Drug and alcohol treatment in the North West of England 2008/09. Results from the National Drug Treatment Monitoring System (NDTMS)

Transcription

1 Drug and alcohol treatment in the North West of England 2008/09 Results from the National Drug Treatment Monitoring System (NDTMS)

2 Drug and alcohol treatment in the North West of England 2008/09 - Results from the National Drug Treatment Monitoring System (NDTMS) Ayesha Hurst, Adam Marr, Ellie McCoy, Jim McVeigh and Mark A. Bellis Published by: Centre for Public Health Research Directorate Faculty of Health and Applied Social Sciences Liverpool John Moores University Kingsway House Hatton Garden Liverpool L3 2AJ Tel: +44 (0) ndtms@ljmu.ac.uk ISBN: (Printed version) ISBN: (Web version) 2

3 Executive Summary - Region Problematic Drug Users (PDUs) During 2008/09, there were PDUs in effective treatment in the North West of England (95.75% of PDUs in treatment). The majority of PDUs in effective treatment were male (70.88%), stated their ethnicity as White (95.95%) and were aged 35 years and over (61.26%). The majority of PDUs in effective treatment stated they injected at some point in their most recent treatment journey (64.10%). The vast majority of PDUs in effective treatment were still engaged in their most recent treatment journey at the end of the financial year (82.79%). When only those discharged from their most recent treatment journey were considered, 33.30% of PDUs in effective treatment had a planned exit from treatment. Individuals in contact with structured drug treatment During 2008/09, there were individuals in contact with structured drug treatment in the North West of England. The majority were male (72.09%) and described their ethnicity as White (95.62%). The median age was 35 years, significantly older than during 2007/08. There has been a 57.23% increase in the number of individuals in treatment aged 40 years and older between 2005/06 and 2008/09. There has also been a decrease in the actual number of individuals aged years between this time period. The majority of individuals stated the use of heroin (66.18%). Whilst only 2.89% of individuals stated the primary use of crack, this proportion increased to 25.80% when all drug use was considered. The most common referral source into YP specific services was via the Criminal Justice System (CJS, 37.02%). In contrast, the most common referral source into adult treatment was self referral (39.74%). Half of adult modalities of treatment involved a specialist prescribing intervention (50.40%), with 19.01% involving an other structured intervention. Very few modalities of treatment involved tier 4 inpatient detoxification (1.63%) or residential rehabilitation (0.73%). Of those discharged from their most recent episode of treatment, 39.49% had a planned exit from treatment. Young people (aged under 18) in contact with structured drug and alcohol treatment During 2008/09 there were 4586 individuals aged under 18 in contact with structured drug and alcohol treatment in the North West of England. The majority of under 18s were male (63.78%). However, this proportion was lower in comparison to the overall proportion of males in structured drug treatment (72.09%). The majority of under 18s stated their ethnicity as White (93.38%), a proportion lower than the overall drug treatment population (95.62%). Over half of individuals in this age group stated the primary use of cannabis (56.56%). This was followed by alcohol (34.47%). The majority of under 18s were discharged from their most recent episode of treatment (n=2760, 60.18%). When only those discharged from treatment were considered, 1829 (66.27%) were discharged in a planned way. 3

4 Individuals in contact with structured alcohol treatment During 2008/09 there were individuals in contact with structured alcohol treatment in the North West of England. The majority of individuals were male (62.17%) and stated their ethnicity as White (97.78%). The median age was 40 years. The median age of individuals in contact with alcohol treatment varied from 36 years in Blackburn with Darwen PCT to 43 years in Sefton and Trafford PCTs. The most common route of referral was via self referral (33.36%), followed by GP referrals (19.97%). When only those discharged from treatment were considered, 48.46% had a planned discharge. 4

5 Executive Summary - D(A)AT/ PCT Blackburn with Darwen During 2008/09 there were 1128 individuals in contact with structured drug treatment. There were a high proportion of males in contact with treatment (76.77%) when compared to the regional average of 72.09%. Blackburn with Darwen DAT had a high proportion of self referrals into YP treatment (25.00%) in comparison to the regional average (11.34%). There was a high proportion of CJS referral into adult treatment (41.69%) when compared to the regional average. During 2008/09 there were 844 PDUs in effective treatment. Blackburn with Darwen PCT had a high proportion of under 25s (n=145, 27.83%) in contact with structured alcohol treatment when compared to the regional average. Blackburn with Darwen PCT had the lowest proportion of older individuals (aged 65 and older) in contact with structured alcohol treatment (0.77%). Blackburn with Darwen DAT had a high proportion of BME aged under 18 in contact with drug and alcohol treatment (11.85%). This compares to the proportion of 6.64% BME amongst all those in contact with drug treatment in Blackburn with Darwen DAT. Blackpool During 2008/09 there were 1800 individuals in contact with structured drug treatment. This DAAT displayed the highest prevalence of individuals in contact with treatment (29.28 per 1,000 population aged years). The FY1 postcode, located within Blackpool DAAT had high prevalence of individuals in contact with drug treatment (53.88 per 1,000 population aged 15-64). There were a lower proportion of males in contact with treatment in Blackpool DAAT (69.89%) when compared to the regional average. During 2008/09 there were 1475 PDUs in effective treatment resident in Blackpool DAAT. The DAAT had a higher proportion of their estimated number of PDUs in effective treatment (60.81%) when compared to the regional average (52.77%). Blackpool PCT had the second highest prevalence of individuals in contact with structured alcohol treatment (6.48 per 1,000 population aged years). Bolton During 2008/09 there were 1821 individuals in contact with structured drug treatment. There has been a slight fall in prevalence of individuals in treatment from per 1,000 population aged in 2006/07 to per 1,000 population in 2008/09. Bolton DAAT had a slightly higher proportion of BME in treatment (6.44%) when compared to the regional average of 4.38%. During 2008/09 there were 1398 PDUs in effective treatment resident in Bolton DAAT. Bolton DAAT had low proportion of YP referrals from CJS (8.85%) when compared to the regional average (37.02%). Bolton DAAT had a high proportion of unplanned discharges to prison (11.31%) in comparison to the regional average (6.62%). 5

6 Bury During 2008/09 there were 904 individuals in contact with structured drug treatment. Bury DAT had the lowest proportion of individuals still in contact with their most recent episode of treatment at the end of the financial year (n=534, 59.07%). Bury DAT had a higher proportion of under 18s in contact with drug treatment (13.16%) when compared to the regional average of 6.66%. There were a high proportion of CJS referrals into adult treatment (35.71%) when compared to the regional average. During 2008/09 there were 538 PDUs in effective treatment resident in Bury DAT. Bury PCT had the lowest number of individuals in contact with structured alcohol treatment in the region (n=407, 1.98% of regional total). Cheshire During 2008/09 there were 2314 individuals in contact with structured drug treatment. Cheshire DAT had the lowest prevalence of individuals in contact with treatment (7.66 per 1,000 population aged years). Cheshire DAT had the highest proportion of individuals still engaged in their most recent episode of treatment at the end of the financial year (n=1736, 75.02%). Cheshire DAT had a high proportion of unplanned discharges to prison (11.76%) in comparison to the regional average (6.62%). There was a high proportion of self referral into adult treatment services (69.10%) in comparison to the regional average. During 2008/09 there were 1898 PDUs in effective treatment resident in Cheshire DAT. The vast majority of referrals into YP services in Cheshire DAT came from the CJS (82.95%). Cumbria During 2008/09 there were 1931 individuals in contact with structured drug treatment resident in Cumbria DAT. There were a lower proportion of males in contact with treatment in Cumbria DAT when compared to the regional average (69.34% when compared to regional average of 72.09%). There was a high rate of stated benzodiazepine use amongst those in treatment resident in Cumbria DAT (22.42%) when compared to the regional average (9.14%). There were a high proportion of GP referrals into adult treatment services (23.13%) when compared to the regional average. During 2008/09, there were 1442 PDUs in effective treatment resident in Cumbria DAT. Cumbria DAT had the lowest proportion of PDUs stating the use of crack in the region (3.26%), along with the lowest penetration rate of crack users (when compared to the prevalence rates for crack users in the area) in effective treatment in the region (8.53%). 6

7 Halton During 2008/09 there were 755 individuals in contact with structured drug treatment. This was the lowest number of individuals in treatment in the region. The prevalence of individuals in contact with treatment has fallen slightly from per 1,000 population aged in 2006/07 to per 1,000 population in 2008/09. Only 0.67% of the in-treatment population in Halton were BME in comparison to the regional average of 4.38%. A smaller proportion of those in treatment stated the use of heroin (54.97%) when compared to the regional average of 66.18%. In contrast, there was a higher proportion of stated crack use (32.98%) when compared to the regional average (25.80%). During 2008/09, there were 462 PDUs in effective treatment. Halton DAAT had a high proportion of their estimated number of PDUs in effective treatment (62.55%) when compared to the regional average (52.77%). The vast majority of under 18s in contact with drug and alcohol treatment were male (78.72%). Knowsley During 2008/09 there were 1272 individuals in contact with structured drug treatment. Whilst only 49.14% of Knowsley DAT residents in treatment stated the use of heroin (regional average, 66.18%), 27.99% stated the use of cocaine. Knowsley DAT had a high level of planned discharges from treatment (56.17%) in comparison to the regional average (39.49%). During 2008/09 there were 709 PDUs in effective treatment resident in Knowsley DAT. Knowsley DAT had a higher proportion of under 18s in contact with drug treatment (12.03%) when compared to the regional average of 6.66%. Knowsley DAT had a high prevalence of under 18s (per 1,000 population aged 10-17) in contact with drug and alcohol treatment (11.31). Knowsley DAT had a relatively high proportion of YP referrals from employment and education services (40.11%) in contrast to the regional average (20.65%). Lancashire During 2008/09 there were 5469 individuals in contact with structured drug treatment resident in Lancashire DAAT. This was the highest number of individuals in contact with treatment in the region. There were a high proportion of individuals who stated the use of methadone (18.92%) when compared to the regional average (9.14%). Lancashire DAAT had the highest number of PDUs in effective treatment in the region (3845). Lancashire DAAT had the highest number of under 18s in contact with drug and alcohol treatment in the region (n=681, 14.68% of regional total). Central Lancashire PCT had the lowest prevalence of individuals in contact with structured alcohol treatment in the region (2.59 per 1,000 population aged years). 7

8 Liverpool During 2008/09 there were 4767 individuals in contact with structured drug treatment. Liverpool DAAT had the highest proportion of individuals triaged for their most recent episode of treatment during the financial year in region (58.93%). High prevalence rates were found in the L5 postcode district of Liverpool (55.21 per 1,000 population). Liverpool DAAT had a high median age (38 years) when compared to the regional average (35 years). This DAAT area also had the second highest proportion of individuals in treatment aged 40 and over in the region (41.54%). The highest proportion of individuals in treatment stating the use of crack in the region (41.91%) was found in Liverpool DAAT. During 2008/09, there were 3348 PDUs in effective treatment resident in Liverpool DAAT. The highest number of PDUs in effective treatment stating crack use was found in this DAAT (n=1763). The majority of referrals into YP services in Liverpool DAAT came from the CJS. Manchester During 2008/09 there were 3925 individuals in contact with structured drug treatment. A high proportion of individuals in contact with treatment resident in Manchester DAAT were aged 40 and over (39.39%) when compared to the regional average (30.78%). A high proportion of individuals stated their ethnicity as BME (12.33%) when compared to the regional average (4.38%). There were a high proportion of individuals in treatment resident in Manchester DAAT who stated the use of crack (38.60%) when compared to the regional average (25.80%). During 2008/09 there were 3071 PDUs in effective treatment resident in Manchester DAAT. This area had the lowest penetration rate of PDUs in effective treatment (45.72%). Manchester DAAT had a high proportion of BME aged under 18 in contact with drug and alcohol treatment (21.51%). This compares to the proportion of 12.33% BME amongst all those in contact with drug treatment resident in Manchester DAAT. Manchester PCT had the highest actual number of individuals in contact with structured alcohol treatment in the region (n=1913, 9.33% of regional total). There were a low proportion of under 25s in contact with structured alcohol treatment in Manchester PCT (10.56%) when compared to the regional average (16.21%). 8

