Cambridgeshire Drug and Alcohol Action Team Needs Assessment

Transcription

1 Cambridgeshire Drug and Alcohol Action Team Needs Assessment This report covers the: Adult drug needs assessment Adult alcohol needs assessment Young people s substance misuse needs assessment January

2 CONTENTS EXECUTIVE SUMMARY 5 A DRUG TREATMENT BACKGROUND What is drug dependency? Risks to health Prevalence and cost of drug misuse Why invest in drug treatment? The impact of drug treatment on reconviction Trends in drug use over the last ten years THE CAMBRIDGESHIRE PICTURE Prevalence: How widespread is drug dependency in Cambridgeshire CAMBRIDGESHIRE DRUG TREATMENT ACTIVITY Service provision Client numbers in treatment Substance misusing parents Criminal Justice Cambridgeshire activity compared with cluster group 14 B ALCOHOL TREATMENT BACKGROUND What is alcohol misuse? Risks to health Prevalence and cost of alcohol misuse Why invest in alcohol treatment? THE CAMBRIDGESHIRE PICTURE Prevalence: How widespread is alcohol misuse in Cambridgeshire? Health impacts Alcohol specific and related hospital admissions Mortality CAMBRIDGESHIRE ALCOHOL TREATMENT ACTIVITY Service provision Cambridgeshire alcohol treatment data Prevention and early intervention work Detoxification treatment Community detoxes Inpatient detox Substance misusing parents Criminal Justice Licensing issues Cambridgeshire activity compared with the East of England 24 C YOUNG PEOPLE S SUBSTANCE MISUSE TREATMENT BACKGROUND Why do young people misuse and drugs and alcohol? 26 2

3 1.2 Prevalence and cost of young people s substance misuse THE CAMBRIDGESHIRE PICTURE How widespread is substance misuse in Cambridgeshire? CAMBRIDGESHIRE YOUNG PEOPLE S TREATMENT ACTIVITY Service provision Cambridgeshire Young People s treatment data Hospital admissions Multiple vulnerabilities Professionals view of the treatment service 34 D CROSS CUTTING THEMES Substance misusing parents Local response Prevention and Early Intervention Local response Emergence of Novel Psychoactive Substances Local response Harm reduction Local response Transitions from young people s services to adult services Local response Older people in treatment Local response Victims of domestic abuse Local response Support for recovery Accommodation Local response Mental health Local response Education, employment and training Recovery Champions Families and carers Local response 44 E CONSULTATIONS Novel Psychoactive Substances and Club Drugs Key findings of the consultation Recommendations from the consultation Service user consultation Key findings of the consultation Recommendations from the consultation 46 APPENDICES 47 Appendix 1: Service user consultation 47 Appendix 2: Novel Psychoactive Substances and Club Drugs 50 Appendix 3: Cambridgeshire Constabulary Criminal Justice data 53 Appendix 4: START Criminal Justice referrals 59 3

4 How to read this report This report is an update on the 2012 Needs Assessments an update because in the summer of 2015, a Joint Strategic Needs Assessment will be undertaken that will investigate and analyse data in depth. As an interim measure, this report provides up to date information. Data used is 2013/14 unless otherwise indicated and from: Diagnostic Outcomes Monitoring Executive Summary Quarter 4, 2013/14 Public Health England Adult partnership quarterly performance report 2013/14 Quarter 4 Public Health England (green report) drugs Adult partnership quarterly performance report 2013/14 Quarter 4 (NDTMS) Public Health England (purple report) alcohol Young people quarterly activity report 2013/14 Quarter 4 Public Health England Up until now, the Drug and Alcohol Action Team (DAAT) has produced three separate needs assessments to cover drug, alcohol and young people s treatment. This year however, the three have been combined and shortened. Drug treatment, alcohol treatment and young people have a section each, but then cross-cutting themes that apply to them all are presented in section D. 4

5 EXECUTIVE SUMMARY Key points: DRUG MISUSE a. Numbers in treatment: 1,423 clients were engaged in effective treatment in 2013/14, with the main age bands being years. This is a slight increase on last year. b. Opiate/ crack misusers: 83% of adults in treatment are opiate and/or crack cocaine misusers and clients in long term treatment are predominantly opiate users; 23% of all clients in service have been in treatment between 4-6 years. (This is 3% with non opiates) c. Injectors: 91 clients reported injecting at the start of treatment a drop from 126 last year. d. Successful completions: Successful completions were 13% - a slight increase from 11% last year. In addition, successful completions against PHE 2.15 has finally shown significant improvement to reach the national average. Significant progress has been made with performance against PHE indicator 2.15 drug users that left treatment successfully who do not present within sixth months as the national average has been reached following previous poor performance. e. Drug related deaths: The drug related death rate in Cambs is the lowest in the region. f. Drug Rehabilitation Requirements: DRR completion rates are currently exceeding targets. Key points: ALCOHOL MISUSE a. Prevalence: Synthetic estimates of prevalence suggest that in Cambridgeshire, 26% of men and 17% of women drink over government guidelines. b. District hospital and death rates: Districts with highest rates of drinking, hospital admissions and deaths include: Huntingdonshire (drinking levels), Cambridge (alcohol specific hospital admissions), Fenland alcohol related hospital admissions, Cambridge and Huntingdonshire (alcohol specific deaths) and Cambridge and Fenland (alcohol related deaths). c. Numbers in treatment: Numbers of alcohol misusers in treatment have risen to 720 (from 622). 59% of all clients in treatment were new presentations. The main age bands in treatment were Half of referrals were from self, family and friends. This is an indication of the hard work the service has put into publicising what it does and how to access treatment. d. Duration of treatment: Time in treatment is significantly higher than the national average. e. Successful Completions: 38% successfully completed treatment - similar to national averages. f. Hospital initiatives: Designated hospital liaison workers are now employed by Addenbrookes and Inclusion to encourage identified patients to link with community based treatment. g. Community detox: Community detoxes remain static, with work underway to identify how to maximise this treatment within NICE guidelines. Negotiations are under way to allocate a house for hostel clients to reside in post detox to mitigate against relapse. This may help with increasing numbers of detoxes undertaken in the community. 5

6 Key points: YOUNG PEOPLE S SUBSTANCE MISUSE a. Numbers in treatment: 223 young people (similar to last year) were in treatment. b. New clients: There were 146 presentations. Half were from Education and Children and Families - an indication of the work CASUS has undertaken with schools and departments. c. Substances used: The main substances misused continue to be cannabis and alcohol with the main age band presenting being year olds. Despite indications of the stabilising and in some areas decreasing in young people s drinking 1, there is still concern about a small but significant number of young people drinking to excess. Figures for alcohol specific hospital admissions show the highest rates for Cambridge equalling the national average. d. Planned exits: There has been a significant increase in young people leaving treatment in a planned way 92% (compared with 75% last year). The service has worked particularly hard to achieve this and ensure that young people know that they can return at any time. e. Multiple needs: Whilst young people in treatment tend to be complex with multiple needs, data appears to under report this. What is of note is that there are significantly more young people than national averages engaged with Cambridgeshire Child and Adolescent Substance Use Service (CASUS) who are Looked After Children (LAC) or Not in Education, Employment or Training (NEET). For eg., 8% of the treatment population were Independent Looked After Children ; this is a particularly vulnerable group. Key points: CROSS CUTTING THEMES a. Children of substance misusing parents: Snapshot data from the drug and alcohol treatment services in 2014 showed that there were a total of 646 children living with 365 substance misusing parents in treatment; there are concerns that these children may be hidden and their needs not met. However, new roles of child link worker posts at Inclusion, and a worker at CASUS to encourage young carers to access support are in place, but the numbers involved highlights the need for maintained and monitored provision to meet the needs of this vulnerable group. b. Prevention/ Early Interventions: Preventative interventions and early intervention work continue, but there remain issues with numbers of young people and adults hospitalised due to alcohol misuse. c. Novel Psychoactive Substances :(NPS also known as legal highs/club drugs) is of concern nationally, but local figures are not yet showing similar trends; however a local strategy has been agreed between the DAAT and the Safer Peterborough Partnership on how to proceed. In addition, a recent survey has been conducted to ascertain legal high use, and the situation is being closely monitored. 1 Balding Report Cambridgeshire Safer Communities Partnership (July 2013) The Health Related Behaviour Survey; a ten year analysis of trends. Drug and Alcohol section

7 d. Mental health: It is well known among all partner agencies that a significant number of substance misusers have mental health issues. However, there are continued difficulties with accessing data to support this situation. This means that potential service delivery and improvements are hampered by lack of data. e. Support for recovery: Work continues to build a recovery community in Cambridgeshire to support the long term recovery of service users. The new post detox house for hostel residents who have undergone community based detox will increase chances of maintaining abstinence. In addition, accommodation for ex-offenders has been commissioned for Cambridge and Huntingdon. RECOMMENDATIONS Drug and alcohol misuse Successful completions: Ongoing efforts are required to ensure successful completions occur for as many opiate users as is appropriate. This must not be at the expense of non OCU clients who also require ongoing monitoring to ensure the best possible chances of successful completion. Service provision needs reviewing to understand why alcohol clients are staying longer in treatment than national averages. BBV s: Continued focus is required both on testing and provision of vaccinations as a contractual requirement Community detoxes: Work is required to agree how to maximize community detoxes whilst remaining within NICE guidelines. Cross cutting themes Children of substance misusing parents/carers: The potential needs of this group and their parents/carers should be responded to with greater partnership working and joint, family based interventions to ensure that vulnerabilities are addressed and the cycle of inter-generational substance misuse is broken. Prevention/ Early Interventions: Continued targeting and delivery of services needs to aim to reduce the prevalence of substance misuse. This includes alcohol awareness and continued delivery of brief intervention work is to bring down the rates of alcohol related and specific hospital admissions and deaths that are in some cases above national levels in Huntingdonshire, Cambridge and Fenland. Health education is required to target communities of young drinkers who are defying the general trend of a reduction in alcohol misuse. NPS: Continual monitoring is required to ensure that health education and service response is able to identify and meet the needs of NPS users should they become apparent. Mental health: The partnership needs to ensure that data is gathered on substance misusers with mental health needs undiagnosed aswell as diagnosed, in order to deliver services based on quantitative data rather than anecdote. 7

