9) Poisoning by narcotics and psychodyseltics (Hallucinogens) Poisoning by anaesthetic and therapeutic gases, other than unspecified general anaesthetics (includes but not limited to gamma T41.2 hydroxybutyrate GHB and ketamine) Poisoning by psychotropic drugs, not elsewhere classified, other than unspecified antipsychotic and neuroleptics (includes but is not limited T43.5 to poisoning by tranquilizers) T43.6 Poisoning by psychotropic drugs not else classified Poisoning by agents primarily acting on smooth and skeletal muscles and the respiratory system, antitussives (includes but is not limited to T48.3 poisoning by tranquilizers) Ingested mushrooms (includes but is not limited to poisoning from magic T62.0 mushrooms ) Accidental poisoning by drugs, medicaments and biological X40 X44 substances Intentional self-poisoning by drugs, medicaments and biological X60 X64 substances X85 Assault by drugs, medicaments and biological substances Poisoning by drugs, medicaments and biological substances, Y10 Y14 undetermined intent Patient Demographics required Patient Unique Identifier- To establish any repeat admissions including cross morbidity/admissions for alcohol and drugs. Number of Episodes Gender Age Ethnicity Primary diagnosis and all available diagnosis fields where ICD10 code is recorded ICD10 diagnosis and description Post code- This will aggregated to produce Directly Standardised Rates and mapped by ward, it would not be combined with any other individual level characteristics, therefore would not be patient identifiable. Date of Admission Admission Method General Practice 176

177 177

178 Appendix 12: Drug Use and Frequency Reported in 2011 Mixmag / Guardian Survey Drugs very frequently reported - Cannabis - Ecstasy - Cocaine Drugs frequently reported, NPS indicated in bold - Ketamine - Mephedrone - Valium - Mushrooms - Poppers - Speed (amphetamine) Drug use sometimes reported, NPS indicated in bold - LSD - 2C-B - Methotexamine - 2 C-I - DMT - Synthetic cannabis - Benzo-Fury - MDAI Drugs rarely reported, NPS indicated in bold - Opium - Ritalin - GBL - GHB - Methylone - Crack cocaine - Heroin - Methamphetamine 178

179 Appendix 13: Salford Drug Early Warning System. Outline and background to system development. 22/04/13 1. Background An astonishing and growing variety of what are known as legal highs / research chemicals or Novel Psychoactive Substances (NPS) are now on sale in the UK. These are often cheaper, more potent and longer lasting than their illegal counterparts. As one NPS is banned, a newer version quickly replaces it with the newly banned drugs often reappearing in the illicit market. The European Monitoring Centre (EMCDDA) has described this worldwide phenomenon as a convergence of the markets. The existing market for illicit drugs has also been in a state of flux, since the heroin drought of Although a number of national and European wide warning systems exist, none of these systems are designed to identify, risk assess or respond to localized outbreaks of NPS or adulterated drug use. The current situation in the UK varies region by region, with some areas already reporting significant NPS use among a variety of drug markets including among the existing population of injectors. So far, there has been little in the way of reported incidence of NPS s in Salford, however, keeping up to date with this rapidly changing market, even knowing which substances are legal, presents a considerable challenge for already busy services. In the context of this background, Salford DAAT (Drug Alcohol Action Team) asked Lifeline Publications and Research to establish a drug early warning system (EWS) on their behalf. Lifeline Publications and Research (LPR) are a department of the national drug charity Lifeline and specialists in drug research and information and are certified members of the Information Standard (The Department of Health approved mark of quality information providers). 2. Purpose of the System. The purpose of the Salford Drug Early Warning System (SDEWS) is to establish an interactive multi-agency system for professionals working in Salford who are likely to come across the use of NPS and or adulterated traditional drugs. The SDEWS will be designed to respond to information needs/concerns of its members. Facilitate the cascading of information or warnings to appropriate staff and when deemed necessary to send alerts to specific target audiences of service users and/or the media. The SDEWS will also enable the DAAT to formally report where necessary to the NTA/Public Health England. The SDEWS is designed to be low or no cost and require the minimum of time commitments from its members. If no incidents arise, there will be no time commitment at all. The SDEWS has been designed to be used when it is needed. However, the SDEWS could also be used to pass on information of relevance, such as changes to the law, information from other networks and issues seen 179