9 Oldham During 2008/09 there were 1183 individuals in contact with structured drug treatment. There were a high proportion of individuals who stated their ethnicity as BME (13.31%) when compared to the regional average (4.38%). There were 819 PDUs in effective treatment in 2008/09 resident in Oldham DAAT. Oldham DAAT had a higher proportion of under 18s in contact with drug treatment (12.00%) when compared to the regional average of 6.66%. Oldham DAAT had a high proportion of BME aged under 18 in contact with drug and alcohol treatment (15.93%). This compares to the proportion of 13.31% BME amongst all those in contact with drug treatment resident in Oldham DAAT. Rochdale During 2008/09 there were 1631 individuals in contact with structured drug treatment. There has been a slight fall in the prevalence of individuals in contact with structured drug treatment from per 1,000 population aged in 2006/07 to per 1,000 population in 2008/09. There were a high proportion of individuals who stated the use of crack (33.97%) in comparison to the regional average (25.80%). In contrast there was a lower than average stated use of heroin (58.19%) amongst the in treatment population. During 2008/09 there were 1071 PDUs in effective treatment resident in Rochdale DAT. Rochdale DAT had a higher proportion of under 18s in contact with drug treatment (14.78%) when compared to the regional average of 6.66%. Rochdale DAT had the highest prevalence of under 18s (per 1,000 population aged years) in contact with drug and alcohol treatment (15.04). Salford During 2008/09 there were 1261 individuals in contact with structured drug treatment. Almost half of all referrals into adult treatment were via self-referral (49.09%). During 2008/09 there were 893 PDUs in effective treatment. There has been a slight fall in the prevalence of individuals in contact with structured drug treatment from per 1,000 population aged in 2006/07 to per 1,000 population in 2008/09. Salford DAAT had the lowest penetration rate of opiate users in effective treatment (41.69%). 9

10 Sefton During 2008/09 there were 1904 individuals in contact with structured drug treatment. High prevalence rates were found in the L20 district of Sefton (41.35 per 1,000 populations). There were a high proportion of individuals in contact with treatment aged 40 and over (35.18%) resident in Sefton DAAT. Sefton D(A)AT had high levels of planned discharges from treatment (51.75%) in comparison to the regional average (39.49%). During 2008/09 there were 1249 PDUs in effective treatment resident in Sefton DAAT. St Helens During 2008/09 there were 1282 individuals in contact with structured drug treatment. There was a slightly higher prevalence of individuals in contact with treatment (16.03 per 1,000 population aged years) when compared to the regional average (12.20 per 1,000 population aged years). The proportion of individuals in treatment who stated their ethnicity as BME was low (0.55%) in comparison to the regional average (4.38%). There were 894 PDUs in effective treatment resident in St Helens DAT. Stockport During 2008/09 there were 1035 individuals in contact with structured drug treatment. There was a low prevalence of individuals in contact with treatment when compared to the regional average (7.94 per 1,000 population aged years). There were a high proportion of individuals who stated the use of cocaine (20.39%) in comparison to the regional average (12.84%). During 2008/09 there were 687 PDUs in effective treatment. Stockport DAT had a high proportion of self referrals into YP treatment (35.05%) in comparison to the regional average (11.34%). Stockport DAT had the lowest actual number (n=79) and the lowest prevalence of young people (per 1,000 population aged years) in contact with drug and alcohol treatment (2.62) in the region. 10

11 Tameside During 2008/09 there were 1205 individuals in contact with structured drug treatment. The prevalence rate of individuals in contact with treatment was similar to the regional average (12.08 per 1,000 population). Amongst those in contact with treatment resident in Tameside DAT, methadone use was high (17.68% in comparison to regional average of 15.07%). The stated use of other opiates (5.89%) and benzodiazepines (16.27%) were also high in comparison to the regional averages (3.38% and 9.14% respectively). During 2008/09 there were 919 PDUs in effective treatment resident in Tameside DAT. There were a high proportion of referrals into YP treatment via education and employment services (31.58%). Trafford During 2008/09 there were 790 individuals in contact with structured drug treatment. There was a low prevalence of individuals in contact with treatment when compared to the regional average (7.71 per 1,000 population aged years). A high proportion of individuals resident in Trafford DAT stated their ethnicity as BME (10.65% when compared to regional average of 4.38%). There were a high proportion of CJS referrals into adult treatment services (35.46%) when compared to regional average. During 2008/09, there were 529 PDUs in effective treatment resident in Trafford DAT. Highest penetration rate of crack users in effective treatment in the region was found in Trafford DAT (58.00%). There were a low proportion of under 25s in contact with structured alcohol treatment in Trafford PCT (10.43%) when compared to the regional average (16.21%). Trafford DAT had a high proportion of BME aged under 18 in contact with drug and alcohol treatment (14.43%). This compares to the proportion of 10.65% BME amongst all those in contact with drug treatment resident in Trafford DAT. Warrington During 2008/09 there were 861 individuals in contact with structured drug treatment. There has been a slight fall in the median age of those in contact with treatment from 34 years in 2007/08 to 33 years in 2008/09. This is in contrast to an ageing treatment population in all other North West D(A)AT areas. Individuals resident in Warrington DAT were more likely to state the use of crack (32.98%) and cocaine (23.58%) when compared to the regional average (25.80% and 12.84% respectively). During 2008/09 there were 584 PDUs in effective treatment. 11

12 Wigan and Leigh During 2008/09 there were 1715 individuals in contact with structured drug treatment. The prevalence (per 1,000 population aged years) has increased from in 2006/07 to in 2008/09. There was a high level of stated amphetamine use (13.76%) amongst those in treatment in comparison to the regional average (6.44%). In contrast there were a low proportion of stated crack users (10.15% compared to a regional average of 25.80%). During 2008/09 there were 1252 PDUs in effective treatment. The highest penetration rate of PDUs in effective treatment (76.39%) in the region was found in Wigan and Leigh DAT. There were a high proportion of females in contact with structured alcohol treatment in Ashton, Leigh and Wigan PCT (43.67%) when compared to the regional average of 37.83%. Wirral During 2008/09 there were 2832 individuals in contact with structured drug treatment. The lowest proportion of individuals triaged for their most recent episode of treatment during the financial year was found in this DAAT (36.55%). Wirral DAAT had the third highest prevalence rate of general population in structured drug treatment (19.44 per 1,000 population 15-44). The highest concentrations of individuals in contact with treatment were found in the postcode district of CH41 in the Birkenhead area of Wirral (73.20 per 1,000 population aged 15-44). The highest median age of the in treatment population in the region (39 years) was found in this DAAT area. The biggest difference in the median age at triage and at year end in region (6 years) was also found in this DAAT area. A high proportion of individuals in contact with drug treatment aged 40 and over (45.90%) when compared to regional average (30.78%). There were 2216 PDUs in effective treatment resident in Wirral DAAT. Wirral PCT had the highest prevalence rate of individuals in contact with structured alcohol treatment (7.12 per 1,000 population aged years). This PCT area also had a high actual number in contact with alcohol treatment (n=1455, 7.10% of regional total). Wirral PCT had a high proportion of individuals aged 65 years and over in contact with structured alcohol treatment (2.96%) when compared to the regional average (2.39%). 12

13 Acknowledgements The authors would like to thank the following people for their help in the collection of data and in the production of the report: the staff at all treatment providers, along with the following colleagues at the Centre for Public Health; Karen Hoare, Jessica Salmon, Charles Gibbons, Clare Heraty, Mark Whitfield, Howard Reed, David Seddon, Lee Tisdall and Sian Connolly. The authors would also like to thank the Drug (and Alcohol) Action Teams in the North West of England, along with the staff at regional and national NTA and all structured treatment clients in the North West. The authors Ayesha Hurst (tel , is the North West NDTMS liaison manager, based at the Centre for Public Health, Liverpool John Moores University. Adam Marr (tel , is the North West NDTMS regional manager at the Centre for Public Health. Ellie McCoy is a research assistant based in the NDTMS team at the Centre for Public Health. Jim McVeigh is the Head of Substance Misuse/ Reader in Substance Use Epidemiology and Mark A. Bellis is the Director of the Centre for Public Health. This report, along with previous NDTMS reporting by the Centre for Public Health, Liverpool John Moores University, is available on the CPH website, The Centre for Public Health, Liverpool John Moores University, would welcome feedback on the contents of the report. Any comments or queries should be directed to: Ayesha Hurst Centre for Public Health Research Directorate Faculty of Health and Applied Social Sciences Liverpool John Moores University Kingsway House Hatton Garden Liverpool L3 2AJ a.hurst@ljmu.ac.uk 13

14 Contents Introduction 17 New Developments 18 NDTMS themed reporting 20 SECTION ONE: Problematic Drug Users (PDU) and all drug users (aged over 18) in effective structured drug treatment 21 SECTION TWO: Individuals in contact with structured drug treatment 36 SECTION THREE: Young People (under 18) in contact with structured drug and alcohol treatment 64 SECTION FOUR: Individuals in contact with structured alcohol treatment 70 Methodology 80 Methodological Notes 81 References 83 Glossary 85 14

15 Figures and Tables Figures Figure 1: PDU treatment status, 2008/09 21 Figure 2: Age bands of PDUs in effective treatment, 2008/09 22 Figure 3: Demographic profile of PDUs in effective treatment, 2008/09 23 Figure 4: Discharge reason of PDUs in effective treatment, 2008/09 24 Figure 5: Figure 6: Figure 7: Figure 8: Figure 9: Smoothed estimates of PDUs and actual PDUs aged in effective treatment by D(A)AT of residence, 2008/09 26 Smoothed estimates of PDUs and actual opiate users aged in effective treatment by D(A)AT of residence, 2008/09 28 Smoothed estimates of problematic crack users and actual crack users aged in effective treatment by D(A)AT of residence, 2008/09 30 Proportion of PDUs in effective treatment still engaged in their most recent treatment journey by D(A)AT of residence, 2008/09 32 Discharge reason of PDUs exiting effective treatment by D(A)AT of residence (most recent treatment journey), 2008/09 33 Figure 10: Discharge reason of all drug users (aged 18 and over) exiting effective treatment, 2008/09 35 Figure 11: Prevalence levels for the number of year olds in contact with treatment per 1,000 population by D(A)AT of residence, 2008/09 39 Figure 12: Number of year olds in contact with treatment per 1,000 population of postcode districts, with D(A)AT boundaries overlaid, 2008/09 41 Figure 13: Age distribution of individuals in contact with treatment, 2003/ /09 44 Figure 14: Number of individuals in contact with treatment aged <25, and 40+, 2003/ /09 45 Figure 15: Median age at triage and at year end by D(A)AT of residence, 2008/09 47 Figure 16: Age bands by D(A)AT of residence (ordered by level of deprivation), 2008/09 48 Figure 17: All substance use of individuals in contact with treatment, 2008/09 53 Figure 18: Proportion of substance use of individuals in contact with treatment, 2008/09 54 Figure 19: Stated substance use by D(A)AT of residence, 2008/09 56 Figure 20: Referral source of those in contact with YP treatment providers, 2008/09 57 Figure 21: Referral source of those in contact with YP treatment providers by sex, 2008/09 57 Figure 22: Referral source of those in contact with YP treatment providers by D(A)AT of residence, 2008/09 58 Figure 23: Referral source of those in contact with adult drug treatment, 2008/09 59 Figure 24: Referral source of those in contact with adult drug treatment by D(A)AT of residence, 2008/09 59 Figure 25: YP treatment modalities, 2008/09 60 Figure 26: Adult treatment modalities, 2008/09 61 Figure 27: Discharge reason for most recent episode of treatment, 2008/09 62 Figure 28: Proportion of individuals still engaged in their most recent episode of treatment by D(A)AT of residence, 2008/09 63 Figure 29: Discharge reason by D(A)AT of residence, 2008/09 63 Figure 30: Prevalence levels for the number of year olds in contact with drug and alcohol treatment per 1,000 population by D(A)AT of residence, 2008/09 66 Figure 31: Discharge reason for under 18s in contact with drug and alcohol treatment, 2008/