8 Support for Recovery: The partnership needs to continue to plan and deliver a recovery community for Cambridgeshire residents post treatment, who require longer term support. 8

9 A. DRUG TREATMENT 1.0 BACKGROUND 1.1 What is drug dependency? A drug is a chemical substance that acts on the brain and nervous system, changing a person s mood, emotion or state of consciousness. Drugs can be broadly divided into three categories based on their main effects. They may act solely as stimulants, as depressants or as hallucinogens (aka psychedelics). 2 Dependency describes a compulsion to continue taking a drug in order to feel good or to avoid feeling bad. This can be either physical or psychological or both. Physical dependence: This is when someone has taken drugs for a time and comes to rely on the use of them in order to feel well and for their body to function 'normally'. In its absence, physical withdrawal symptoms appear. This mainly occurs with depressant drugs such as alcohol, barbiturates, heroin or tranquillisers. Psychological dependence: This is when the user experiences an overwhelming desire to continue with the drug experience. This can be because of the pleasurable effects and the desire to keep experiencing them. It can, however, also represent some sort of psychological crutch Risks to health As well as addiction, drug misuse has serious health risks and is associated with a wide range of conditions and complications. For example, cocaine can cause heart failure and heroin can cause respiratory failure (loss of normal lung function), both of which can be fatal. Drug poisoning deaths: In England and Wales, the number of deaths related to drug poisoning registered in 2013 was 2,955 (2,032 male, 923 female). 4 This involved both legal and illegal drugs and shows an increase of 19% in male deaths compared with Heroin and morphine are the drugs most commonly involved. Overdose and infection: Drug use is linked with risks such as accidents while someone is intoxicated, overdose, or infection from sharing injecting equipment. The Department of Health estimates that, in England, 90% of all cases of hepatitis C and 6% of all HIV cases are caused by injecting drugs Prevalence and cost of drug misuse 6 Figures from Public Health England report that 2.7 million adults used an illegal drug in the last year. Of this number, 294,000 were heroin and crack users. An estimated 1,200,000 individuals are affected by drug addiction in their families mostly in poor communities. The cost of drug addiction is therefore huge with estimated costs to society per year of over 15 billion pounds. The following key figures show the extent of this per year: Advisory Council on the Misuse of Drugs. The primary prevention of hepatitis C among injecting drug users 6 Figures extracted from Public Health England (2014) Alcohol and drugs prevention, treatment and recovery: why invest?. 9

10 Crime: A heroin or crack user not in treatment commits crime costing on average 26,074. Health: Drug misuse costs the NHS in England 488 million. Children: The cost of looking after drug using parents children who have been taken into care is 42.5 million. Figure 1: The annual cost of drug addiction Why invest in drug treatment? Spending on drug treatment is reported to lead to a wide range of benefits including: 8 Making communities safer by reducing crime, drug litter and street prostitution and troubled families stabilised. Protecting public health by preventing drug-related deaths, restricting blood-borne viruses (HIV, hepatitis C) and reducing the burden on the NHS. Helping drug users overcome addiction: For example, 366,200 adults have been treated for drug addiction in England since 2005, 29% left free of addiction and 35% are still being treated. In actual cost terms, it is calculated 9 that: Every 1 spent on drug treatment saves 2.50 in costs to society. Drug treatment prevents and estimated 4.9 million crimes per year. Treatment saves an estimated 960 million costs to the public, businesses, criminal justice and the NHS The impact of drug treatment on reconviction Detailed findings from the study, The Impact of Drug Treatment on Reconviction 10, showed that: 7 Public Health England (2014) Alcohol and drugs prevention, treatment and recovery: why invest? 8 NTA (Why invest: How drug treatment and recovery services work for individuals, communities and society 9 Figures extracted from Public Health England (2014) Alcohol and drugs prevention, treatment and recovery: why invest?. 10

11 Individuals who successfully completed a drug treatment programme after at least six months reduced their convictions by 48%. Individuals retained in treatment for the entire two-year research period reduced their convictions by 47%. The most dramatic falls in convictions were for soliciting (59%), and fraud or forgery (57%). The biggest single reduction in offences was almost 11,000 fewer thefts, a 24% fall. Heroin and crack addicts were twice as likely to have convictions before treatment than other drug users Trends in drug use over the last ten years. The following diagram shows significant reductions in any drug for young people in the long term, but a sharp increase over the last year. Despite slight falls over the long term, both Class A use with young people and any drug for all ages are showing increases. Class A use over all ages shows little change. The argument for continued funding for treatment remains as important as ever. Figure 2: Trends in illicit drug use (excluding mephedrone) in the last year among adults, by age group, 1996 to 2013 to 2014, Crime Survey for England and Wales

12 2.0 THE CAMBRIDGESHIRE PICTURE 2.1 Prevalence: How widespread is drug dependency in Cambridgeshire? 11 Estimates of Class A misuse: The estimated rate per 1,000 population of opiate and crack users (OCU) is 5.3, 12 less than the national average rate of 8.7. This means that an estimated 57.5% of opiate and crack users are in treatment; this is a higher penetration rate than the 52.3% national figure and means that Cambridgeshire is reaching more Class A users. What drug use has risen most? Trends of drugs use in Cambridgeshire over the last 10 years indicate that overall, the use of opiates, crack cocaine and cocaine, whilst still rising, is showing small increases whereas cannabis is exhibiting a steeper recent rise. Alcohol consumption has decreased slightly CAMBRIDGESHIRE DRUG TREATMENT ACTIVITY 3.1 Service provision Inclusion run the community based drug treatment service in Cambridgeshire from five sites: these are based in Cambridge, Wisbech, Huntingdon, St Neots and Ely. 3.2 Client numbers in treatment In 2013/14, there were 1,423 clients in effective treatment, which is slightly higher than the previous year of 1,392 clients. In early summer of 2013 the Cambridge based service moved site to an area that was shown on a mapping exercise to be the area of residence for a high proportion of service users. This geographical placing, along with the building offering much improved space and facilities may have contributed to this increase in clients. The following data gives further details: New treatment journeys: 487 clients engaged in effective treatment (some of these may have been re-presenting in treatment). This is almost the same as the previous year. Client characteristics o Gender: Whilst just under half of Cambridgeshire s population are male, the percentage of men in treatment is far higher at 70%. This indicates that males are over-represented in the treatment system and more work needs to be done to attract females into treatment. o Ethnicity: 92% of Cambridgeshire s population aged are of White ethnicity compared with 89% of the DAAT s adult clients in structured drug treatment. o Age: The age bands with the most clients represented are (20%) and (19%). o Accommodation: 79 clients in treatment journeys had urgent housing needs. This is an increase from 69 in the previous year. Opiate/ crack misusers: 269 of Cambridgeshire s adult drug clients are opiate and/or crack cocaine users (OCUs), which represents 83% of all adult clients in structured drug treatment. This is a considerable drop from 361 (73%) last year. This may mean that the cohort of opiate/ 11 Cambridgeshire has a total population of 632,095. For all ages (0-90) 315,136 are male and 316,959 are female. 92.3% of the population are classed as White British. This is consistent in all districts apart from Cambridge where it is 82.4%. 12 Diagnostic Outcomes Monitoring Executive Summary Quarter 4, 2013/14 Public Health England 13 Public Health England (NDTMS data provided for needs assessments) 12

13 crack cocaine users are moving through the system for a variety of reasons (successful outcomes or death in some cases) and there are fewer new opiate and crack cocaine users requiring treatment. This will in time alter the profile of treatment required. Injecting drug misusers: 91 clients (18%) reported injecting at the start of new treatment journeys. This is a decrease since last year from 126. Of interest is the data that at the sixth month review point in treatment, 40% of this cohort reported that they had ceased injecting. Successful completions: 13% of all those in treatment left with a successfully planned discharge. This is a slight improvement from 11% last year. Public Health Indicator 2.15: This measures the Number of drug users that left drug treatment successfully (free of drug(s) of dependence) who do not then represent to treatment again within six months as a proportion of the total number in treatment. At the year end, for opiate and non-opiate users, Cambridgeshire was similar to the national average. This is a significant improvement on previous years. For opiates, the 2012 baseline was set at 5.8% and national average was then 6.6%. Now, local is 7.5% and national is 7.8%. The services have worked particularly hard at going through all case files, identifying any clients on their caseload who needed extra attention to reduce already low dose scripts or treatment interventions. This has resulted in a number of the stuck cohort being able to successfully leave treatment. Of course, there are still a proportion of long term clients; the paragraph and table following summarises the current situation. Clients in long term treatment: Over recent years, there has been national concern at the length of time some substance misusers remain in treatment. Despite the roll out of the Recovery Agenda that seeks to promote a care planned goal of recovery, opiate users are by far the most prevalent group who remain in treatment longer term. Time in treatment Opiates 2013/14 Non opiates 2013/14 (% of all clients in treatment) Between 2-4 years 16.9% 7% Between 4-6 years 23% 3% 2012/13 combined was 19% 6 years + 22% 1% 2012/13 combined was 17% Average years in treatment 4.1 years 0.9 years Figure 3: Time in treatment 2013/14 The above table shows the significant difference between opiate and non-opiate users, especially after four years; this has considerable impact for service planning and resources. However, the increase in successful completions shows that continued attention by the service can and is making a difference. Residential rehabilitation: 15 individuals attended residential rehabilitation for drug treatment, or 1% of the treatment numbers. Last year saw an increase in applications from 14 to 19, and an increase in successful completions. However, the number of individuals in residential rehab is still below the national average of 5% of the total drug (and alcohol) treatment population. 13