180 in other areas etc. Exactly what level of general information is needed/wanted by members will be decided during the pilot phase of this project. 3.Establishing the core group The first phase of the project was making contact with relevant professionals from the police, ambulance service, A and E, drug services, criminal justice services, education etc. This group is scheduled to meet in May and is now in the process of being set up as an online discussion group. At present we are setting this up as a Google Group, although we are currently seeking advice from the council IT department on this issue. The current members will form the core of the Salford EWS. Membership will be expanded, depending on the views of the group as to the best way of operating and cascading relevant information within their profession. For instance, it may make sense for practical purposes to have a number of representatives from each profession/service, who can make use of their own internal information networks/systems for cascading information to other staff. 4. Group Support/Facilitation. Lifeline Publications and Research (LPR) will help facilitate the group through its establishment, and for the first year of operation/piloting this service. LPR is a founder member of a national informal network called UK DrugWatch. This is a group of professionals and organizations working in the drugs field that share information and expertise on NPS and adulterated drugs. The group has been running for two years, without any funding and is very much a bottom up worker led initiative. Lifeline staff have also set up their own DrugWatch group that has been feeding in and receiving information from UK DrugWatch for the past year. It is planned that the SDEWS will operate in a similar way to Lifeline DrugWatch. SDEWS, is locally based and has a range of professionals other than drug workers, so may need to operate slightly differently from the groups mentioned above this will be ironed out during the piloting. 5. Ownership of the Group. It is envisaged that this model and way of working will be made creative common or some similar non-commercial copyright. SDEWS and the on-line SDEWS Google Group ownership will lay with Salford DAAT. Mark Knight, Joint Commissioning Manager for Salford DAAT has been made the SDEWS Google Group owner. The manager of the Google Group will be Michael Linnell from Lifeline and A N Other from the core group. 6. Establishing a network of networks. The plan, once the Salford group has been established, is to proselytize and encourage other local areas to set up their own groups based on the Salford Model, so that a network of networks is established. 180

181 7. Confidentiality and information sharing The purpose of the group is to share information about drugs and patterns of drug use etc. The information sent within the group will not be used to pass on any details about individuals and should be treated as any other work related in terms of confidentiality. Relevant information about individuals, i.e. I had a client who says they used drug X which resulted in Y happening to them may be used if anonymized. There are no plans to store the information on a database. 8. The Alert system The Alert part of the system will be established/agreed during the pilot phase. This will detail how the alert system will work. When/how to issue alerts: There are some brief existing guidelines from the NTA for when/how to produce/grade alerts using Red/Amber/Green grading. Red = urgent action to prevent confirmed risk of death. Amber = action to prevent possible harm Green= for information only. It is envisaged that with minimal adaption, this system can be used for SDEWS. The decision to then put out an alert would be based on that the above criteria and agreed by the core group and the DAAT. It is planned that an alert template is produced/adapted from existing materials. 9. Informal alerts/briefings It is envisaged that information made available on the SDEWS will be cascaded to appropriate staff when and where relevant /appropriate. This will be done through members existing communication networks. This may be done informally and may involve issuing specific drug briefings or information from other sources supplied by SDEWS. Information from SDEWS will also be cascaded to other networks as and when they exist and if appropriate. 10. Alerts to service users: It is envisaged that existing mechanisms for alerting service users are used, which may be enhanced by producing warning templates/guidance as the network of networks develop and more resources of this nature become available. 11. Alerts to media: Drug alerts put out in the media are often (if not usually) full of errors and often just plain wrong. The experience in both the UK and Europe has been that the media warnings about new legal highs, is one of the most effective ways of promoting the use of that drug. Equally, media warnings about very strong drugs is unlikely to have the intended effect on long term entrenched users. Alerting the media should therefore be done with care. It is planned that a template for media alerts/mechanism is produced. It is planned that the City Councils communications department, take the lead in issuing alerts. We are at present waiting to meet them to discuss this system. 181