16 Figure 32: Discharge reason for under 18s in contact with drug and alcohol treatment and all those in drug treatment, 2008/09 69 Figure 33: Number of year olds in contact with alcohol treatment per 1,000 population of postcode districts, with PCT boundaries overlaid, 2008/09 72 Figure 34: Sex of individuals in contact with alcohol treatment by PCT of residence, 2008/09 74 Figure 35: Age and sex distribution of individuals in contact with alcohol treatment, 2008/09 75 Figure 36: Age distribution of individuals in contact with alcohol treatment by PCT of residence, 2008/09 76 Figure 37: Referral source of those in contact with alcohol treatment, 2008/09 77 Figure 38: Referral source of those in contact with alcohol treatment by PCT of residence, 2008/09 78 Tables Table 1: Public Service Agreement (PSA) targets for drug treatment and substance use 17 Table 2: Number of PDUs in effective treatment by D(A)AT of residence, 2008/09 25 Table 3: Table 4: Table 5: Number of PDUs in effective treatment (aged 15-64) and penetration rate of estimated PDUs in effective treatment by D(A)AT of residence, 2008/09 27 Number of opiate users in effective treatment (aged 15-64) and penetration rate of estimated PDUs in effective treatment by D(A)AT of residence, 2008/09 29 Number of crack users in effective treatment (aged 15-64) and penetration rate by D(A)AT of residence, 2008/09 31 Table 6: Number of individuals aged 18 and over (all drugs) in effective treatment by D(A)AT of residence, 2008/09 34 Table 7: Table 8: Number of individuals in contact with treatment, prevalence rates and deprivation scores by D(A)AT of residence, 2008/09 37 Prevalence levels of individuals (15-44 years) in contact with treatment per 1,000 population by D(A)AT of residence, 2006/ /09 38 Table 9: Sex, ethnicity and age of individuals in contact with treatment by D(A)AT of residence, 2008/09 42 Table 10: Age distribution of individuals in contact with treatment, 2008/09 43 Table 11: Median age of individuals in contact with treatment by D(A)AT of residence, 2007/08 and 2008/09 46 Table 12: Age bands of individuals in contact with treatment by ethnicity, 2008/09 49 Table 13: Proportion of under 25 and 25 and over in contact with treatment by ethnicity, 2008/09 50 Table 14: Primary, secondary and tertiary substances for individuals in contact with treatment, 2008/09 51 Table 15: Primary and secondary substance profile of individuals in contact with treatment, 2008/09 52 Table 16: All substance use by age group of individuals in contact with treatment (percentage), 2008/09 53 Table 17: All substance use by ethnicity, 2008/09 54 Table 18: Stated substance use by D(A)AT of residence, 2008/09 55 Table 19: Modality exit status for all adult interventions, 2008/09 61 Table 20: Under 18s in contact with drug and alcohol treatment by D(A)AT of residence, 2008/09 65 Table 21: Sex and ethnicity of individuals under 18 in contact with drug and alcohol treatment, 2008/09 67 Table 22: Primary, secondary and tertiary substances for under 18s in contact with drug and alcohol treatment, 2008/09 68 Table 23: Number of individuals in contact with alcohol treatment and prevalence rates by PCT of residence, 2008/09 71 Table 24: Sex, ethnicity and age of individuals in contact with alcohol treatment by PCT of residence, 2008/09 73 Table 25: Age distribution of individuals in contact with alcohol treatment, 2008/09 75 Table 26: Discharge reason of individuals in contact with alcohol treatment by PCT of residence, 2008/

17 Annual report 2008/09 Introduction This publication details the results of the National Drug Treatment Monitoring System (NDTMS) in the North West of England during 2008/09. The NDTMS was introduced in April 2001 to collect data on all clients in contact with structured treatment services (i.e. high threshold tier 3 and 4 services as defined by the Models of Care, see National Treatment Agency [NTA] 2002). Until 2007/08, the NDTMS was used as the key source to monitor the overall number of individuals in contact with structured drug treatment. During 2007/08, the Government released Drugs: protecting families and communities, the 2008 drug strategy, detailing the main focus of policy for the next ten years, With the introduction of the 2008 drug strategy, the Government also launched a new measure of treatment effectiveness. Public Service Agreement (PSA) 25: the Percentage change in the number of drug users recorded as being in effective treatment measures the percentage change in the number of Problematic Drug Users (PDUs) (those using opiates and/ or crack cocaine) in treatment in the financial year (see table 1). Effective treatment relates to those who are still in continuous treatment, who have been discharged from the treatment system after 12 weeks or, if discharged prior to 12 weeks, were successfully discharged in a care planned way. The NDTMS is the key indicator for monitoring the number in effective drug treatment in comparison to the 2007/08 baseline. During 2008/09, the routine monitoring of the NDTMS was also expanded to collect data on clients receiving specialist alcohol treatment interventions to address their alcohol misuse, where the provision of specialist treatment is in line with that described in Models of Care for Alcohol Misuse (MoCAM). The data collection does not include tier 2 and unstructured alcohol treatment (e.g. AA), or treatment in other parts of the NHS for secondary complications arising out of the misuse of alcohol (e.g. treatment for liver disease). To take into account the recent developments in NDTMS monitoring and reporting, this report provides an overview of the NDTMS data for the region and has been divided into the following sections: Problematic Drug Users (PDU) and all drug users (aged over 18) in effective structured drug treatment Individuals in contact with structured drug treatment Young People (under 18) in contact with structured drug and alcohol treatment Individuals in contact with structured alcohol treatment. The report also provides comparisons to previous years; 2003/04, 2005/06, 2006/07 and 2007/08. It offers supplementary detailed information to build on the national figures quoted by the National Drug Evidence Centre (NDEC) and the NTA. The report only includes data for those individuals resident within the region who were in contact with treatment services within the North West. The results of this report were compiled by the NDTMS regional team, based within the North West Public Health Observatory at the Centre for Public Health, Liverpool John Moores University. This regional team collects data from all structured drug and alcohol treatment providers in the North West on behalf of the NTA. Table 1: Public Service Agreement (PSA) targets for drug treatment and substance use PSA PSA definition Source of information PSA 25: Reduce the harm caused by alcohol and drugs The number of drug users recorded as being in effective treatment The rate of drug related offending The percentage of the public who perceive drug use or dealing to be a problem in their area NDTMS, NTA Home Office Communities and Local Government PSA 14: Increase the number of children and young people on the path to success The proportion of young people frequently using illicit drugs, alcohol or volatile substances Department for Children, Schools and Families 17

18 New Developments Policy developments: Abstinence and harm reduction The 2008 Drug Strategy, Drugs: protecting families and communities (Home Office, 2008) places greater emphasis on treatment outcomes, completion and exit. The emphasis on treatment outcomes was highlighted with the introduction of The Treatment Outcomes Profile (TOP) into routine NDTMS reporting in 2007 to monitor the progression on individuals throughout their treatment journey. The government s 2008 Drug Strategy describes the purpose of treatment as follows: The goal of all treatment is for drug users to achieve abstinence from their drug, or drugs, of dependency. For some, this can be achieved immediately, but many others will need a period of drug assisted treatment with prescribed medication first. Drug users receiving drug-assisted treatment should experience a rapid improvement in their overall health and their ability to work, participate in training or support their families. During 2008, it was announced that abstinence based drug treatment would grow by more than 2000 places a year (NTA, 2008b). Whilst there has been growing interest in the achievement of abstinence amongst those in contact with treatment, a recent report by the Advisory Council on the Misuse of Drugs with regard to hepatitis C (ACMD, 2009), highlights the need to continue investment in harm reduction services by local partnerships to prevent the spread of hepatitis C. The report also highlighted the importance of needle and syringe distribution services as a means to facilitate entry into drug treatment, so that users are able to make lasting change and stop injecting altogether. The report, Reducing Drug-Related Harm: An Action Plan (DH & NTA, 2007) emphasises the importance of both harm reduction along with the eventual achievement of abstinence: Harm reduction combines work aimed directly at reducing the number of drug related deaths and blood borne virus infections, with wider goals of preventing drug misuse and of encouraging stabilisation in treatment and support for abstinence. Providing effective substitution treatments and effective support for abstinence are complementary aims of such a balanced response. NDTMS Core Dataset F During 2009/10, the NTA introduced key changes and amendments to the NDTMS core dataset. The addition of new data items have principally affected Young Persons (YP) specific services. During 2008 the NTA consulted with regional groups of substance misuse commissioners, children s services commissioners, treatment providers, NDTMS regional staff, information analysts and Department for Children, Schools and Families (DCSF) on developments to the core dataset for YP services. Following consultation the YP NDTMS was amended to provide: Clarification to referral codes Status and outcome questions at treatment entry and treatment exit Discharge destination at treatment exit. The new YP dataset should provide a better understanding of how young people s treatment works and should better inform the needs assessment and treatment planning process. In addition to the new YP specific fields within core dataset F, the NTA has also included a TOP care co-ordination field to both adult and YP datasets to denote the treatment provider with overall responsibility of TOP care coordination for a client. There have also been amendments to the parental status, children, hepatitis B and C intervention status and discharge reason fields. NDTMS Core Dataset G The NTA have been in consultation with key stakeholders to consider and comment on proposals to amend the codes used in NDTMS to record types of treatment. These codes (which have until now been described as modalities ) are widely used within the drug and alcohol treatment field to describe recognisable units of treatment that may include a range of interventions. Collectively these units of activity constitute structured drug and alcohol treatment. The existing codes used to record the types of drug treatment being provided were defined in 2002 in line with Models of Care (NTA, 2002) and refined on publication of Models of Care: Update 2006 (NTA, 2006), which clarified the position of specific interventions within the four tier system. Since then there have been further key publications, and particularly: 18