14 Currently the pre-rehab groups run in each district as preparation groups. Numbers are approximately 8-10 per district. Harm reduction: (See also Cross Cutting Themes) In Cambridgeshire, the treatment service is aware that a high number of new clients agree to vaccinations, but a low number actually arrive at appointments later. In Wisbech, the service is piloting a new way of working which delivers vaccinations at the same time as assessment or very close. In addition, there is a reporting issue; at assessment, the client is recorded as not accepting vaccination this is only changed when, at appointments with the BV nurse, they accept the vaccination. This is the opposite way round to many other agencies; the DAAT will be reverting to their previous recording system next year. For this reason, the data is as follows: 7% of eligible presentations accept Hep B vaccinations (against 43% nationally). However, 33% of this proportion then started a course of vaccination higher than the national average of 20%. Drug related deaths: Cambridgeshire has a drug-related death rate of 0.19 per 100,000 and the lowest in the East of England. It also shows a fall from 2.7 in Substance misusing parents/carers (See also Cross Cutting Themes) Nationally, the percentage of drug misusers who have children living with them ranges from 8% of opiate users in treatment to 42% of all non-opiate users in treatment. The repercussions of this can be severe; for example, parental drug us is a risk in 29% of all serious case reviews. 15 However, these figures may be misrepresentative for opiate users in particular; changes in circumstances- such as stability in treatment meaning that they can be re-united with children, but this may not have been recorded during their longer treatment journey. A snapshot survey undertaken in July 2014 by the substance misuse agencies reported that 365 adults in treatment were parents who between them, had a total of 646 children living with them. In Cambridgeshire, the number of opiate users (recorded at successful completion point) living with children was 9.4%. This is similar to last year. The figure for non-opiate users living with children is much higher at 34% and shows an increase since last year from 27.4% but is much lower than the national average of 42%. 3.4 Criminal Justice 16 Start specific criminal justice service: Inclusion, the treatment service has a specific service Start for clients involved in the criminal justice system. The caseload has remained static over the last five years at approximately 225 clients per year. Whilst the service is predominantly for drug misusers, if a person presents with a primary alcohol problem, they will be triaged; if they have high needs, they 14 St George s, University of London (2013) Drug related deaths in the UK: January December Figures extracted from Public Health England (2014) Alcohol and drugs prevention, treatment and recovery: why invest? 16 Criminal justice data, provided by Cambridgeshire constabulary available at Appendix 3 14

15 will be referred to the alcohol service, but will remain with Start if their needs are lower and require no clinical interventions. In such cases, IBA will be delivered. Drug Rehabilitation Requirements: Inclusion deliver the DRR programme with an expectation of 93 commencements per year. Probation set a target of a 45% completion rate; this is currently being exceeded at 53%. All DRR clients are encouraged to continue to engage with the service on completion of their DRRs to ensure that treatment needs are met. Prison community interface: Inclusion have a designated prison inreach worker who liaises with all prisons where any Cambridgeshire residents are in custody who have drug and/or alcohol problems and require treatment on release. This predominantly means HMP Peterborough where the worker will visit all such prisoners. The aim of this role is to ensure smooth transitions from prison based to community based substance misuse services, and thus prevent dis-engagement with treatment and re-offending. Approximately 37 individuals per month are referred from prisons to the community treatment service predominantly for drug treatment. 3.5 Cambridgeshire activity compared with cluster group For 2012/13, the rate of adults in structured drug treatment in the region was as follows: 17 Cambridgeshire was 3.3 per 1,000. The area with the highest rate is Peterborough at 7.9 and lowest is Hertfordshire at 2.8. The total East of England average is 4.2 per 1,000 population. Key findings: Drugs Last year, an estimated 2.7 million adults in England used an illegal drug; 294,000 were heroin and crack users. 18 The annual cost amounts to 15.4 billion. There have been increases since last year on the use of any drug and Class A drugs. Cambridgeshire a. The estimated rate per 1,000 population of opiate and crack users is 5.3. This equates to 57.5% of such users being in treatment a higher rate than the national 52% figure. 19 b clients engaged in effective treatment, with the main age bands being years. There has been an increase in clients reporting urgent housing need at the commencement of treatment. c. 83% of adults in treatment are opiate and/or crack cocaine misusers d. 91 clients reported injecting at the start of treatment a significant drop from 126 last year. e. Successful completions were 13% - a very slight increase from 11% last year. In addition, successful completions against PHE 2.15 has finally shown significant improvement to finally reach the national average Public Health England (2014) Alcohol and drugs prevention, treatment and recovery: why invest? Diagnostic Outcomes Monitoring Executive Summary Quarter 4, 2013/14 Public Health England 15

16 f. Significant progress has been made with performance against PHE indicator 2.15 drug users that left treatment successfully who do not present within sixth months as the county has now reached the national average following previous poor performance. g. Clients in long term treatment are predominantly opiate users; 23% of all clients in service have been in treatment between 4-6 years. (This is 3% with non opiates) h. Harm reduction data is particularly low against national averages, but a pilot is introducing a change in practice to start vaccinations immediately, thus avoiding the drop out caused by waiting for further appointments. i. The drug related death rate in Cambs is the lowest in the region. 20 j. DRR completion rates are currently exceeding targets. 20 St George s, University of London (2013) Drug related deaths in the UK: January December

17 B. ALCOHOL TREATMENT 1.0 BACKGROUND 1.1 What is alcohol misuse? Alcohol use is categorised in various ways that denote risk. These are as follows: Categorisation by units per day: This uses daily limits 21 as an indicator of risk, with recommended maximum daily limits for alcohol intake are 3-4 units per day for men and 2-3 units for women. Based on this: Hazardous drinking- is above recommended limits but not yet experiencing harm (AUDIT 8-15) Harmful drinking is above recommended limits and experiencing harm (AUDIT score 16-19) Binge drinking is drinking over double the daily recommended level in one day. Alcohol dependence - is drinking at a level that causes harm and symptoms of dependency (AUDIT 20+) A unit of alcohol 22 is 10 ml of pure alcohol. An average adult takes about one hour to process one unit resulting in no alcohol left in their bloodstream. AUDIT 23 (Alcohol Use Disorders Identification Test) is the tool used by the World Health Organisation to screen and identify people who are at risk of developing alcohol problems. Of note is the issue that defining a person s units relies on self-report. Research 24 indicates that both adults and young people tend to underestimate the amount of alcohol they have consumed, and what a unit comprises of. 1.2 Risks to health Current data 25 estimates that 9 million adults in England drink at levels that increase the risk of harm to their health. Of this number, 1.6 million show some kinds of alcohol dependence. This equates to alcohol being the third biggest risk factor for illness and death in this country. Health effects can include heart disease, stroke, liver cirrhosis and cancer, high blood pressure, reduced fertility, cancers of the mouth, throat, oesophagus, breast cancer in women and harm to unborn babies. Alcohol related deaths: in England, 21,485 people died from alcohol-related causes in This includes a doubling of alcohol-related liver disease since A quarter of all deaths among young men aged are attributable to alcohol Boniface S, Kneale J, Shelton N (2012) Actual and Perceived Units of Alcohol in a Self-Defined "Usual Glass" of Alcoholic Drinks in England Alcoholism: Clinical and Experimental Research. de Visser, Richard O and Birch, Julian D (2012) My cup runneth over: young people's lack of knowledge of low-risk drinking guidelines. Drug and Alcohol Review, 31 (2) pp ISSN Figures extracted from Public Health England (2014) Alcohol and drugs prevention, treatment and recovery: why invest?. 17

18 1.3 Prevalence and cost of alcohol misuse 26 Evidence from Public Health England cite harms of alcohol misuse; they include almost half of all violent assaults, a significant contributory factor in domestic violence and marital breakdown and physical, psychological and behavioural problems for children of alcohol misusing parents. In addition, 13% of all road fatalities are alcohol related. The following costs show the enormity of the problem: The overall cost to society is estimated at 21 billion. Crime: 11bn per year in crime costs. Health: 3.5bn cost to the NHS. Productivity: 7bn in lost productivity Why invest in alcohol treatment? Evidence suggests 27 that investing in alcohol treatment can have the following outcomes: Screening: Every 5,000 patients screened in primary care may prevent 67 A&E visits and 61 hospital admissions. This costs 25,000 as saves 90,000. Liaison nurses: One alcohol liaison nurse can prevent 97 A&E visits and 57 hospital admissions. This costs 60,000 and saves 90,000. Treatment: Every 100 alcohol-dependent people treated can prevent 18 A&E visits and 22 hospital admissions. This costs 40,000 and saves 60, THE CAMBRIDGESHIRE PICTURE 2.1 Prevalence: How widespread is alcohol misuse in Cambridgeshire? 28 In the last needs assessment, synthetic estimates of local prevalence were calculated. These have not been revised, but a summary of that data still gives a good indication of prevalence and is as follows: Men: It is estimated that 26% of men aged 16 and over drink above government guidelines (n=64,000). This increases to 30% in the age group. Huntingdonshire has the greatest number of men consuming over 21 units per week followed by South Cambridgeshire. Women: An estimated 17% of women aged 16 and over drink above government guidelines (n=43,600). This increases to 20% in the age group. As with men, Huntingdonshire has the greatest number of women consuming over 14 units per week, followed by South Cambridgeshire Health impacts Alcohol-specific and related hospital admissions The table below shows the rate of alcohol-specific and related hospital admissions in Cambridgeshire. 26 Figures extracted from Public Health England (2014) Alcohol and drugs prevention, treatment and recovery: why invest? 27 As above 28 Cambridgeshire has a total population of 632,095. For all ages (0-90) 315,136 are male and 316,959 are female. 92.3% of the population are classed as White British. This is consistent in all districts apart from Cambridge where it is 82.4%. 18