182 England Yorkshire and The Humber West Midlands South West South East North West North East London East of England East Midlands Appendix 14: Regional Alcohol Indicators Table XXX Local Alcohol Profiles for England (LAPE) by Region Months of Life Lost due to alcohol: Males aged less than 75 years ( ) Months of Life Lost due to alcohol: Females aged less than 75 years ( ) Alcohol-Specific Mortality: Males, all ages, DSR per pop. ( ) Alcohol-Specific Mortality: Females, all ages, DSR per pop. ( ) Mortality from Chronic Liver Disease: Male, all ages, DSR per pop. ( ) Mortality from Chronic Liver Disease: Females, all ages, DSR per pop. ( ) Alcohol-Attributable Mortality: Males, all ages, DSR per pop. (2010) Alcohol-Attributable Mortality: Females, all ages, DSR per pop. (2010) Under 18s admitted to hospital with alcohol specific conditions: Persons, crude rate per pop (2008/ /11) Admitted to hospital with alcohol specific conditions: Males, all ages, DSR per pop. (2010/11) Admitted to hospital with alcohol specific conditions: Females, all ages, DSR per pop. (2010/11) Admitted to hospital with alcohol attributable conditions: Males, all ages, DSR per pop (2010/11) Admitted to hospital with alcohol attributable conditions: Females, all ages, DSR per pop (2010/11) Admission episodes for alcohol-attributable conditions (previously NI39): All ages, DSR per pop (2010/11) Recorded crime attributable to alcohol: Persons, all ages, crude rate per 1000 pop. (2011/12) Violent crimes attributable to alcohol: Persons, all ages, crude rate per 1000 pop. (2011/12) Sexual crimes attributable to alcohol: Persons, all ages, crude rate per 1000 pop. (2011/12) Claimants of IB/SDA whose main medical reason is alcoholism: Persons, crude rate per , workingage pop. (Aug 2011) Deaths form land transport accidents due to alcohol: Persons, all ages, DSR per pop. ( ) Mid 2009 synthetic estimate of the percentage within the total pop. aged 16 years and over who report in abstaining from drinking Mid 2009 synthetic estimate of the percentage within the drinking pop. (not including abstainers) aged 16 years and over who report engaging in lower risk drinking Mid 2009 synthetic estimate of the percentage within the drinking pop. (not including abstainers) aged 16 years and over who report engaging in increasing risk drinking Mid 2009 synthetic estimate of the percentage within the drinking pop. (not including abstainers) aged 16 years and over who report engaging in higher risk drinking Synthetic estimate of the percentage of the pop. aged 16 years and over who report engaging in binge drinking ( ) Percentage of all employees, employed in bars (2010)

183 Appendix 15: Geographical Service Data Analysis There has been little change in the distribution of both OCUs and primary alcohol clients over the last 4 years. The two plots below show the number of clients in the years and with each point representing a different ward. The possible exceptions are Irwell Riverside and Walkden North which each saw a 40% increase in alcohol clients over the 4 years. The increase in Walkden North occurred between and after which there has been a small decrease. Interestingly the largest fall was seen in Walkden South. Irwell Riverside meanwhile has seen a steady year on year increase. The wards with the highest numbers of both OCUs and alcohol clients are Langworthy, Barton, Broughton and Little Hulton. 183

184 This chart compares numbers of OCUs and alcohol clients and again shows a very strong correlation, suggesting that drug problems and alcohol problems tend to occur in the same areas. Of note is the correlation between OCUs and non-ocus in treatment. For this plot, four years of data has been used given the relatively small number of non-ocus accessing treatment each year. The area with the highest ratio of non-ocus to OCUs is Little Hulton, those with the lowest ratios are Broughton and Barton. 184

185 Successful completions vs unsuccessful completions 185

186 Claremont has the best Walkden North and Little Hulton have the worst ratio of successful to unsuccessful completions Ordsall & Langworthy neighbourhood has the best representation rate for opiate users. Geographical distribution of alcohol clients 186

187 The maps and chart below allow comparison of successful and unsuccessful completions amongst alcohol clients. The neighbourhood area with the best ratio of successful completions compared to unsuccessful completions is Walkden and Little Hulton neighbourhood, with the Swinton neighbourhood also performing well. Each of these neighbourhoods has a ratio of 3:1 i.e. three successful completions for every one unsuccessful completion. Eccles neighbourhood has the poorest ratio at just better than 1:1. However Eccles neighbourhood has a low representation rate Summary There is a strong correlation between the wards where alcohol clients and opiate clients live There has been little change over the last four years in the wards with highest treatment numbers These wards are Langworthy, Broughton, Barton and Little Hulton. They are also amongst the most deprived parts of Salford. Little Hulton has the highest proportion of non-opiate drug users in treatment 187