19 NICE suite of clinical and public health guidance (NICE, 2007a & b), which recommends a range of specific evidence-based pharmacological and psychosocial interventions Drug Misuse and Dependence: UK Guidelines on Clinical Management (DH & devolved administrations, 2007) which recommends a range of evidence-based and expert consensus-supported interventions Since the publication of the 2007 Clinical Guidelines, the NTA have been working with local treatment systems to ensure robust clinical governance systems are in place to take full account of the 2007 Clinical Guidelines. Furthermore, the NTA are currently developing guidance for commissioners on how to commission systems effectively that are in tune with the 2007 Clinical Guidelines. Codes and definitions proposed to record what type of treatment is provided on the NDTMS are intended to be consistent with and reflect these more recent documents. The current adult drug treatment codes used to record activity through the NDTMS are: Inpatient treatment Residential rehabilitation Specialist prescribing GP prescribing Structured psychosocial intervention Structured day programmes Other structured treatment. The NTA propose to modify and add to these codes to better reflect the range of drug treatment intervention types that should be provided by services according to the latest guidance. If agreed and introduced, the new codes would: Include more detailed analysis of prescribing Include more analysis of residential rehabilitation types Better reflect the range of psychosocial interventions being provided. These proposals only relate to structured adult community drug treatment services. Codes that have been recently introduced for young people s services and alcohol treatment are not part of this consultation process, although views about the degree of consistency of alcohol codes for types of interventions will be welcomed. Tier 2 codes are also not included within this consultation process as, although some treatment agencies provide tier 2 data as part of their monthly upload, they are not required for NDTMS submission and no national analysis is performed upon them. The amendments to codes used to record the types of drug treatment being provided on the NDTMS will take place in April NDTMS and Prisons The national drug strategy, Drugs: protecting families and communities, the 2008 drug strategy, contains a commitment from the Department of Health to ensure that clinical treatment is brought to minimum standards across all prisons by As part of this commitment, NDTMS data collection within prisons was introduced during 2009/10, utilising the new Drug Interventions Record (DIR) form. The DIR form has incorporated all core data set items from the NDTMS, with this information then being transferred to DIRweb, the secure internet tool used to collect all Drug Interventions Programme (DIP) data. The initial year of implementation will be used to establish the process of NDTMS data collection within prisons, as well as providing a baseline for full reporting to commence in 2010/11. Training and employment pathways for Problematic Drug Users (PDUs) A central aim of the national drug strategy for , Drugs: protecting families and communities is a commitment to provide advice on practice regarding securing treatment and support to access employment for problem drug users in receipt of benefits. The Department of Health (DH) has committed 9m over three financial years to fund Jobcentre Plus drugs coordinators across England. These coordinators will act as a regional and local resource in the development and coordination of the employment and drugs pathway. Each region will have a Jobcentre Plus drugs coordinator who, in partnership with NTA regional teams, will oversee the delivery of the work of local and district level Jobcentre Plus drugs coordinators. Distribution of the posts are based on numbers of problem drug users in effective treatment, estimated levels of treatment-naïve problematic drug users and the estimated percentage of problem users who may be claiming welfare benefits. 19

20 NDTMS themed reporting During 2008/09, the North West NDTMS produced three themed reports based on various aspects of the NDTMS dataset. The North West Public Health Observatory (NWPHO) also produced a report, Indications of Public Health in the English Regions 10: Drug Use on illicit drug use in the English Regions. All of these reports are available on the Centre for Public Health website, Parental Status The first NDTMS themed report of 2008/09 Parental Status, 2007/08 detailed the parental status of those presenting to structured drug treatment from April According to the Hidden Harm report, there are estimated to be 250, ,000 children of problem drug users in the UK (Advisory Council on the Misuse of Drugs [ACMD], 2003) with only 37% of fathers and 64% of mothers with a drug problem still having their children living with them. The report highlighted several data issues which may mean the number of children affected by drug use may have been underestimated. The report also provided information on the number of individuals in contact with treatment who stated that they had children living with them, along with an estimation of the number of children in the North West living with a Problematic Drug User (PDU) in contact with treatment. Non-opiate, AACCE substance use in the North West of England The second themed report detailed the demographic profile, referral sources in, and the exit status upon leaving, of those individuals in contact with structured treatment stating non-opiate substance use, incorporating Alcohol, Amphetamines, Cannabis, Cocaine and Ecstasy (AACCE). Analysis was conducted to compare this AACCE group to those in treatment who entered due to opiate use to determine whether AACCE clients are a distinct group when compared to opiate users, who constitute the majority of those in structured drug treatment. This themed report attempted to evidence the scale and pace of change in presentations to tier 3 and 4 services in the North West. Analysis of AACCE clients revealed that those individuals who did not state opiates as a substance were a distinct group. AACCE clients were significantly younger, referred via different referral routes and engaged in different treatment modalities to traditional opiate users. The report highlighted the need for D(A)ATs to be aware of the growing use of AACCE substances amongst their younger service users and the potential increase in demand for non prescribing interventions of treatment. Patterns of mortality amongst individuals in contact with drug treatment services in the North West of England - 5 years of data capture The third themed report detailed causes of death of individuals in contact with treatment discharged as having died between 2003/04 and 2007/08. The information was used to investigate the causes of death of those in contact with structured drug treatment services, and also to identify any potential differences in the characteristics of those dying from a DRD and those dying from residual causes, along with any trend data across the five years of the study. The analysis of five years of NDTMS data provided a large data source for the determination of the underlying causes of death of those in contact with structured drug treatment. Analysis of the data revealed that the majority of individuals died of a non DRD and that those who died of a DRD were more likely to have a history of IDU in comparison to those who died of a non DRD. The investigation of all causes of death for those in contact with structured drug treatment is important as a means for greater understanding of risk amongst the in-treatment population. It can also act as a measure of the effectiveness of public health interventions for those in treatment. The five years of research identified the increase in deaths as a result of alcohol use, along with a consistent pattern of non DRDs as a result of blood borne viruses across all years. This highlights the need to address alcohol issues of those in contact with drug treatment, along with the necessity for hepatitis C screening and hepatitis B vaccination. Whilst some causes of death were more common than others, there were also several contrasting causes of death over the five years of research, highlighting the need to address general physical and psychological health of those in treatment, in addition to treating their drug use. Indications of Public Health in the English Regions 10: Drug Use As part of the series of Indications of Public Health in the English Regions, commissioned from the Association of Public Health Observatories (APHO) by the Chief Medical Officer (CMO), the North West Public Health Observatory (NWPHO) produced this report on illicit drug use in the English Regions. The regional indications report contains 46 separate indicators of drug use relating to the individual, community, and population, with various measures of the effects this has on health and wellbeing. In particular, the report focuses on the nine English regions, but, where possible, the situation in England has been put into a wider European context (APHO, 2009). 20

21 SECTION ONE: Problematic Drug Users (PDU) and all drug users (aged over 18) in effective structured drug treatment 1 With the introduction of Drugs: protecting families and communities, the 2008 Drug Strategy, the Government launched a new measure of treatment effectiveness for the 2008/09 financial year. The indicator measures the percentage change in the number of Problematic Drug Users (PDUs) (those using opiates and/or crack cocaine), and all drug users (over the age of 18) in effective treatment in the financial year. Effective treatment relates to those who are still in continuous treatment, who have been discharged from the treatment system after 12 weeks or, if discharged prior to 12 weeks, were successfully discharged in a care planned way. Treatment effectiveness measures have been introduced to be used alongside partnership prevalence estimates for opiate and/or crack cocaine users provided through Home Office estimates with a view to increasing treatment penetration where performance is below the national average. This section details the demographic profile of PDUs and all drug users aged over 18 in effective treatment, whilst also providing information on prevalence estimates for the number of PDUs in the North West by partnership area (see Hay et al., 2007, 2008; Frischer et al., 2007; Frischer and Forsyth, 2008). Number of PDUs in effective treatment in 2008/09 - regional results 2 Figure 1: PDU treatment status, 2008/ (4.25%) PDUs not in effective treatment (95.75%) PDUs in effective treatment 1 For explanation and methodological notes please refer to the methodological section at the end of the report 2 For explanation and methodological notes please refer to the methodological section at the end of the report 21

22 During 2008/09 there were PDUs in effective treatment. The majority of PDUs in effective treatment were male (n=20682, 70.88%) and stated their ethnicity as White (n=27524, 95.95%). Very few PDUs in effective treatment were aged under 18 3 (n=69, 0.24%), with 61.26% of PDUs in effective treatment aged 35 and over (n=17877). Figure 2: Age bands of PDUs in effective treatment, 2008/ % 0.52% 4.36% < % 12.42% % 26.24% 21.20% For explanation and methodological notes please refer to the methodological section at the end of the report 22

23 The vast majority of PDUs in effective treatment stated the use of heroin at some point in their most recent treatment journey (n=26385, 90.42%), highlighting the dominance of this drug amongst this population. The stated use of crack cocaine at some point in this journey was lower when compared to heroin use (n=11318, 38.79%). Whilst all PDUs stated the use of opiates and/or crack within their treatment journey, there were a number of additional commonly stated substances. For example, 4015 (13.76%) stated the use of benzodiazepines, 3685 (12.63%) stating the use of cannabis and 2742 (9.40%) stating alcohol use. Of the PDUs in effective treatment, (39.50%) stated the additional use of a substance other than opiates and/or crack, highlighting polydrug use amongst a significant proportion of those PDUs in treatment. The monitoring of the level of injecting drug users (IDUs) in treatment is important due to the vulnerability of these drug users to a wide range of infections, including those caused by viruses such as hepatitis C and HIV and bacteria such as Clostridium botulinum and group A streptococci. Hepatitis C is currently the most important infectious disease amongst IDU with 90% of all newly diagnosed infections occurring in this group (HPA, 2008). Amongst PDUs in effective treatment in 2008/09, (64.10%) stated that they had injected at some point within their most recent treatment journey, highlighting the importance of hepatitis B vaccination and hepatitis C screening amongst the PDU in-treatment population. Figure 3: Demographic profile of PDUs in effective treatment, 2008/ % were aged under % stated heroin as a problem substance 70.88% were male 61.26% were aged 35 or older PDUs in effective treatment 39.50% had additional use of substances other than opiates or crack 64.10% had an injecting history 23

24 Treatment Outcomes of PDUs in effective treatment Of the PDUs in effective treatment in 2008/09, the vast majority (n=24159, 82.79%) were still actively engaged in a treatment journey at the end of the financial year. When only those discharged from their most recent treatment journey were considered, figure 4 shows that 33.30% (n=1672) of PDUs in effective treatment had a planned discharge. Figure 4: Discharge reason of PDUs in effective treatment, 2008/ % 12.01% Planned 33.30% Referred on 25.65% 18.56% Unplanned - dropped out Unplanned - prison Unplanned - other 24

25 PDUs in effective treatment by D(A)AT of residence The number of PDUs in effective treatment within a D(A)AT area has become increasingly important due to the introduction of the new PSA measure of treatment effectiveness during the 2008/09 financial year. There were differences in the number of PDUs in effective treatment dependent on D(A)AT of residence from 462 in Halton to 3845 in Lancashire. The number of PDUs in effective treatment by D(A)AT of residence displayed in table 2 differ slightly from the figures published by NDEC and NTA (see methodological notes and appendix 1). Table 2: Number of PDUs in effective treatment by D(A)AT of residence, 2008/09 4 D(A)AT of residence Number in effective treatment Blackburn with Darwen 844 Blackpool 1475 Bolton 1398 Bury 538 Cheshire 1898 Cumbria 1442 Halton 462 Knowsley 709 Lancashire 3845 Liverpool 3348 Manchester 3071 Oldham 819 Rochdale 1071 Salford 893 Sefton 1249 St Helens 894 Stockport 687 Tameside 919 Trafford 529 Warrington 584 Wigan and Leigh 1252 Wirral 2216 Total* *The regional total does not equal the sum of the D(A)AT figures as some individuals may have been resident in more than one D(A)AT area during the financial year but are only counted once in the regional figure. 4 For explanation and methodological notes please refer to the methodological section at the end of the report 25

26 Figure 5 and table 3 display the number of PDUs in effective treatment aged years alongside the prevalence estimates for PDUs in each partnership area. Whilst the estimates of the number of PDUs resident within a D(A)AT area have been calculated from 2004/ /07 estimates ( smoothed estimates, see Hay et al., 2008), table 3 shows that the penetration levels of users entering treatment varied dependent on D(A)AT of residence from 36.91% in Salford to 76.39% in Wigan and Leigh. Figure 5: Smoothed estimates of PDUs and actual PDUs aged in effective treatment by D(A)AT of residence, 2008/ Actual number of PDUs in effective treatment Estimated number of opiate and/or crack users* Blackburn Blackpool Bolton NUMBER Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan Wirral D(A)AT OF RESIDENCE *Source Hay et al. (2008) 26