19 Alcohol specific hospital admissions (2012/13) Alcohol related hospital admissions (2012/13) District Male Female Male Female Cambridge East Cambridgeshire Fenland Huntingdonshire South Cambridgeshire National (England) Figure 4: Hospital admissions with alcohol specific and related conditions/ all ages 2012/13 (DSR directly age standardised rate) per 100,000 population 29 Alcohol specific hospital admission rates (2012/13) Men: For men, the highest rate of alcohol-specific admissions is in Cambridge this is above the national average and the same as in 2010/11. The lowest rate is in South Cambridgeshire. Women: For women, the highest rate of alcohol-specific admissions is again in Cambridge and the same as in 2010/11 and again above the national average. The lowest rate is in East Cambridge. Alcohol related hospital admission rates (2012/13) Alcohol-related admissions were not reported in the last needs assessment, but current data shows: Men: For men, the highest rate of alcohol-related admissions is Fenland this is above the national average. The lowest rate is in South Cambridgeshire. Women: For women, the highest rate of alcohol-related admissions is again in Fenland and again above the national average. The lowest rate is in East Cambridge. Hospital admissions continue to be of concern in the county. Public Health Indicator 2.18 measures Alcohol related hospital admissions. In Cambridgeshire, the number of alcohol-related admissions in 2012/13 was 589 and remains higher than the East of England average of Given the rates of admissions for alcohol specific or related conditions, Addenbrookes and Hinchingbrooke are critical in the identification of alcohol misusers and liaison with the community treatment service. Addenbrookes has for some years had a consultant in substance misuse psychiatry and an alcohol liaison nurse. In addition, Inclusion has employed a hospital liaison worker, full time at Addenbrookes to also work with liaison and encourage patients into community treatment on discharge. This includes linking with Hinchingbrooke hospital Mortality The table overleaf shows rates of alcohol specific and related deaths 31 per 100,000 population (all ages) 29 Public Health England, Local Authority Alcohol Indicator 30 Public Health England/ Fingertips survey 31 Public Health England, Local Authority Alcohol Indicator 19

20 District Alcohol specific deaths per 100,000 ( ) Alcohol related deaths per 100,000 (2012) Male Female Male Female Cambridge East Cambridgeshire Fenland Huntingdonshire South Cambridgeshire Cambridgeshire average East of England England Figure 5: Alcohol specific and related deaths Alcohol specific mortality rates Men: For men, the district with the highest rate of alcohol specific deaths was Cambridge this is the same as in 2008/10; at 17.80, this is significantly higher than East of England and national averages. The district with the lowest is Fenland. Women: For women, the district with the highest rate of alcohol specific deaths was Huntingdonshire a shift from Fenland in 2008/10; this was higher than East of England averages but lower than the national average. Alcohol-related mortality rates Men: For men, the district with the highest rate of alcohol-related deaths was Cambridge; this is higher than the East of England average but lower than the national average. Women: For women, the highest rates were Fenland- the same as in 2008/10. The rate is considerably higher than the East of England and national rate. The following diagram show the main districts of concern based on the above information. This is of particular use when planning alcohol harm reduction events. Indicator Districts with highest rates Men Women Drinking above government guidelines Huntingdonshire Huntingdonshire Alcohol specific hospital admissions Cambridge Cambridge Alcohol related hospital admissions Fenland Fenland Alcohol specific deaths Cambridge Huntingdonshire Alcohol related deaths Cambridge Fenland Figure 6: Summary table - synthetic estimates of districts with highest rate of alcohol hospital admissions and deaths. Please note that the above data is based on synthetic estimates and cannot show age differences or other demographic variables and is therefore a guide only. 20

21 3.0 CAMBRIDGESHIRE ALCOHOL TREATMENT ACTIVITY 3.1 Service provision Currently, Cambridgeshire Safer Communities Partnership Team commissions the services shown below on behalf of Public Health. There are additional services in the county that support alcohol misusers that are commissioned by different commissioning bodies; these include the Gainsborough Foundation, Drinksense and GPs. Provider Provision Area covered Inclusion (from April 2014) Information and advice Assessment Structured interventions clinical and psychosocial and day programmes Hospital liaison service Non structured interventions Support groups family, peer, carer Harm reduction Extended Brief Interventions County-wide Cambridge and Peterborough Foundation Trust (CPFT) GP liaison and support Detox beds in Fulbourn hospital x 3 County-wide Jimmy s Cambridge Controlled drinkers beds x 6 County-wide Figure 7: Alcohol treatment providers in Cambridgeshire 3.2 Cambridgeshire alcohol treatment activity data Client numbers in treatment Numbers in treatment year to date data shows that alcohol was recorded as a primary substance and resulted in structured treatment in 720 cases in 2013/14. This is a very significant increase from 622 in 2012/13. This reflects the work of the service to reach out to more clients, and is seen below in the percentage of new presentations. New presentations: Number of clients with new presentations into treatment (YTD) numbered 426 in 2013/14. This was 59% of all in treatment. (there were 314 in 2012/13) This means that the service has been publicised enough to attract increasing numbers of new clients. 85% of clients in treatment were drinking at higher risk levels in the 28 days prior to entering treatment. This is greater in Cambridgeshire than the national average of 77%. 32 Client characteristics Gender: More men (64%) than women accessed treatment. This is consistent with the previous year. Ethnicity: 95% are White British, 2% are White Other. 32 Public Health England JSNA support pack for Cambridgeshire 21

22 Age: Most men and women in treatment were for men ( 33%) women (18%), this remains similar to previous years. Employment and benefits: 33 30% of new starts in treatment were in regular employment. This is considerably higher than the national average of 21%. 14% were registered as sick or disabled, lower than the 20% national average for new starts. Of the number in alcohol treatment on 31 st March 2012, 50% were on benefits, slightly lower than the national 54%. A breakdown of this shows the highest percentage of people were claiming Employment Support Allowance (20%) and Disability Living Allowance (20%). A further 16% claimed Incapacity Benefit. Of successful completions in (2011/12) 35% were on benefits and 65% not in receipt of benefits. (National figures were 47% and 53% respectively). Accommodation: 3% of clients at the start of treatment said they had an urgent housing problem. A further 11% had a housing problem, but less urgent, similar to national averages. Referral sources: Self, family, friends: 53% self-referred in 2013/14; this is similar to the 51% self, friends, family route in 2011/12 and higher than average. It again suggests the work of the service to publicise what it does and how to access treatment. Health and mental health services, GP: 18%, slightly reduced from 2011/12. Criminal justice route: 12% of referrals were from the CJ system, a reduction from 16% in 2011/12. Waiting times: 94% of clients waited less than three weeks to start treatment in 2013/14 in line with national average. Previous year this was 89% so progress has been made. Length of time in treatment: Nationally, the typical treatment time is about 6 months. NICE guidance recommends that harmful drinkers and those with mild dependence may benefit from a three month package, with length of time increasing with dependence up to a year. Time to exit Cambridgeshire National average Exits in under 3 months 20% 38% 3-6 months 26% 30% 6-12 months 33% 23% 1 year + 21% 10% Average days in treatment Figure 8: Length of time in alcohol treatment. 34 This shows that clients receiving alcohol treatment in Cambridgeshire stay in treatment for significantly longer than the national average. Successful Completions: The percentage of successful completions numbered 38% (as a proportion of all in treatment) in 2013/14 and was similar to national figures. Residential rehabilitation: 12 individuals attended residential rehabilitation for alcohol treatment or 2% of the treatment numbers. The national average is 4%. (see also drug misuse section) 33 As above 34 JSNA support pack 22

23 3.3 Prevention and early intervention work Identification and Brief Advice (IBA) Investment in preventative and early intervention work is key to reducing later incidence of alcohol misuse and associated costs. Central to this is Identification and Brief Advice (IBA). IBA is an intervention that helps non specialist substance misuse professionals identify drinking patterns that may be impacting on an individual s health, and delivering simple, structured advice. A range of training opportunities are used to deliver these sessions; some are delivered by Inclusion and some by the DAAT. Additional training is delivered as part of Local Safeguarding Children s Board (LSCB) training. Key groups that have been trained include social care and health practitioners. IBA in hospital: The community alcohol treatment service had been tasked with providing IBA in A&E at Addenbrookes. This struggled to become embedded, and there was a very poor return rate of patients who returned for their IBA session following discharge. Hospital A&E data over 10 years suggested that this was as low as 2%. The new role of liaison nurse will investigate how such an intervention can be best delivered. IBA in custody: Inclusion has trained staff in all custody suites. IBA training sessions were delivered to 15 different staff groups in 2013/ Detoxification treatment Community detoxes Community detoxes can only be promoted if GPs feel confident to oversee them. A Local Enhanced Service (LES) is in place with GPs whereby the DAAT pays the GP a set amount per detox. Whilst the community alcohol treatment service report that they undertake a significant number of assessments for community detoxes, many are not passed as appropriate. This area requires further investigation to ensure that an efficient and effective service is being safely delivered. The following data shows the number of assessments undertaken for community based alcohol detox, and the resultant number of detoxes that took place in 2013/14. Number of assessments: 90 Number of community detoxes undertaken: 40 This number has remained static since last year. The DAAT is reviewing this area in order to maximise the numbers of community detoxes that can be delivered within the parameters of NICE guidelines. The new detox house should help with the recovery pathway for community detoxes, and indeed, may help to increase the number undertaken Inpatient detox Data from CPFT shows that for the year 2013/14 the following inpatient detoxes were undertaken: Inpatient drug or alcohol detox : 75 Alcohol: 60 Drug: 15 Last year s data was combined so comparison is not possible. However, comparing with East of England data, Cambridgeshire has a rate of inpatient alcohol detox of 8% (of adults in structured alcohol treatment receiving inpatient detox) as opposed to the East of England average of 5.8%. 23

24 Waiting times: These are not necessarily reflective as some patients are elective (meaning that detox may have had to take place as an emergency procedure) and others non-elective. The average wait, taking this into account was 79 days. 3.5 Substance misusing parents (See also Cross Cutting Themes) 26% of individuals in treatment were living with children (n=187) - similar to national figures. 26% were parents but not living with their children and 47% had no child contact again similar with national figures. No female clients in treatment in 2013/14 were pregnant during treatment. 3.6 Criminal Justice 35 Extensive work and planning has been undertaken in the county to ensure that alcohol misuse treatment can be accessed at any point in the criminal justice system and in particular in the early stages of criminal justice processes. Thus, interventions are now in planning, or available at street level, custody level, court level, and part of community or prison sentences. Alcohol Diversion Scheme: Funding has been granted by the PCC for the scheme to be introduced county-wide. The aim of diversion is, where possible, to divert possibly new individuals out of the criminal justice system. Drinksense have recently been commissioned to deliver this by Cambridgeshire Constabulary on behalf of the Police and Crime Commissioner. Custody suite training: During 2013/14, all staff in custody suites received IBA training to enable them to deliver interventions to individuals held in custody. In addition, a custody referral form is used to refer to treatment services, anyone for whom a brief intervention is not sufficient. Alcohol Treatment Requirements: ATRs are delivered by Inclusion. The commencements target per year is 80. In quarter 1 of 2013/14, there were 15 commencements and 11 completions. The target for completions is 50%. Prison community interface: Inclusion have a designated prison inreach worker who liaises with all prisons where any Cambridgeshire residents are in custody who have drug and/or alcohol problems and require treatment on release. This predominantly means HMP Peterborough where the worker will visit all such prisoners. The aim of this role is to ensure smooth transitions from prison based to community based substance misuse services, and thus prevent dis-engagement with treatment and re-offending. Public Health Indicator 2.16 measures People entering prison with substance dependence issues who are previously not known to community treatment. The most recent figures suggest that the county is on par with the national average for the percentage of opiate users engaged in the community before prison and lower than average for cannabis. Whilst recognising more primary cannabis users could be engaged in the community, particularly through the criminal justice pathway so this is not really a surprise. Although services are concentrating more on engagement with primary cannabis users, most of this cohort do not commit the type or frequency of crime that brings them into focus. 35 Criminal justice data, provided by Cambridgeshire constabulary available at Appendix 3 24

25 3.7 Licensing issues Cambridgeshire Constabulary chairs an Alcohol Related Violent Crime Group in Cambridge City. This multi-agency group uses the Innovative 'Cardiff Traffic Light Model' which aims to link hospital admissions for alcohol related assaults to where incidents occurred. The model applies a red, amber or green approach to licensed premises dependent on the number of incidents which originate from those premises. This has led to proactive work with those premises which has then led to a reduction in hospital admissions for alcohol related assaults. Following the National Alcohol Strategy 2012 Public Health Teams became one of the 'responsible authorities' who have to be consulted when new alcohol licensing applications come in or requests to amend current licenses are received. Whilst this has been helpful it has not so far been complemented with another government pledge to introduce a specific health objective to the current list of objectives shown below: Prevention of crime and disorder Public safety Prevention of public nuisance Protection of children from harm Without an additional health objective it remains more challenging to influence licensing decisions for health related reasons and the consequence of this is that alcohol related assaults and incidents place a heavy burden on the NHS. 3.8 Cambridgeshire activity compared with the East of England For 2012/13, the rate of adults in structured alcohol treatment in the region indicated that: Cambridgeshire was 1.6 per 1,000 The area with the highest rate was Luton at 4.4 and the lowest is Cambridgeshire along with Hertfordshire. The East of England average is 2.0 This means that Cambridgeshire has the lowest rate (with Hertfordshire) of adults in structured alcohol treatment in the region. 25

26 Key findings: Alcohol It is estimated that 9 million adults in England drink at levels that may harm their health. 36 A quarter of all deaths for young men aged are attributable to alcohol. The annual cost to society is estimated at 21 billion. Cambridgeshire a. Synthetic estimates of prevalence suggest that 26% of men and 17% of women in Cambridgeshire drink over government guidelines. b. Districts with highest rates of drinking and hospital admissions and deaths include: Huntingdonshire (drinking levels), Cambridge (alcohol specific hospital admissions), Fenland alcohol related hospital admissions, Cambridge and Huntingdonshire (alcohol specific deaths) and Cambridge and Fenland (alcohol related deaths). c. Numbers of alcohol misusers in treatment have risen to 720 (from 622). 59% of all clients in treatment were new presentations. The main age bands in treatment were Half of referrals were from self, family and friends. This is an indication of the hard work the service has put into publicising what it does and how to access treatment. d. Time in treatment is twice as high as the national average. e. The percentage of successful completions numbered 38% (as a proportion of all in treatment) in 2013/14 and was similar to national figures. f. IBA training sessions have now covered all custody staff in the county. g. Designated hospital liaison workers are now employed by both Addenbrookes and Inclusion to encourage, when identified, patients to link with community based treatment. h. Community detoxes remain static, with work underway to identify how to maximise this treatment within NICE guidelines. Negotiations are under way to allocate a house for hostel clients to reside in post detox to mitigate against relapse. i. 26% of clients (187) were living with children; this is of concern and has resulted in new posts in both the drug and YP service to meet the needs of these children who are often young carers. 36 Health England (2014) Alcohol and drugs prevention, treatment and recovery: why invest?. 26

27 C. YOUNG PEOPLE S SUBSTANCE MISUSE TREATMENT 1.0 BACKGROUND This section is set out in a slightly different way to the drug and alcohol sections. This is partly because the background to drug and alcohol use is already set out, but also because young people in substance misuse treatment tend to present with complex needs quite apart from their substance misuse. Please also read the cross cutting themes that extend the details here. 1.1 Why do young people misuse drugs and alcohol? Substance misuse is one of the few social issues that impacts so comprehensively on modern society and levels of alcohol and illegal drug misuse in children and young people remain of significant concern. Consequences of substance misuse range from non-attendance and poor attainment at school, poor health, committing crime to support habits and also increased risk of being a victim of violent crime and sexual exploitation. In addition to this, many children and young people who live with substance misusing parents and carers are suffering its ill effects. They are often neglected, impacted upon by domestic violence and are at an increasing risk of misusing alcohol and illegal drugs themselves. Young people do not start misusing drugs or alcohol to become addicted on purpose and many will never end up becoming dependent. However, for a significant number of young people, casual and/ or social use may result in regular use or addiction. Of particular note is the national data regarding the increase use of Novel Psychoactive Substances (NPS). 37 A report from the United Nations Office on Drugs and Crime 38 states that the UK is the largest market for NPS in the European Union, with 670,000 young people aged experimenting with such drugs in Whilst increased use has not been recorded locally, commissioners of services are ensuring that specialist and non-specialist staff can conduct effective screening to identify such misuse and offer preventative advice. According to a government source, reasons why young people start using drugs can include: 39 - To escape from problems they may be having in other parts of their life - Peer pressure and fitting in with another group of people - Being curious about the effects of drugs and alcohol 1.2 Prevalence and cost of young people s substance misuse National figures 40 estimate that 19,126 young people aged under 18 are in treatment. A further 3106 are in young people s services aged Nationally, 1702 young people in the secure estate are in treatment. (These figures are calculated on age at 1 st April 2013) 37 Advisory Council of the Misuse of Drugs; Consideration of the Novel Psychoactive Substances ( Legal Highs ) The United Nations Office on Drugs and Crime (UNDOC) World Drug Report Public Health England. Young People s Specialist Substance Misuse Executive Summary Quarter 4, 2013/14 27

28 A report, written by Frontier Economics (2011) 41, looking at the costs and benefits associated with young people s drug and alcohol treatment found that while measuring the costs of treatment is relatively straightforward, assessing the benefits associated with treatment is more complicated. There is significant evidence that many of these young people would, in the absence of treatment, impose significant economic and social costs on society. These costs can be split into: Immediate costs: The annual cost of crime per young drug and alcohol user of around 4,000 per person per year in the absence of treatment. The annual counterfactual health care cost of young people s drug and alcohol misuse is around 179 per person per year. It is likely that young people s substance misuse contributes to further costs, including those associated with children s services, and particularly the costs of being taken into local authority care. However, it was not possible to isolate the proportion of these costs attributable to substance misuse in the study, so these were not factored into the overall cost figures. Long-term costs: Young people with substance misuse issues are more likely to be involved in substance misusing activities when grown up. Research suggests that between 30% and 40% of moderate/heavy teenage alcohol and cannabis users would develop drug/ alcohol misuse problems as adults while the remaining 60%-70% would experience natural remission (even if not treated). The proportion is however higher for teenage Class A drug users (up to 95% of teenage Class A drug users continue to use drugs in adulthood). The estimated costs per each category are as follows: non-problematic adult drug users: 21,300-45,100 per year adult alcohol abusers : 173, ,397 per year problematic adult drug users 550, ,848 per year In the absence of concrete evidence on long-term effectiveness of young people s treatment, the authors adopt a scenario-based approach. They find that if the number of those who are likely to develop substance misuse problems as adults is reduced by 2.8% - 5.6%, the long-term benefits of treatment would offset the cost of treatment (assuming that the immediate benefits are excluded from this analysis). Moreover, with a slightly higher reduction in the number of those who would have long-term drug related problems 7%-10% reduction the long-term benefits of treatment would exceed the cost of treatment. Nevertheless, one of the most significant reasons to invest in drug treatment is that since 1996, there have been great successes in treating young drug misusers. This is not cause for complacency as national trend data indicates. The diagram below shows that whilst the largest fall in all drug misusing populations in the longer term had been for any drug with young people, there was a steep rise in the last year. It is important to note however that this is still considerably lower than Class A use with young people has also risen slightly after a decline since The diagram cannot show is the changes in drug use in the any drug category. 41 Frontier Economics (2011) 28

29 Figure 9: Trends in illicit drug use (excluding mephedrone) in the last year among adults, by age group, 1996 to 2013 to 2014, Crime Survey for England and Wales 2.0 THE CAMBRIDGESHIRE PICTURE 2.1 How widespread is substance misuse in Cambridgeshire? Trends in substance misuse: The Balding Report states that in the last 10 years 42 data shows significant falls in substance misuse. This data is gained via self-report from school pupils and it is of note that it does not pick up the trends in the diagram in the previous section. For example: Reported alcohol consumption in the week before a survey has fallen by 17% over 10 years and the number of pupils reported as drinking nothing has increased by 17%. Decreases in units drunk is also evident. Whilst pupils report similar drug use over the 10 year period, there are reductions in pupils saying they have ever taken drugs, been offered or used cannabis. A recent Department of Education report 43 of risk behaviours with secondary school students stated that overall, drug misuse was rare, but alcohol misuse was common. It cited statistics that more girls than boys reported getting drunk. It also reported that 30% of young people interviewed knew about legal highs and 4% had used them. The misuse of NPS is of concern nationally. Local information states that the trend is that fewer pupils are being offered and taking such drugs. One third of those offered subsequently take the drug This amounted to 44 individuals in (This is discussed more fully in the Cross Cutting Themes) 42 Balding Report Cambridgeshire Safer Communities Partnership (July 2013) The Health Related Behaviour Survey; a ten year analysis of trends. Drug and Alcohol section Department of Education (Nov 2014) Policy Briefing 10 (127) Longitudinal study of young people in England: cohort 2, wave 1, Research report _Longitudinal_study_of_young_people_in_England_cohort_2 wave_1.pdf 29