27 Table 3: Number of PDUs in effective treatment (aged 15-64) and penetration rate of estimated PDUs in effective treatment by D(A)AT of residence, 2008/09 D(A)AT of residence Number of PDUs in effective treatment aged Penetration rate* Blackburn with Darwen Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan and Leigh Wirral Total** *Penetration rate based on smoothed estimates **The regional total does not equal the sum of the D(A)AT figures as some individuals may have been resident in more than one D(A)AT area during the financial year but are only counted once in the regional figure. 27

28 When only opiate use was considered, there was again variation in the penetration levels of opiate users entering treatment dependent on D(A)AT of residence. Virtually all D(A)AT areas in the North West had a higher penetration rate for opiate users only in comparison to their overall penetration rate for PDUs into treatment. In Stockport DAT, there were a greater number of opiate users in effective treatment in comparison to the prevalence estimate (penetration rate of %). This was in contrast to a penetration rate of 41.69% in Salford DAAT. Figure 6: Smoothed estimates of PDUs and actual opiate users aged in effective treatment by D(A)AT of residence, 2008/ Actual number of opiate users in effective treatment Estimated number of opiate users* NUMBER Blackburn Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan Wirral D(A)AT OF RESIDENCE *Source Hay et al. (2008) 28

29 Table 4: Number of opiate users in effective treatment (aged 15-64) and penetration rate of estimated PDUs in effective treatment by D(A)AT of residence, 2008/09 D(A)AT of residence Number of opiate users in effective treatment aged Penetration rate* Blackburn with Darwen Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan and Leigh Wirral Total** *Penetration rate based on smoothed estimates **The regional total does not equal the sum of the D(A)AT figures as some individuals may have been resident in more than one D(A)AT area during the financial year but are only counted once in the regional figure. 29

30 The penetration rates of crack cocaine users were much lower in all D(A)AT areas in comparison to the overall penetration rate for PDUs suggesting that opiate users are more likely to be in effective drug treatment in comparison to crack users, even though a large proportion of primary opiate users in treatment state the secondary use of crack (see table 5). There was also greater disparity in the penetration levels of crack users in treatment dependent on D(A)AT of residence from 8.53% in Cumbria DAT to 58.00% in Trafford DAT. Figure 7: Smoothed estimates of problematic crack users and actual crack users aged in effective treatment by D(A)AT of residence, 2008/ Actual number of crack users in effective treatment Estimated number of crack users* Blackburn Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan Wirral NUMBER D(A)AT OF RESIDENCE *Source Hay et al. (2008) 30

31 Table 5: Number of crack users in effective treatment (aged 15-64) and penetration rate by D(A)AT of residence, 2008/09 D(A)AT of residence Number of crack users in effective treatment aged Penetration rate* Blackburn with Darwen Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan and Leigh Wirral Total** *Penetration rate based on smoothed estimates **The regional total does not equal the sum of the D(A)AT figures as some individuals may have been resident in more than one D(A)AT area during the financial year but are only counted once in the regional figure. 31

32 Throughout all D(A)ATs in the region, the majority of PDUs in effective treatment were still actively engaged in treatment at the end of the financial year. This proportion varied from 72.43% in Warrington DAT to 86.20% in Cheshire DAT. Figure 8: Proportion of PDUs in effective treatment still engaged in their most recent treatment journey by D(A)AT of residence, 2008/09 90% 85% PERCENTAGE (%) 80% 75% 70% 65% Blackburn Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan Wirral D(A)AT OF RESIDENCE 32

33 When only those discharged from their most recent treatment journey were considered, there were differences in the proportion of planned and unplanned discharges amongst PDUs in effective treatment dependent on D(A)AT of residence (see figure 9). A high proportion exited treatment in a planned way in Trafford, Sefton and Knowsley D(A)ATs (55.96%, 45.80% and 47.05% respectively). In contrast, only 16.15% PDUs in effective treatment resident in Manchester DAAT exited treatment in a planned way. A high proportion of PDUs exited as referred on in Blackpool, Lancashire and Salford DAAT areas (40.91%, 34.56% and 33.50% respectively). There was high level of drop outs from most recent treatment journeys amongst PDUs in Oldham DAAT (45.00%). In comparison, only 8.82% of PDU exits in Knowsley DATs were as a result of dropping out from treatment. Bolton and St Helens D(A)ATs had a high proportion of unplanned discharges to prison (15.02% and 16.22% respectively) in comparison to the regional average (10.48%). Figure 9: Discharge reason of PDUs exiting effective treatment by D(A)AT of residence (most recent treatment journey), 2008/09 100% 80% PERCENTAGE (%) 60% 40% 20% Planned Referred on Unplanned - dropped out Unplanned - prison Unplanned - other 0% Blackburn Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan Wirral D(A)AT OF RESIDENCE 33

34 All drug users (aged 18 and over) in effective drug treatment, 2008/09 5 In 2008/09 there were individuals aged 18 and over (all drugs) in effective treatment. The majority of adults in effective treatment were male (n=24940, 71.66%) and stated their ethnicity as White (n=32864, 96.01%) 6. Table 6: Number of individuals aged 18 and over (all drugs) in effective treatment by D(A)AT of residence, 2008/09 D(A)AT of residence Number in effective treatment Blackburn with Darwen 957 Blackpool 1654 Bolton 1583 Bury 691 Cheshire 2064 Cumbria 1701 Halton 650 Knowsley 1043 Lancashire 4574 Liverpool 4076 Manchester 3395 Oldham 952 Rochdale 1288 Salford 1103 Sefton 1611 St Helens 1088 Stockport 928 Tameside 1062 Trafford 653 Warrington 752 Wigan and Leigh 1489 Wirral 2592 Total* *The regional total does not equal the sum of the D(A)AT figures as some individuals may have been resident in more than one D(A)AT area during the financial year but are only counted once in the regional figure. 5 For explanation and methodological notes please refer to the methodological section at the end of the report 6 For explanation and methodological notes please refer to the methodological section at the end of the report 34

35 Treatment Outcomes of individuals aged 18 and over (all drugs) in effective treatment Of the individuals (all drugs) in effective treatment in 2008/09, the vast majority (n=26754, 76.87%) were still engaged in their most recent treatment journey at the end of the financial year, a slightly lower proportion than PDUs in effective treatment (n=24159, 82.79%). When only those discharged from their most treatment journey were considered, figure 10 shows that 45.61% (n=3671) had a planned discharge, proportionately higher than the number of PDUs in effective treatment exiting treatment in a care planned way (n=1672, 33.30%, see page 24). Figure 10: Discharge reason of all drug users (aged 18 and over) exiting effective treatment, 2008/ % 23.28% 10.01% 13.69% 45.61% Planned Referred on Unplanned - dropped out Unplanned - prison Unplanned - other 35

36 SECTION TWO: Individuals in contact with structured drug treatment Regional results During 2008/09 there were individuals in contact with structured drug treatment in the North West of England (tier 3 or 4 as defined by Models of Care [NTA, 2002 and 2006] see for further details). This is an increase of 4.38% from 2007/08 when the equivalent figure was (Hurst et al., 2008). The number of individuals in contact with structured drug treatment equates to 1.22% of the North West population aged Variations between local areas within the region There were considerable variations in the number of individuals in contact with treatment dependent on D(A)AT of residence, ranging from 755 in Halton DAAT to 5469 in Lancashire DAAT. There were also variations in the number of new and ongoing clients dependent on area of residence. The proportion of clients who were triaged for their most recent episode of treatment during 2008/09 varied from 36.55% in Wirral DAAT to 58.93% in Liverpool DAAT. Table 7 shows the number of individuals in contact with structured drug treatment by D(A)AT of residence. This table includes deprivation scores. These scores have been included as deprivation may be one contributory factor in determining the number of drug users in an area (ACMD, 1998). Table 7 shows that several areas with high levels of deprivation also had a high prevalence of individuals in contact with structured drug treatment. D(A)ATs with relatively low levels of deprivation such as Cheshire, Stockport, Trafford and Warrington, also had correspondingly low levels of individuals in contact with treatment (7.66, 7.94, 7.71 and 9.77 respectively). Liverpool and Manchester DAATs, the areas with the highest levels of deprivation in the region also had high prevalence levels of individuals in contact with drug treatment (19.48 and per 1,000 population respectively). 7 For explanation and methodological notes please refer to the methodological section at the end of the report 36

37 Table 7: Number of individuals in contact with treatment, prevalence rates and deprivation scores by D(A)AT of residence, 2008/09 D(A)AT of Residence New Ongoing Total in contact Prevalence (per 1,000 aged No. Row % No. Row % No. Col. % 15-44) 8 Deprivation score Blackburn with Darwen Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan and Leigh Wirral For explanation and methodological notes please refer to the methodological section at the end of the report 37

38 Table 8 and figure 11 display the prevalence levels of individuals in contact with treatment per 1,000 of the general population in each partnership area in 2008/09. Table 8 also shows the prevalence levels of those in treatment in previous years; 2006/07 and 2007/08. Blackpool DAAT had the highest prevalence of individuals in contact with treatment (29.28 per 1,000 population), considerably higher than the next highest prevalence rate of per 1,000 population within Liverpool DAAT. There has also been an increase in the prevalence rate in Blackpool DAAT from in 2006/07 to per 1,000 population in 2008/09. Whilst there has been an increase in the number of individuals in contact with treatment in several D(A)AT areas, in 11 of the 22 North West D(A)ATs there has been a decrease in the prevalence rate of year olds in treatment between 2006/07 and 2008/09. Table 8: Prevalence levels of individuals (15-44 years) in contact with treatment per 1,000 population by D(A)AT of residence, 2006/ /09 D(A)AT of residence Prevalence 2006/ Prevalence 2007/ Prevalence 2008/ Blackburn with Darwen Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan and Leigh Wirral

39 Figure 11: Prevalence levels for the number of year olds in contact with treatment per 1,000 population by D(A)AT of residence, 2008/09 Prevalence (15-44 years) per 1,000 population (D(A)AT of residence)

40 Prevalence by postcode area Variations in levels of deprivation occur within D(A)ATs as well as between D(A)ATs in the North West. Some D(A)ATs contain areas with high levels of deprivation, whilst also housing particular areas with low levels of deprivation (Noble et al., 2008). Therefore, prevalence levels of those in contact with treatment per 1,000 population in all North West postcode areas has been included in this section of the report. Figure 12 illustrates the number of people per 1,000 population (aged 15-44) from each postcode district (e.g. L1 or FY8) in the region in contact with treatment during 2008/09. The map demonstrates high concentrations of individuals in contact with services around central urban areas such as Merseyside and Greater Manchester. The highest concentrations of individuals in contact with treatment were found in the postcode district of CH41 in the Birkenhead area of Wirral (73.20 per 1,000 population) and FY1 postcode district in Blackpool (53.88 per 1,000 population). These areas have had consistently high prevalence levels of individuals in treatment in recent reporting years (Khundakar et al., 2007; Hurst et al., 2008) with both areas experiencing an increase in prevalence rates between 2007/08 and 2008/09. High prevalence rates were also found in the L5 and L20 districts of Liverpool and Sefton (55.21 and per 1,000 populations respectively). 40

41 Figure 12: Number of year olds in contact with treatment per 1,000 population of postcode districts, with D(A)AT boundaries overlaid, 2008/09 Postcode prevalence (15-44 years) per 1,000 population