30 3.0 CAMBRIDGESHIRE YOUNG PEOPLE S TREATMENT ACTIVITY 3.1 Service provision Since the last Needs Assessment, and following a successful competitive tender in 2013, the young people s treatment service continues to be in Cambridgeshire and Peterborough NHS Foundation Trust, but the department has recently moved from the specialist to the children services area. Young people s drug and alcohol treatment is very different to adult treatment. Few young people fall into the category of problem substance misusers that we would associate with adult treatment. Young substance misusers also differ from adults in that they will typically not misused drugs or alcohol for sufficiently long to have developed dependencies. This therefore affects the type of treatment typically provided for young people. The types of specialist intervention required to treat young people are more likely to involve psychosocial interventions and harm reduction measures, rather than specialist pharmacological interventions (such as methadone prescribing) which are more appropriate for treatment dependent adults. A small number of young people may need more intensive support, including a package of care that combines support from a specialist children s home or foster care placement with the substance misuse service. A very small number may need pharmacological interventions. Many young people benefit from general interventions and open access drug and alcohol treatment or preventative advice; this early help offer is often via the County Council s Children s Service locality teams, health professionals and voluntary sector organisations. By identifying and working with young people who may be at risk of developing more serious substance misuse problems later on, it can help to ensure that the that the adult substance misusing population continues to decline. However, such individuals are not captured in the data we have used for this analysis as the treatment they receive does not form part of a structured care plan. The DAAT can only analyse the profile of the specialist treatment population. To ensure that access to advice and treatment is as wide as possible, in 2013 the young people s substance misuse treatment service commissioned a review, interviewing a number of year olds to identify the potential for using digital applications to help young people identify their own possible substance misuse, and then receive advice and signposting via the app. This idea was enthusiastically received and European funding is now being sought after to pilot some innovative response to the problem. In Cambridgeshire there are two main treatment agencies for young people: CASUS are part of the Cambridgeshire and Peterborough NHS Foundation Trust and have been a local provider since 2010; in 2013 (operating from 1 st April 2014) they won the recommissioned contract for the service. The service is delivered from two main offices, CASUS South covering Cambridge City, South Cambridgeshire and East Cambridgeshire and CASUS North covering Huntingdonshire and Fenland. Ten members of staff are divided equally between the two areas and include nurses, project workers, drug and alcohol workers and social workers. Cambridgeshire Youth Offending Team (YOT) also has a substance misuse team comprising of three people, commissioned by the DAAT and separate to CASUS. They support young offenders and undertake similar work to CASUS. Their close alignment with CASUS often includes joint working, or referring people to CASUS once their YOT order has finished. The referral route to the YOT substance misuse service is solely from within the YOT. 30

31 3.2 Cambridgeshire Young People s treatment data The Cambridgeshire young people s service works primarily with young people up to the age of 18. However, they will continue to work with young people over the age of 18, if they continue to need treatment, and transfer to the adult service would not be in their best interest at that point. (See also Cross Cutting Themes). Numbers in treatment: Estimates of young people known to the treatment service are (Of this number, 18 young people are aged 18 or 19 and have stayed in the young people s service rather than transferring to the adult service). Last year this was 221. New presentations: 146 were new presentations. Half of referrals are from Education, and Children and Families services; this is a result of the continued liaison CASUS have undertaken with schools to ensure they are clear about identification and referral. The next largest referral category is Family, Friends and Self. Client characteristics o Gender: 52% of Cambridgeshire s 9-17 population are male compared with 70% of the DAAT s young people treatment population. o o o o o Age: At presentation, 17% were aged (n=38), 21% aged 15 (n = 47), 30% and 16 (n-67) and 31% aged 17 (n = 70). Ethnicity: 91% of Cambridgeshire s 9-17 population are of White ethnicity compared with 89% of the CASUS s young people treatment population. This suggests that the treatment population has more non-white ethnicities than the general population. Accommodation: 76% of the treatment population in 2013/14 were recorded as living with their parents or other relatives. Independent Looked After Children in settled accommodation were 8% (n=17); this group is known as being particularly vulnerable. The links between unsuitable accommodation and offending and risk-taking behaviours are well known. In Cambridgeshire, following the remodelling of the Floating Supporting People Services, some 20 smaller contracts have been replaced with five larger contracts which hopefully will provide better coverage and a consistent service to support under 18s housed by the Local Authority. Rate per 1,000: Cambridgeshire has a rate of young people known to substance misuse treatment of 3.7 per 1,000 population aged 9-17, compared with the East of England rate of 2.5. This means that more young people Main substances used: The table below indicates the age of young people in treatment and substances used. 44 Public Health England. Young People s Specialist Substance Misuse Executive Summary Quarter 4, 2013/14 (this includes young people over the age of 18 and still in service) 31

32 Substance Age Total Nat. total <= n % % Heroin and/or crack % 2% Stimulants (cocaine, ecst, % 23% amphet, not crack) Cannabis % 84% Alcohol % 56% Novel psychoactive substances % 2% Tobacco % 9% Other drug % 8% Total (n) Total (%) 6% 30% 58% 6% Figure 10: Age and substance misused (JSNA) The above table shows that the majority of young people in treatment are in the years age band with cannabis being overwhelmingly the presentation drug, followed by alcohol and then stimulants. For all age bands, cannabis is the most presented drug (part from age where alcohol was recorded by one person more than cannabis). The overall percentage of young people misusing cannabis is slightly higher at 87% than the national average of 84%. Presentations of alcohol misuse are slightly less than national figures and NPS is not recorded. Additionally, age of first use of a drug can be an indicator of vulnerability; 72 young people in treatment in 2013/14 began using their main problem substance under the age of 15 years. 58% of young people in treatment were recorded as using two or more substances. The Consultant Child and Adolescent Psychiatrist working for CASUS 45 stated that there is a trend emerging of young people who do misuse alcohol, starting drinking at a younger age, drinking more, and using drugs alongside their drinking. Treatment times: Unlike adult drug users, who are more likely to be treated successfully after at least a 12 week engagement, most young people need to engage with specialist drug and alcohol interventions for a short period of time, often weeks rather than months, before continuing with further support elsewhere, within an integrated young people s care plan. The following table shows this pattern of short treatment duration: Duration Percentage of young people in treatment in Cambridgeshire 2013/14 Percentage of young people in treatment in Cambridgeshire 2012/ wks 36% 39% 42% wks 26% 32% 30% wks 26% 20% 19% 52+ wks 12% 12% 9% Figure 11: Duration of treatment National data 2013/14 The above table shows that 36% of young people were in treatment for up to 12 weeks. This percentage drops significantly until only 12% remain after 1 year. This number will represent the young people with the most complex needs

33 Planned exit numbers: 92% of young people leaving treatment left with a planned exit. This is a significant improvement on recent years of 75%. The service has worked particularly hard to ensure exits are planned, but also to ensure that young people know that they can return to service at any time, and this is seen as positive rather than negative. The following data gives the re-presentation percentage. Planned exits and re-presentations: 9% of young people re-presented, slightly less than last year (12%). Treatment Interventions Psychosocial interventions: The majority of young people in treatment services received psychosocial interventions; this amounted to 81%. Psychosocial interventions, sometimes known as talking therapies, use psychological, psychotherapeutic and counselling skills to encourage change. Harm reduction: Harm reduction interventions totalled 35% and included structured harm reduction includes support to manage injecting, overdose and accidental injury through substance misuse. Residential services: There were no referrals made to residential services. This is in line with national best practice that does not advocate such treatment as the norm for young people. Pharmacological interventions: 3% of young people (n=6) received a pharmacological intervention. This is the same percentage as last year. CASUS team has a Consultant Psychiatrist who works with young people and their families who are affected by substance use disorders (SUD) or who suffer from co-morbid substance use and at least one other mental health diagnosis; as a result, prescribing can be delivered. Structured consultations to non-specialists: Structured consultations specified in the service contract, are delivered by CASUS to non-specialist professionals working with young people with substance misuse problems. Additionally, training is offered to multi agency professionals to assist with early intervention and prevention. Given the national rise in NPS, it is important that such staff are confident in identifying NPS use and understand appropriate treatment options. Children of substance misusing parents/carers (See Cross Cutting Themes) 3.3 Hospital admissions Within Health Related Behaviour Survey 46 there is evidence of young people s drinking stabilising and in some areas decreasing. However, concern remains about a small but significant number of young people who drink at high levels infrequently and those drinking on a regular basis. In Cambridgeshire few young people have been referred to the team with a physical dependence on alcohol. The team would offer only four to five detoxification interventions each year but often this is not enacted as the young person has reduced their alcohol consumption without medication, using intensive psychological interventions and support. The table below shows the rate of under 18s admitted to hospital with alcohol-specific conditions (2010/ /13) per 100,000 population. 46 Balding Report Cambridgeshire Safer Communities Partnership (July 2013) The Health Related Behaviour Survey; a ten year analysis of trends. Drug and Alcohol section

34 District Rate per 100,000 Cambridge East Cambridgeshire Fenland Huntingdonshire South Cambridgeshire National (England) Figure 12: rate of under 18s admitted to hospital with alcohol-specific conditions (2010/ /13) 47 The average rate of hospital admissions for young people in Cambridgeshire was 31.5 hospital per 100,000 population (2010/ /13) due to alcohol and 20.8 due to drugs (2006/ /09) compared with regional rates of 27.9 and 15.3 respectively. 48 This continues to appear to be high. Locally, it is believed that our hospitals record data extremely well, and this may be being compared with other hospitals with less robust reporting systems. In addition, it may be that harm reduction information initiatives have been successful in that young people are taking friends to hospital A&E if they are concerned that a friend has had too much to drink and/or may have an injury because of this. 3.4 Multiple Vulnerabilities Few young people under 18 develop dependency. Those who use drugs and/or alcohol problematically are likely to be vulnerable and experiencing a range of problems. An internal audit of case files at CASUS indicated a trend over several years of increasing numbers of young people accessing the service with complex needs; infact it is now rare to see a young person with substance misuse as their only problem. Wider vulnerabilities: The following table shows numbers defined as having wider vulnerabilities, along with national averages. Wider vulnerability Local numbers Local % National % Looked After Child 14 18% 10% Child in Need 3 4% 5% Affected by Domestic abuse 7 9% 17% Identified mental health problem 10 13% 15% Involved in sexual exploitation 1 1% 4% Involved in self harm 7 9% 16% Not in education, employment or training (NEET) 19 24% 17% NFA./ unsettled housing 1 1% 2% Involved in offending 4 5% 24% Pregnant/ parent 1 1% 2% Subject to Child Protection Plan 1 1% 5% Affected by others substance misuse 4 5% 16% Figure 13: Wider vulnerabilities of young people in treatment 47 Public Health England, Local Authority Alcohol Indicator 48 National Public Health Profiles, Public Health England Substance Misuse: Under 18 drug and alcohol misuse 34