42 Demographics of the treatment population This section describes the demographic profile of individuals in contact with structured drug treatment in the North West of England during 2008/09. Table 9 provides a summary of results for each of the 22 North West D(A)ATs in terms of sex, ethnicity and age. Table 9: Sex, ethnicity and age of individuals in contact with treatment by D(A)AT of residence, 2008/09 9 D(A)AT of residence Male White Under 25 No. % No. % No. % Total in contact Blackburn with Darwen Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan and Leigh Wirral Total* *The regional total does not equal the sum of the D(A)AT figures as some individuals may have been resident in more than one D(A)AT area during the financial year but are only counted once in the regional figure. Ethnicity percentages calculated from total treatment population where ethnicity is stated Sex The majority of individuals in contact with structured drug treatment were male (n=29081, 72.09%), a proportion similar to previous years. There were variations in the proportion of males in contact with treatment dependent on partnership of residence, from 69.34% in Cumbria DAT to 76.77% in Blackburn with Darwen DAT. 9 For explanation and methodological notes please refer to the methodological section at the end of the report 42

43 Age The median age of individuals in contact with treatment in 2008/09 was 35 years. This compared to the median age at which individuals entered their most recent episode of treatment of 32 years, suggesting that a number of individuals have been in treatment for a number of years. Over half of those in contact with treatment were aged 35 years and over (n=21167, 52.47%). Only 16.96% were aged under 25 (n=6843), with 6.66% aged under 18 (n=2687). Nationally during 2007/08, the average (median) age of individuals in contact with structured drug treatment was 32 years 10, indicating an older treatment population in the North West of England when compared to the rest of the country. Table 10: Age distribution of individuals in contact with treatment, 2008/09 Age Band Number Percentage < Total For explanation and methodological notes please refer to the methodological section at the end of the report 43

44 The proportions of individuals in contact with treatment services in 2008/09 according to age are presented in figure 13. Figure 13 also offers comparisons to previous financial years (2003/04; 2005/06; 2006/07 and 2007/08). There has been a 4.38% increase in the number of individuals in contact with treatment from 2007/08 to 2008/09, with an increase in numbers in the majority of age bands. However, this increase has not been consistent in all age bands. Figure 13 shows the increase, year on year, in the proportion of individuals aged 40 years and older, from 15.88% in 2003/04 to 30.78% in 2008/09. Contrastingly, there has been a decrease in the proportion of individuals in their twenties from 30.69% in 2003/04 to 19.41% in 2008/09. Between 2003/04 and 2007/08 there was an increase in the proportion of under 18s from 4.79% to 6.89%. This proportion of under 18s has only fallen slightly within the two most recent years to a proportion of 6.66% in 2008/09. The increasing proportion of older individuals in contact with treatment has led to a significant increase in the average age of individuals between 2007/08 and 2008/09. The trend of increasing proportions of older individuals in treatment, along with a corresponding decrease of those in their twenties, indicates an ageing treatment population within North West treatment services. This finding is corroborated by research indicating an ageing population within syringe exchange and treatment services in Cheshire and Merseyside. An ageing treatment population within treatment services could have important public health implications for services in the area, with a possible need for adaptation to accommodate the needs of this older population (Beynon et al., 2007). Figure 13: Age distribution of individuals in contact with treatment, 2003/ /09 30% 2003/ / / / /09 25% PERCENTAGE (%) 20% 15% 10% 5% 0% < AGE BANDS 44

45 There has been a year on year increase in the number of individuals in contact with structured drug treatment between 2003/04 and 2008/09. This has resulted in an increase in the number of individuals in virtually all age bands between these periods. These increases have not been consistent dependent on age. Figure 14 displays actual number of individuals in treatment during 2008/09, along with previous years (2003/04; 2005/06; 2006/07 and 2007/08). Figure 14 shows that, whilst the number of individuals aged 40 years and older has increased by 57.23% between 2005/06 and 2008/09, there has been a decrease in the actual number of individuals aged between 25 and 39 in this same time period. The actual number of individuals in treatment by age again indicates an ageing population within North West drug treatment services. Figure 14: Number of individuals in contact with treatment aged <25, and 40+, 2003/ /09 < NUMBER / / / / /09 YEAR 45

46 Table 11 shows the median age of those in contact with structured drug treatment dependent on D(A)AT of residence. It also gives a comparison to the previous reporting year; 2007/08. Within Bury DAAT, the average (median) age of those in contact with treatment in 2008/09 was 33 years. This compares to a median age of 39 years in Wirral DAAT. Liverpool DAAT also had a high median age of those in treatment (38 years) when compared to the regional average. There has been an increase in the average age of those in treatment in all D(A)ATs between the two reporting years with the exception of Warrington DAT. Table 11: Median age of individuals in contact with treatment by D(A)AT of residence, 2007/08 and 2008/09 D(A)AT of residence Median age 2007/ /09 Blackburn with Darwen Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan and Leigh Wirral Regional average

47 Figure 15 displays the median age of those in treatment at the year end, along with the median age of individuals at triage within their most recent episode of treatment. There was some disparity in the age of those in treatment at year end in comparison to their age at the end of the 2008/09 financial year, dependent on D(A)AT of residence. Whilst regionally, there was a three year gap between age at triage and age at year end, there was a six year difference between ages at these two time points amongst residents in Wirral DAAT, suggesting many of those in treatment in this area have been active for several years. Figure 15: Median age at triage and at year end by D(A)AT of residence, 2008/09 45 Age at triage Age at year end Blackburn Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan Wirral MEDIAN AGE D(A)AT OF RESIDENCE 47

48 Figure 16 shows all age bands for those in contact with treatment in 2008/09 by D(A)AT of residence, ordered by levels of deprivation. This figure shows that the distribution of age ranges was not consistent across North West D(A)AT areas. Rochdale, Bury, Oldham and Knowsley D(A)ATs had a higher proportion of under 18s in contact with drug treatment (14.78%, 13.16%, 12.00% and 12.03% respectively) when compared to the regional average of 6.66%. Liverpool and Manchester, the DAAT areas with the highest levels of deprivation in the region, had elevated levels of those aged 40 and over in comparison to the regional average (41.54% and 39.39% respectively). Whilst these areas had a high proportion of those aged 40 and older in contact with treatment, Sefton and Wirral DAATs also had high proportions of older individuals in contact with treatment (35.18% and 45.90% respectively). In contrast, Cumbria and Blackburn D(A)ATs had a low proportion of individuals in treatment aged 40 and older relative to the regional average (20.20% and 21.37% respectively). The disparity in the proportion of older individuals in treatment dependent on partnership of residence may be as a consequence of an earlier epidemic of drug use in central urban areas, such as Liverpool and Manchester, with this drug use spreading to surrounding areas of the region later (McVeigh et al., 2003). Figure 16: Age bands by D(A)AT of residence (ordered by level of deprivation), 2008/09 100% PERCENTAGE (%) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% < Liverpool Manchester Knowsley Blackpool Salford Blackburn Rochdale Halton Oldham St Helens Bolton Tameside Wirral Wigan Sefton Lancashire Bury Cumbria Stockport Warrington Trafford Cheshire D(A)AT OF RESIDENCE 48

49 Ethnicity The majority of individuals in contact with treatment in the region stated their ethnicity as White (95.62%). Regionally, no other ethnic group accounted for over one percent of the in-treatment population. This contrasts to an overall national proportion of BME in contact with treatment in 2007/08 of 12% (NTA, 2008). Whilst, on the whole, there was a very low percentage of Black and Minority Ethnic (BME) individuals in contact with treatment in the North West, there were certain D(A)AT areas with higher proportions of BME when compared to the national average. Manchester, Oldham and Trafford D(A)ATs had high proportions of BME in contact with treatment (12.33%, 13.31% and 10.65% respectively). In contrast, less than one percent of those in contact with treatment in Blackpool, Halton, Sefton, St Helens and Wirral D(A)ATs stated their ethnicity as BME (see table 9). Table 12: Age bands of individuals in contact with treatment by ethnicity, 2008/09 11 Age band White BME Number % Number % < Total* *Percentages total more than 100% due to rounding 11 For explanation and methodological notes please refer to the methodological section at the end of the report 49

50 Only 16.78% of individuals who stated their ethnicity as White British were aged under 25. In contrast, 31.73% of individuals who stated their ethnicity as Bangladeshi were aged under 25. Whilst there were a greater proportion of individuals with an ethnicity stated as Bangladeshi aged under 25 in comparison to other minority ethnic groups, this proportion has decreased slightly in comparison to 2007/08 when the equivalent proportion was 35.51%. Whilst the number within particular minority ethnic groups were low, table 13 demonstrates that different ethnic groups may have different treatment needs and access issues in comparison to White populations (Holloway & Bennett, 2008; Fountain, 2009 a, b, c, d). Table 13: Proportion of under 25 and 25 and over in contact with treatment by ethnicity, 2008/09 Ethnicity Under and over Number % Number % White British White Irish Other White White & Black Caribbean White & Black African White & Asian Other mixed Indian Pakistani Bangladeshi Other Asian Caribbean African Other Black Chinese Other

51 Substance Use The NDTMS records the primary substance of those in contact with drug treatment services, along with secondary and tertiary substances. Regionally, the majority of individuals stated the primary use of heroin (n=25083, 62.18%), a proportion similar to 2007/08 and also similar to the national proportion of primary heroin use amongst those in treatment in 2007/08 (61%, NTA, 2008). This was followed by cannabis (n=5147, 12.76%) and cocaine (n=3192, 7.91%). Only 2.89% stated the primary use of crack. Of the individuals in contact with treatment in 2008/09, (59.57%) stated a secondary substance, with 9322 (23.11%) stating a tertiary substance. Whilst only 2.89% of individuals stated the primary use of crack cocaine, 33.40% stated the secondary use of this drug. Table 14: Primary, secondary and tertiary substances for individuals in contact with treatment, 2008/09 Substance Primary Substance Secondary Substance * Tertiary Substance ** Number % Number % Number % Alcohol Amphetamines Benzodiazepines Cannabis Cocaine Crack Ecstasy Heroin Methadone Other Opiates Other Drugs *Percentages calculated for those who stated a secondary substance **Percentages calculated for those who stated a tertiary substance 51

52 Table 15 displays only those who had, in association with their primary substance, stated a secondary substance. Approximately half of individuals who stated heroin as a primary substance stated a secondary use of crack cocaine (n=7748, 49.70%). This is consistent with evidence that suggests an increased prevalence of crack cocaine use in the UK, usually in combination with opiates (Rhodes et al., 2007; Sumnall et al., 2005). A large proportion of those who stated the primary use of methadone stated the secondary use of heroin (n=490, 46.98%), suggesting the use of both illicit methadone and heroin amongst opiate users within the in-treatment population. There was also a strong interaction between the primary use of cannabis and cocaine, and secondary use of alcohol (62.88% and 43.71% respectively). The concomitant use of alcohol and cocaine poses significant health issues due to increased toxicity from the simultaneous use of these substances (EMCDDA, 2007). Only 6.38% (n=994) of individuals who stated heroin as a primary substance stated secondary use of alcohol. This is despite evidence of increased alcohol use amongst individuals in contact with structured drug treatment for opiate use (McCusker et al., 2001; Ryder et al., 2009). The low proportion of heroin users stating the secondary use of alcohol may be due to the high incidence of polydrug use, including crack and benzodiazepines amongst opiate users in treatment, resulting in an individual not being able to record all substance use within the three substance fields within NDTMS. Table 15: Primary and secondary substance profile of individuals in contact with treatment, 2008/09 Secondary Substance* Primary Substance Alcohol Amphetamines Benzodiazepines Cannabis Cocaine Crack Ecstasy Heroin Methadone Other Drugs Other Opiates Amphetamines Benzodiazepines Cannabis Cocaine Crack Ecstasy Heroin Methadone Other Opiates Other Drugs *Some substances may be stated as both primary and secondary substance due to the use of parent groups to describe a number of different substances 52

53 All stated substance use The following section details all stated substance use of those in contact with treatment, encompassing an individual s entire substance use profile (primary, secondary and tertiary substances). When all substance use was considered the proportion of individuals who stated the use of heroin increased to 66.18% (n=26696). Whilst only 2.89% of individuals stated the primary use of crack, this proportion rose to 25.80% when all substance use was considered, a proportion similar to the 2007/08 reporting year. This was followed by the use of cannabis (22.81%) and methadone (15.07%). Figure 17: All substance use of individuals in contact with treatment, 2008/09 70% 60% 50% PERCENTAGE (%) 40% 30% 20% 10% 0% Alcohol Amphetamines Benzodiazepines Canabis Cocaine Crack SUBSTANCE Ecstasy Heroin Methadone Other Opiates Other Drugs The stated substance use of individuals in contact with treatment was dependent on age. The vast majority of individuals aged under 18 stated the use of cannabis (n=2533, 94.27%), with a large proportion of this age group also stating alcohol as a substance (n=1414, 52.62%). In contrast only 13.42% (n=4496) of individuals aged 25 years and older stated the use of cannabis with 9.69% (n=3244) stating the use of alcohol. Only 1.08% (n=29) of under 18s stated the use of heroin, in contrast to 76.22% (n=25531) of those aged 25 and older. Table 16: All substance use by age group of individuals in contact with treatment (percentage), 2008/09 Substance Age bands (%) < Alcohol Amphetamines Benzodiazepines Cannabis Cocaine Crack Ecstasy Heroin Methadone Other Opiates Other Drugs

54 Figure 18: Proportion of substance use of individuals in contact with treatment, 2008/09 100% Alcohol Cannabis Cocaine Heroin 90% 80% 70% PERCENTAGE (%) 60% 50% 40% 30% 20% 10% 0% < AGE BANDS Substance use and ethnicity* A significantly greater proportion of clients identified as BME reported the use of crack cocaine (n=557, 32.03%) in comparison to those who stated their ethnicity as White (n=9775, 25.74%, X 2 = 34.22, p<0.01). A significantly higher proportion of those with a BME ethnicity status stated the use of cannabis (n=520, 29.90% of BME in contrast to n=8586, 22.61% of White, X 2 =50.10, p<0.01). In contrast, a significantly higher proportion of individuals who stated their ethnicity as White stated the use of heroin (n=25203, 66.36% of White, in contrast to n=1084, 62.33% of BME, X 2 =12.01, p<0.01). This is consistent with research that has found considerable variation in patterns of drug use between different ethnic groups (Bashford et al., 2003; Holloway & Bennett, 2008; Fountain, 2009 a, b, c, d) and suggests that different ethnicities may have diverse treatment needs resulting from differing patterns of drug misuse. Table 17: All substance use by ethnicity, 2008/09 Substance White BME Number % Number % Alcohol Amphetamines Benzodiazepines Cannabis Cocaine Crack Ecstasy Heroin Methadone Other Opiates Other Drugs *Ethnicity percentages calculated from total treatment population where ethnicity is stated 54

55 There were differences in the proportion of individuals stating the use of various substances dependent on geographical location of residence. For example, 41.91% (n=1998) of those in contact with treatment resident in Liverpool DAAT stated the use of crack cocaine. There was also high proportional use of crack amongst residents of Manchester DAAT (n=1515, 38.60%). In contrast, only 3.26% (n=63) resident in Cumbria DAT stated the use of crack cocaine. There was also a low stated use of powder cocaine in Cumbria DAT (n=135, 6.99%) in comparison to the regional average. Amongst Knowsley DAT residents, whilst only 49.14% (n=625) stated the use of heroin (regional average, 66.18%), 27.99% (n=356) stated the use of cocaine. Table 18: Stated substance use by D(A)AT of residence, 2008/09 D(A)AT of residence Alcohol Amphetamines Benzodiazepines Cannabis Cocaine Crack Ecstasy Heroin Methadone Other Opiates Other Drugs Blackburn with Darwen Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan and Leigh Wirral

56 Figure 19: Stated substance use by D(A)AT of residence, 2008/ Other Drugs Other Opiates 8000 Methadone NUMBER Heroin Ecstasy Crack Cocaine Cannabis Benzodiazepines Amphetamines Alcohol Blackburn Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan Wirral D(A)AT OF RESIDENCE Referral sources, modality types and treatment outcomes During 2008/09, each individual in treatment may have received more than one episode of care at one or more treatment agencies. In turn, each agency may have provided the individual with one or more modality of treatment. Therefore, to provide the fullest possible understanding of the ways in which people are referred into service, the types of interventions provided and the outcomes of individuals within services for each recorded episode are presented here. Referrals 12 In this section of the report, all episodes of treatment in 2008/09 are recorded, regardless of whether an individual entered on more than one occasion during the year (n=55988 including double counting). During 2008/09, the NTA introduced key amendments to the young persons NDTMS reference data. These modifications included changes and clarifications of referral sources. These changes came into effect in July Due to these modifications the following section has been divided into referrals into YP specific and adult drug treatment services. 12 For explanation and methodological notes please refer to the methodological section at the end of the report 56

57 Referral into YP specific services During 2008/09 there were 4443 episodes of treatment within YP specific services. Figure 20 displays the referral sources into treatment for YP specific agencies. Within the YP sector, the most common route into treatment was via Criminal Justice Services (CJS, n=1635, 37.02%). Figure 21 shows that there was variation in the proportion of individuals in contact with YP services who were referred via the CJS dependent on sex. Only 18.28% of females in contact with YP services were referred via the CJS in contrast to 43.90% of males. Figure 20: Referral source of those in contact with YP treatment providers, 2008/ % 1.61% Substance misuse services GP 7.06% 20.65% 17.30% 11.34% 37.02% Self CJS Hospital Mental health services Other 1.52% 0.41% Social Services Education and employment services Figure 21: Referral source of those in contact with YP treatment providers by sex, 2008/09 50% 45% 40% 35% Female Male 30% 25% 20% 15% 10% 5% 0% Substance misuse services GP Self CJS Hospital Mental health services Other Social Services Education and employment services PERCENTAGE (%) REFERRAL SOURCE 57

58 As demonstrated in figure 22, there were differences in the proportion of CJS referrals into YP services dependent on D(A)AT of residence. The vast majority of referrals into YP services in Cheshire and Liverpool D(A)ATs came from the CJS (82.95% and 66.58% respectively). In contrast, Bolton D(A)AT had only 8.85% of referrals into YP services from the CJS. Knowsley D(A)AT had a relatively high proportion of referrals from employment and education services (40.11%) in contrast to the regional average (20.65%). Stockport and Blackburn with Darwen D(A)ATs had high proportions of self referrals into YP treatment (35.05% and 25.00% respectively) in comparison to the regional average (11.34%). Figure 22: Referral source of those in contact with YP treatment providers by D(A)AT of residence, 2008/09 PERCENTAGE (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Substance misuse services GP Self CJS Hospital Mental health services Other Social Services Blackburn Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan Wirral Education and employment services D(A)AT OF RESIDENCE 58

59 Referral into adult specific services During 2008/09 there were episodes of treatment within adult drug treatment. Figure 23 displays referral sources into adult treatment for all episodes of treatment in 2008/09. In contrast to referral into YP specific services, the most common source of referral into adult treatment was via self referral (n=20437, 39.74%), with 21.63% of referrals from CJS. Figure 23: Referral source of those in contact with adult drug treatment, 2008/ % 7.52% 24.01% Substance misuse services GP 7.10% Self 39.74% CJS Other There were differences in the referral sources into adult treatment services dependent on D(A)AT of residence. For example, in Cheshire DAT, the majority of referrals into adult treatment were via self referral. In contrast, Sefton DAAT had a relatively low proportion of self referrals but a high proportion via substance misuse services (52.09%) when compared to the regional average (24.01%). Blackburn with Darwen, Bury and Trafford D(A)ATs had relatively high proportions of referrals from the CJS (41.69%, 35.71% and 35.46%) when compared to the regional average of 21.63%. Figure 24: Referral source of those in contact with adult drug treatment by D(A)AT of residence, 2008/09 100% 90% 80% Substance misuse services GP 70% Self PERCENTAGE (%) 60% 50% 40% 30% CJS Hospital Mental health services 20% 10% Other 0% Social Services Blackburn Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan Wirral Education and employment services D(A)AT OF RESIDENCE 59

60 Modalities of treatment 13 During 2008/09 a proportion of those in contact with treatment accessed numerous types of interventions (e.g. receiving a prescription and attending counselling). The following section details the modalities of treatment entered during 2008/09 (n=67685). According to NTA guidelines, young person s specific services have separate YP modalities of treatment. These YP modality codes for tier 3 and 4 modalities of treatment are only used in YP services, with adult services only using adult modality codes. Therefore, this section of the report has been divided between adult and YP modalities. In addition to adult and YP treatment modalities, some adult services in the North West offered alcohol treatment interventions in 2008/09. This section excludes alcohol modalities of treatment 14. YP modalities of treatment The majority of YP treatment modalities involved a YP psychosocial intervention. There has been a slight decrease in the number, and proportion of YP criminal justice intervention of treatment between 2007/08 (n=615, 11.61%) and 2008/09 (n=502, 8.54%). Very few YP modalities of treatment involved a specialist pharmacological intervention (n=93, 1.58%). Figure 25: YP treatment modalities, 2008/ % 1.58% 0.39% 20.87% 8.54% 64.97% YP psychosocial intervention YP harm reduction service YP criminal justice interventions YP family work YP specialist pharmacological interventions Other YP modalities of treatment Other YP modalities of treatment consist of YP shared care schemes; YP inpatient interventions; YP supported generic child care and YP residential rehabilitation 13 For explanation and methodological notes please refer to methodological section at end of report 14 For explanation and methodological notes please refer to methodological section at end of report 60

61 Adult treatment modalities Approximately half of adult treatment modalities involved a specialist prescribing intervention (n=30713, 50.40%). Whilst there has been an increase in the number of specialist prescribing modalities of treatment between 2007/08 and 2008/09, there has been a slight fall in the proportion of stated specialist prescribing modalities between the two years (2007/08 n=28141, 52.49%). Very few interventions involved a tier 4 modality of treatment (residential rehabilitation, 0.73%; inpatient treatment, 1.63%). Figure 26: Adult treatment modalities, 2008/ % 0.73% 19.01% Inpatient treatment Specialist prescribing 8.22% 6.63% 50.40% GP prescribing Structured psychosocial intervention 13.38% Structured day programme Residential rehabilitation Other structured intervention Modality Exit Status The modality exit status field was introduced to the NDTMS core dataset in 2007/08 to provide an indication of the reason for exit from a particular intervention of treatment. As an individual can have several modalities within one treatment episode, the modality exit status field can provide a more accurate indicator of outcomes within specific type of treatment in comparison to the discharge reason for the overall treatment episode. Table 19 shows the modality exit status for all adult treatment modalities ending during 2008/09. It shows that GP prescribing interventions of treatment were more likely to end with a mutually agreed planned exit (71.78%) in comparison to the overall regional average (62.25%). The proportion of GP prescribing interventions ending in a mutually agreed planned exit has grown in comparison to 2007/08, when the equivalent proportion was 60.99%. Residential rehabilitation interventions of treatment had a relatively large proportion of interventions withdrawn when compared to other modalities of treatment. Table 19: Modality exit status for all adult interventions, 2008/09 Modality Mutually agreed planned exit (%) Client s unilateral unplanned exit (%) Intervention withdrawn (%) Specialist prescribing GP prescribing Structured psychosocial intervention Structured day programme Other structured intervention Inpatient treatment Residential rehabilitation