35 Many vulnerabilities are recorded here as being below national averages (for example domestic abuse, involvement in self harm),but at the same time there are significantly more young people classed as LAC in substance misuse treatment and more NEET in Cambridgeshire than national averages. In addition, categories of mental health diagnosis and NEET are more prevalent for males. The way the data is recorded however, does not give a full picture of vulnerabilities. The CASUS treatment population for 2013/14 was 234. The table above suggests that only 30% (n = 72) of young people in treatment are recorded as having any vulnerabilities. This is of course not true; the reality is that a significant number of the young people exhibit, for example, mental health problems, but these are not necessarily diagnosed, so cannot be recorded as such. Some possible reasons for this include: The Young People s data set changed on 1 st November 2013 resulting in some questions being rephrased or removed, they may not be mapped across. The question on affected by another substance use although it remained on data sets, specific guidance was issued by PHE that stated that this question could not be asked as this information could not be electronically stored as no consent from parent/carer was gained. As the fields are not updateable, it means that for example, a mental health problem may not have been identified at assessment and cannot later be added. LGBT: A survey of Lesbian, Gay, Bisexual and Transgender young people in Cambridgeshire secondary schools 49 found increased levels of alcohol and drug misuse in this community. It is however, difficult to know whether the treatment service is responding to the needs of LGBT young people as this status is not gathered by the data reporting system. 3.5 Professionals view of the treatment service The work with young people is by its very nature partnership working. The following comments are from an internal audit (July 2014) indicating how professionals in other disciplines regard the service: The Substance Misuse Team was commented on as being very approachable, supportive and helpful to case workers. The assessment system, that refers young people to the substance misuse team, works well and case workers are skilled to assess when specialist help is needed. I have worked several times over the past 2 years and they have been very helpful. I find they are very approachable and I often call for advice. The referral system is very easy and not off putting. Great service for young people and those who I have referred report a positive, supportive, informative experience. They are willing to give info to professionals as we ask for it. Suggestions - more visibility in rural areas. A capacity to input into collapsed time table days within secondary schools. a very successful outcome. As a team we have currently not had a lot of involvement with CASUS. The one thing that was brought up at our meeting by colleague was an instance where CASUS were invited to attend a meeting concerning a young person but due to the fact they were not working with them declined to attend. In this instance the practitioner who invited them to attend felt their knowledge would have been of some help. 49 Balding Report Young People in Cambridgeshire Schools (2012) The Health Related Behaviour Survey. A report for the Lesbian, Gay, Bisexual or Transgender 35

36 Key findings: Young people and substance misuse National trends, despite reducing since 1996, show a recent increase for any drug for year olds. Slight increases have also been noted for Class A use. Local trend data does not pick this up. Cambridgeshire a. 223 young people (similar to last year) are in treatment (of which 18 are over 18 years and are remaining with the young people s service rather than transferring to the adult service) b. There were 146 presentations, half of which were from Education and Children and Families indicating the work CASUS has undertaken with schools and departments on identification and referral. c. 8% of the treatment population were Independent Looked After Children ; this is a particularly vulnerable group. d. The main substances misused continue to be cannabis and alcohol with the main age band presenting being year olds. Most young people have stayed in treatment less than 12 weeks 36% (lower than the national average of 42%) e. There has been a significant increase in young people leaving treatment in a planned way 92% (compared with 75% last year). The service has worked particularly hard to achieve this and ensure that young people know that they can return at any time. f. Despite indications of the stabilising and in some areas decreasing in young people s drinking 50, there is still concern about a small but significant number of young people drinking to excess. Figures for alcohol specific hospital admissions show the highest rates for Cambridge equalling the national average. g. Whilst young people in treatment tend to be complex with multiple needs, data on multiple needs appears to be under reported. However, what is of note is that there are significantly more young people than national averages, engaged with CASUS who are LAC or NEET. 50 Balding Report Cambridgeshire Safer Communities Partnership (July 2013) The Health Related Behaviour Survey; a ten year analysis of trends. Drug and Alcohol section

37 D. CROSS CUTTING THEMES This section covers themes that are relevant to two or all services. By discussing them together, it is hoped that a partnership response can push for change to alleviate the difficulties presented. The themes covered are: Substance misusing parents Preventions and early interventions Novel Psychoactive Substances Harm reduction Older people in treatment Transitions from young people to adult services Domestic abuse Accommodation Mental health Recovery communities and peers Families and carer groups 1.0 Substance misusing parents/ carers The numbers of adults in treatment who live with children and the numbers of children living or caring for substance misusing parents has been already mentioned. National data shows the following picture: At least 30% ( million) children live with at least one binge drinking parent % live with a hazardous drinker and 6% with a dependent drinker. 52 An estimated 79,291 babies under one year old in England live with a parent who is a dependent drinker. 53 Parental alcohol misuse was identified in a study of 22% of serious case reviews. 54 East of England data for adults in treatment reports that 58% are parents, with 31% living with at least one child. In Cambridgeshire 57% are parents, with 24% recorded as living with at least one child. 55 Despite these estimates, the problem remains largely hidden. The report Silent Voices 56 highlights the lack of research and suggests particularly vulnerable groups include young carers, children from Black, Asian and Minority Ethnic (BAME) groups, children who experience substance related bereavement, children of prisoners, children cared for by others, children with FASD and young homeless. Parental alcohol misuse is correlated with family conflict, and domestic abuse. However, children living with parental alcohol misusers are likely to come to the attention of social care services later than children living with drug misusers. In addition, boys are less likely than girls to ask 51 The Health Survey for England (HSfE) and General Household Survey (GHS) (both 2004) cited in: Manning, Best, Faulkner and Titherington (2009) "New estimates of the numbers of children living with substance misusing parents: results from UK national household survey", BMC Public Health 9, 52 The National Psychiatric Morbidity Survey (NPMS) (2000) quoted in the above document. 53 Cuthbert Cited in Silent Voices 54 Brandon et al 2010 Cited in Silent Voices 55 NDTMS data 2011/12 56 Adamson J, Templeton L, (2012) Silent Voices. Supporting children and young people affected by parental alcohol misuse. Children s Commissioner/ Community Research Company 37

38 for help, but more likely to come to the attention of services due to behaviour for example through YOT. Silent Voices advocates that flexibility of services is key to providing support that is not time limited, and allows children to receive support on their own as well as in family units. 1.1 Local response A snapshot was taken on one day in 2014 of the number of parents in drug or alcohol treatment and the number of children that were living with them. This amounted to 646 children to 365 parents. This is a significant number of children, many of which may not be known to services. 57 It poses challenges to services regarding information sharing, liaison and joint working. Services in Cambridgeshire go some way to meeting the needs of the children of parental substance misusers. A large proportion of professionals (including social workers, YOT workers, Family Intervention Partnership workers, young carers workers, adult drug and alcohol workers etc.) offer support to or refer on children of substance misusers, but this tends to happen mainly in cases where risk is identified, or where a child is identified as a young carer. Front line professionals who come into contact with children of substance misusers most frequently (e.g. teachers, GPs) perceive that they lack specialist knowledge about what to do, and who to refer on to, and so generally steer clear of getting too involved, or even asking questions. This may result in the potential for many children and young people to be at risk of falling through the net and coming to the attention of services only when their circumstances have reached complex and critical levels. Local initiatives include the following: Children Link Project Officers post: As part of its response, Inclusion has two designated Children Link Project Officers post. Situated in the adult service, their role is to bridge adult and children s services and liaise with early help services and social care. Midwife business case: In 2009, the Rosie Maternity Hospital in Cambridge set up a Pregnancy Substance Misuse Service. The aim was to improve health outcomes for mothers and babies, encourage the addressing of substance misuse issues, reduce the did not attend (DNA) rate and liaise with multi agency teams. From October 2013 to March 2014, the DAAT funded a specialist midwife post with the proviso that this must result in improved communication between The Rosie, health visitor and substance misuse teams. Results of this included: o Improved communication with all pregnant women being screened for substance misuse, and health visitors informed. o A decrease in admissions to the Neo natal Unit and reduced days in hospital o Close liaison between the specialist midwife and pregnancy liaison specialist nurse at the substance misuse service CASUS: CASUS employs one worker who works almost entirely with such children of substance misusing parents - they may or may not be substance misusers themselves. They are then encouraged to link with young carers support groups. In addition, Stepping Stones is a programme run specifically for such young people. Key to the work is building up resilience in young people and preventing them becoming substance misusers themselves. Through this work, some parents have finally sought treatment. 57 This is reported under the instruction of the Working Together 2013 document 38