62 Treatment outcomes The following section details the discharge reasons for individuals exiting their most recent episode of treatment. During 2008/09, there were key amendments made to the YP NDTMS dataset, including an expansion of discharge reasons within the YP sector to provide greater information on the type of service individuals were referred to. Due to the expansion in the number of discharge reason categories within the YP sector, all discharge information has been categorised into a smaller number of parent groups 15. Of the individuals in contact with treatment during 2008/09, (34.76%) were discharged from their most recent episode of treatment. As seen in figure 27, 39.49% (n=5537) of those exiting their most recent episode of treatment did so in a planned way. Of those with a planned exit, 2347 (42.39%) left having completed treatment drug free. Figure 27: Discharge reason for most recent episode of treatment, 2008/ % 13.16% 39.49% Planned Referred on 26.13% 14.60% Unplanned - dropped out Unplanned - prison Unplanned - other 15 For explanation and methodological notes please refer to methodological section at end of report 62

63 The proportion of individuals who were still engaged in their most recent episode of treatment at the end of the financial year varied dependent on D(A)AT of residence from 59.07% (n=534) in Bury DAT to 75.02% (n=1736) in Cheshire DAT (see figure 28). Figure 28: Proportion of individuals still engaged in their most recent episode of treatment by D(A)AT of residence, 2008/09 80% 70% 60% PERCENTAGE (%) 50% 40% 30% 20% 10% 0% Blackburn Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan Wirral D(A)AT OF RESIDENCE When only those discharged from treatment were considered, there were variations in the levels of planned and unplanned discharges dependent on D(A)AT of residence. Knowsley and Sefton D(A)ATs both had high levels of planned discharges (56.17% and 51.75%) in comparison to the regional average (39.49%). Bolton and Cheshire D(A)ATs had a high proportion of unplanned discharges to prison (11.31% and 11.76% respectively) in comparison to the regional average (6.62%). Figure 29: Discharge reason by D(A)AT of residence, 2008/09 100% 80% Planned PERCENTAGE (%) 60% 40% 20% Referred on Unplanned - dropped out Unplanned - prison Unplanned - other 0% Blackburn Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan Wirral D(A)AT OF RESIDENCE 63

64 SECTION THREE: Young People (under 18) in contact with structured drug and alcohol treatment 16 NDTMS was initially developed to collect data on adult substance misusers in contact with structured drug treatment services. Young Person (YP) treatment services have been required to submit NDTMS data that has been the same as the adult dataset until relatively recently. Since the introduction of NDTMS for YP services, adaptations have been made to the YP dataset to reflect the differing nature of service users and type of treatment within this field in comparison to the adult treatment sector. These amendments included the introduction of YP specific modality and referral source codes in 2007/08 and 2008/09. Unlike the adult treatment sector, YP services have been required to submit data on under 18s stating the primary use of alcohol since the commencement of YP data collection. Following extensive consultation with providers, commissioners, Government and regional NDTMS, considerable changes have been made to the YP dataset for the 2009/10 financial year. These changes have been made to reflect policy changes signposted in the new Drug Strategy, Drugs: Protecting families and communities. This revised data will provide information to local, regional and national PSA 14 boards on how the treatment system is helping to reduce harm arising from drug use; inform children s services, child and Young People s plans and Joint Strategic Needs Assessments; provide evidence on how the young person s treatment system is meeting local need. This amended YP dataset includes outcome measures for all young people, including under 16s. This section provides information on individuals aged under 18 in contact with structured drug and alcohol treatment in the North West in 2008/09. It provides information on the demographic profile, along with referral routes into treatment, the types of treatment entered by this group and the exit status upon leaving treatment. During 2008/09 there were 4586 individuals aged under 18 in drug and alcohol treatment. Whilst the majority of those aged under 18 were male (n=2925, 63.78%), this proportion was lower when compared to the overall number in drug treatment (n=29081, 72.09%). The majority stated their ethnicity as White (n=4025, 93.38%), a proportion lower than the overall in treatment population (95.62%). The vast majority were in contact with a YP specific service (n=4556, 99.35%) and were aged between 15 and 17 years (n=3462, 75.49%). 16 For explanation and methodological notes please refer to the methodological section at the end of the report 64

65 Table 20: Under 18s in contact with drug and alcohol treatment by D(A)AT of residence, 2008/09 D(A)AT of residence Individuals % Blackburn with Darwen Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan and Leigh Wirral Total* *The regional total does not equal the sum of the D(A)AT figures as some individuals may have been resident in more than one D(A)AT area during the financial year but are only counted once in the regional figure. 65

66 Figure 30: Prevalence levels for the number of year olds in contact with drug and alcohol treatment per 1,000 population by D(A)AT of residence, 2008/09 Prevalence (10-17 years) per 1,000 population (D(A)AT of residence)

67 Table 21 displays the sex and ethnicity of all YP in contact with drug and alcohol treatment by D(A)AT of residence. There were differences in the proportion of males aged under 18 in treatment dependent on D(A)AT of residence. Whilst 81.37% of individuals in Salford DAAT aged under 18 were male, less than half of those in this age group in Tameside DAT were male (47.97%). This is in contrast to the total in treatment population in Tameside DAT which had a proportion of males of 71.95%. Virtually all D(A)AT areas had a higher proportion of females aged under 18 in contact with drug and alcohol treatment in contrast to the overall in treatment population. The greater proportion of females in this age group in comparison to the overall treatment population may indicate a possible increase in the number, and proportion of female drug and alcohol users entering adult treatment in future years as these females in young people s treatment services move into the adult treatment sector. According to table 21, the provision of treatment for females may be of greater importance to some D(A)AT areas in comparison to others. There were also differences in the proportion of BME in contact with treatment in certain D(A)AT areas dependent on age. For example, in Blackburn with Darwen and Liverpool DAAT areas, there were a greater proportion of BME aged under 18 in contact with treatment (11.85% and 8.39% respectively) when compared to their overall in treatment population (6.64% and 3.84% respectively). Table 21: Sex and ethnicity of individuals under 18 in contact with drug and alcohol treatment, 2008/09 D(A)AT of residence Male % White % Blackburn with Darwen Blackpool Bolton Bury Cheshire Cumbria Halton Knowsley Lancashire Liverpool Manchester Oldham Rochdale Salford Sefton St Helens Stockport Tameside Trafford Warrington Wigan and Leigh Wirral Total* *The regional total does not equal the sum of the D(A)AT figures as some individuals may have been resident in more than one D(A)AT area during the financial year. 67

68 Over half of young people (aged under 18) in contact with drug and alcohol treatment stated the primary use of cannabis (n=2594, 56.56%), a proportion slightly higher than the national average of under 18s in contact with drug and alcohol treatment in 2007/08 (51%, see NTA, 2009a). This was followed by the primary use of alcohol (n=1581, 34.47%), displaying the dominance of cannabis and alcohol amongst young person s services. Whilst nationally in 2007/08, the primary use of heroin and crack for under 18s was 3% and 1% respectively (NTA, 2009a), in the North West during 2008/09, the proportionate use of these drugs was only 0.63% and 0.35% respectively (see table 22). The primary use of cocaine in this age group in the North West in 2008/09 (n=200, 4.36%) was slightly higher than the national average in 2007/08 (3%, NTA, 2009a). Table 22: Primary, secondary and tertiary substances for under 18s in contact with drug and alcohol treatment, 2008/09 Substance Primary Substance Secondary Substance** Tertiary Substance*** Number % Number % Number % Alcohol Amphetamines Benzodiazepines Cannabis Cocaine Crack Ecstasy Heroin Solvents Other Drugs Total* *Percentages total over 100% due to rounding **Percentages calculated for those who stated a secondary substance ***Percentages calculated for those who stated a tertiary substance 68

69 In contrast to the overall treatment population, the majority of under 18s in contact with drug and alcohol treatment were discharged from their most recent episode (n=2760, 60.18%). When only those discharged from their most recent episode of treatment were considered, the majority of under 18s were discharged in a planned way (n=1829, 66.27%). In contrast, only 39.49% of the total treatment population discharged from their most recent episode of treatment had a planned exit (see figure 32). Very few under 18s were referred on from their most recent episode (3.04%) in comparison to the overall treatment population (14.60%). There were also a low proportion of unplanned discharges to prison amongst those under 18s (n=60, 2.17%). Figure 31: Discharge reason for under 18s in contact with drug and alcohol treatment, 2008/ % 13.77% Planned 14.75% 66.27% Referred on Unplanned - dropped out Unplanned - prison Unplanned - other 3.04% Figure 32: Discharge reason for under 18s in contact with drug and alcohol treatment and all those in drug treatment, 2008/09 70% Under 18s All drug treatment 60% 50% PERCENTAGE (%) 40% 30% 20% 10% 0% Planned Referred on Unplanned - dropped out Unplanned - prison Unplanned - other DISCHARGE REASON 69

70 SECTION FOUR: Individuals in contact with structured alcohol treatment In April 2008, the National Treatment Agency (NTA) expanded NDTMS to collect tier 3 and 4 alcohol data from alcohol treatment agencies across the North West (as defined by Models of Care [NTA, 2002 and 2006] see for further details). The data collection does not include tier 2 and unstructured alcohol treatment (e.g. AA), or treatment in other parts of the NHS for secondary complications arising out of the misuse of alcohol (e.g. treatment for liver disease). This section details the demographic profile of all individuals in alcohol treatment, whilst also providing information on prevalence for the number of individuals accessing alcohol treatment in the North West by Primary Care Trust (PCT). Regional results During 2008/09 there were individuals in contact with structured alcohol treatment in the North West of England. During 2008/09 the North West had a prevalence rate of 4.28 (per 1,000 population, aged 15-64). Variations between local areas within the region Table 23 displays the number of individuals in contact with structured alcohol treatment during 2008/09 by PCT of residence. There were considerable variations dependent on PCT of residence, ranging from 407 (1.98%) in Bury to 1913 (9.33%) in Manchester PCT. 70

71 Table 23: Number of individuals in contact with alcohol treatment and prevalence rates by PCT of residence, 2008/09 PCT of Residence Individuals No. % Prevalence Age per 1,000 population Ashton, Leigh & Wigan Blackburn with Darwen Blackpool Bolton Bury Central & Eastern Cheshire Central Lancashire Cumbria East Lancashire Halton & St Helens Heywood, Middleton & Rochdale Knowsley Liverpool Manchester North Lancashire Oldham Salford Sefton Stockport Tameside & Glossop Trafford Warrington Western Cheshire Wirral Total* *The regional total does not equal the sum of the PCT figures as some individuals may have been resident in more than one PCT area during the financial year but are only counted once in the regional figure. Table 23 also shows the prevalence rate per 1,000 population (of those in treatment aged 15-64). Prevalence rates varied across PCTs ranging from 2.59 in Central Lancashire PCT to 7.12 in Wirral PCT. Prevalence by postcode area Levels of deprivation vary between PCT areas; some PCTs contain areas with high levels of deprivations, such as housing problems. There are differences in the health consequences of alcohol use between richer and poorer local communities across all regions of England (APHO, 2008) with the poorest local authorities (highest measures of multiple deprivation) tending to have the highest recorded levels of health and social outcomes related to alcohol use (AHPO, 2008). Therefore, numbers and prevalence levels of those in contact with treatment per 1,000 population in all North West postcode areas has been included in this section of the report. 71

72 Figure 33: Number of year olds in contact with alcohol treatment per 1,000 population of postcode districts, with PCT boundaries overlaid, 2008/09 Postcode prevalence (15-64 years) per 1,000 population Figure 33 illustrates the number of people per 1,000 population (aged 15-64) from each postcode district (e.g. L1 or FY8) in the region in contact with treatment services during 2008/09. The highest concentrations of individuals were found in the postcode district of CH41 in the Birkenhead area of Wirral (25.08 per 1,000 population). This postcode also had the highest prevalence rate for drug treatment services (73.20 per 1,000 population). High prevalence rates were also found in the CH43 district of Wirral (12.97 per 1,000 population). 72