39 2.0 Prevention and early intervention For both young people and adults, data suggests that ongoing work is needed to both prevent substance misuse in the first place, and ensure that treatment is delivered swiftly, should it be required. The following continue to be of concern: For young people, high rates of hospital admissions for alcohol misuse continue to be recorded for Cambridge. Few adults before the age of 30 access alcohol misuse services. The risks surrounding NPS are not understood by potential users (see next section) 2.1 Local response Local services continue to deliver IBA services; all staff in custody suites have now been IBA trained. In addition, a new role of liaison nurse in Addenbrookes hospital will identify patients at risk and refer to community based services. 3.0 Emergence of Novel Psychoactive Substances (NPS) Novel Psychoactive Substances : NPS can be legally bought and can be categorized as: 1) Products with names which give no indication of what they contain; 2) Named and specific substances which are designed to be similar chemically and/or pharmacologically to known specific, controlled drugs; 3) Substances related to medicines; and 4) Herbal or fungal materials or their extracts 58. Club drugs: Club drugs too have considerable risks associated with them and are defined as a collective term for a number of different substances typically used by young people in bars and nightclubs, at concerts and parties. These drugs can be harmful and heavy use can develop into a dependency. 59 Estimated availability and use: An estimated 670, year olds in the UK had taken a NPS, or 8.2% of the year population; this represents the highest use in Europe 60. It is reported 61 that 280 new psychoactive substances were identified between 2005 and Supply routes: NPS can be bought online and bypass traditional routes of supply. This means that they are being bought by people who might not necessarily use a traditional dealer. Drug related deaths from NPS: In 2013, there were 60 deaths in England and Wales where NPS was mentioned on the death certificate. 62 This equates to 2% of all drug related deaths (n = 2955). 3.1 Local response As a response to concerns about the use of NPS, in 2014, Cambridgeshire DAAT together with the Safer Peterborough Partnership published their Novel Psychoactive Substances and Club Drug Strategy. The overarching priority of the strategy is aligned with Cambridgeshire DAAT existing priorities and is as follows: To work in partnership with stakeholders to plan, implement and deliver an appropriate and effective response to NPS and Club Drugs within Cambridgeshire, incorporating demand and supply 58 Advisory Council of the Misuse of Drugs; Consideration of the Novel Psychoactive Substances ( Legal Highs ) National Treatment Agency; Club Drugs: Emerging risks and trends The United Nations Office on Drugs and Crime; World Drug Report European Monitoring Centre for Drugs and Drug Addictions European Drug Report

40 reduction initiatives, in order to raise awareness and reduce harm to Cambridgeshire s communities with a particular emphasis on young people and those in vulnerable groups. Expected outcomes in 2014/15 include the establishment of baseline data regarding use, increased public awareness and where to access information and support, increased staff confidence to identify and respond, and accessible and effective interventions. (Results of a local consultation exercise on NPS use in Cambridgeshire are in section the next section). 4.0 Harm reduction As mentioned in the drug section, whilst agreement of the offer of harm prevention to new clients is high, later acceptance of vaccinations is low. The report Shooting up 63 provides valuable guidance based on the following prevalence data: Hepatitis C: Data suggests that there are still high levels of hepatitis C in the injecting population. Of substance misusers who inject psychoactive drugs (such as heroin, mephedrone), two in five have hepatitis C, half of which are undiagnosed. On average of one in 30 people who inject image and performance enhancing drugs have hepatitis. C. Hepatitis B is now rarer, and has declined following vaccine uptake; it is considered however that vaccine uptake rates should be higher. HIV: Approximately one in 100 injectors live with HIV; uptake of care is high. Overall, whilst progress has been made, injecting risk behaviours remain a problem, not least because of the change in drug injection. This has recently included amphetamines and amphetamine-type drugs such as mephedrone. An additional issue has been the low numbers of steroid misusers, especially injectors, who present for treatment. This is a treatment gap in the main because of a perception by the users, that they have not a problem or do not fit with a stereotypical treatment client. High rates of alcohol related and specific hospital admissions and deaths also highlight the need for harm reduction work. 4.1 Local response In Wisbech, a BBV pilot scheme is bringing vaccination appointments closer to the actual assessment session, to reduce the low uptake rate. If this is successful, this will be rolled out county-wide. In addition, the team is working towards health promotion initiatives to steroid users, offering a confidential service for Hep B vaccination. Steroid misusers who have accessed treatment are reported to have made the decision based on word-of-mouth recommendations. 5.0 Transitions from young people s services to adult services Historically, once young people in treatment reached their 18 th birthday, they transferred to the adult treatment service if treatment was still required. However, both the services and commissioners were aware that transferring at this age was not always in the young person s best interest and loss of engagement was a continual risk; research conducted in 2012 indicated that a more flexible approach was required. 63 Public Health England (Nov 2014) Shooting up Infections among people who inject drugs in the United Kingdom

41 5.1 Local response Following a review in 2014, the young people s treatment service have been commissioned to work with up to 20 young people aged to ensure that if it is not appropriate for them to transfer directly to the adult service, their treatment needs and vulnerabilities are met. Of course, the service continues to work with all young people with the aim of reaching a point where they have completed treatment by age 18 or are in a position to successfully transfer. As the young people s activity data shows, 18 young people out of the current 223 in treatment in Cambridgeshire have remained to continue treatment with the young people rather than adult service. Transition of care from the secure estate There has been a reduced use of custody for under 18s, but those young people who are detained in secure estates usually have significant and complex needs. Thus, the continuity of care between the secure establishment and community is vital. A snapshot of young people in secure estate in March 2014, who were receiving substance misuse treatment numbered 9 from Cambridgeshire. 6.0 Older people in treatment There are considerable grounds for concern that there are unmet needs within communities and problems are likely to increase. Drug misusers Opiate misuse: In the case of opiate misuse, people aged 40 and over are regarded as older (NTA 2010a). This is because opiate misuse has traditionally been seen as a problem mainly in people under the age of 40; now that many more opiate misusers are surviving for longer, 40 is used as a cut-off point to define the older population (Crome et al, 2009). Estimates suggest that the number of people over 65 with a substance use problem or needing treatment will more than double between 2001 and Alcohol misusers Alcohol Concern research has looked at alcohol related hospital admissions for older people with mental health and behavioural problems associated with alcohol. 65 The key findings include: Between 2011 and 2012, there were 9,814 hospital admissions in England for people aged 60 and over with alcohol related mental health and behavioural disorders. This percentage has risen at a higher rate than that for younger people. For the age group years, the rise is 150% from 3,247 to 8,120. Currently, these admissions outnumber those for alcohol related liver disease. Older people aged 75 plus with mental and behavioural disorders associated with alcohol, experience longer stays in hospital than younger adults. Alcohol misuse in older people is reported to be less recognised than in younger populations; but one in six older men and one in 15 older women are estimated to be drinking at levels that could harm their health Local response The last Cambridgeshire Older People s Joint Strategic Needs Assessment 67 (JSNA)reports that there are 101,400 residents in Cambridgeshire aged 65 years and over. This number is expected to rise by 64 European Monitoring Centre for Drugs and Drug Addiction, 2008; NHS Information Centre, 2009b; National Treatment Agency for Substance Misuse, 2010a 65 Alcohol Concern (2012) Trends in alcohol related admissions for older people with mental health problems: 2002 to

42 19% in the next four years. The CATCH 68 group of surgeries report that for 2012/13, 24% of predicted spend on alcohol related hospital admissions and A&E activity in Cambridgeshire will be for people aged over 65. As most older or elderly people are registered with GPs and will, as they get older, make increasing numbers of visits to GPs, it is logical that early prevention and intervention work should be undertaken in primary health settings with front line professionals trained to identify drug misuse and deliver IBA interventions. 7.0 Victims of domestic abuse Domestic abuse is defined as an incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. 69 This can encompass, but is not limited to psychological, physical, sexual, financial and emotional abuse. Domestic abuse occurs across society regardless of age, gender, race, sexuality, wealth and geography. The overwhelming majority of reported domestic violence is experienced by women and children and perpetrated by men. National Prevalence: National evidence suggests that in 2011/12, 7% of women and 5% of men were victims of domestic abuse. 70 Women experiencing domestic violence are up to fifteen times more likely to misuse alcohol and nine times more likely to misuse other drugs than women generally. 71 Local prevalence: Data provided by the Independent Domestic Violence Advisory Service (IDVAS) indicates that during 2013/14, 1728 referrals were received by the service. This is a dramatic increase since the last needs assessment reported 482 in a six month span in Of last year s total, 61% engaged with the service; 41% of all referrals were repeats. Whilst these numbers are not substance misuse specific, they give an indication of potential prevalence. Substance misuse and domestic violence: Cambridgeshire DAAT and Cambridgeshire Domestic Abuse and Sexual Violence Partnership (CDASVP) work firmly from the perspective that there is not a causal link between substance use and violence; alcohol or drug use should never be accepted as an excuse for violent or abusive behaviour and neither should women s substance use be used to justify their experiences of violence. However, it is understood that violence may increase when individuals are withdrawing from drugs or alcohol and they therefore need to pay close attention to the increased danger in which their partners and children may be placed. In Cambridgeshire, anecdotal evidence suggested that substance use amongst victims experiencing domestic violence is high but as it is not recorded, we do not have any exact figures. 67 JSNA (2013) Prevention of ill health in older people 68 Over, Bar Hill, Willingham, Cottenham, Swavesey, Melbourn, Comberton, Bourn, Linton, Harston, Cornford House, Mill Road, Cambridge, Queen Edith s Way, Cambridge, Gt Shelford, Lensfield Road, Huntingdon Road, Trumpington Street, Bridge Street, Red House, Petersfield, Waterbeach, York Street, Woodlands Surgery, Cambourne, Newnham Walk, Arbury Road, Nuffield Road, East Barnwell, Milton, Cherry Hinton, Histon, Bottisham, Sawston British Crime Survey 2011/12 42

43 7.1 Local response Information sharing: In the last year, the DAAT and the CDASVP has been working closely to encourage workers of both services to share information and refer clients when appropriate. Substance misuse treatment workers also collocated with the colleagues in the IDVAS so that the staff teams are introduced effectively to the work of other agencies. 8.0 Support for recovery The following cross cutting themes specifically address areas that can support recovery. 8.1 Accommodation Appropriate and sustainable housing is a foundation for successful rehabilitation of substance misuser potentially sustaining employment, drug treatment, family support and finances, and is a major resettlement need for those leaving prison and residential rehabilitation in particular. Most housing providers have particular criteria that a potential resident must meet initially and then each client is assessed on their need and suitability as an individual. This often is not manageable for substance misusing clients. Nationally, 4% of clients in alcohol treatment in 2013/14 reported that they had an urgent housing problem; a further 10% had other housing problems. (NDTMS) Local response In Cambridgeshire, Jimmys a controlled drinking house for controlled drinkers with six beds; this provides monitored accommodation for dependent drinkers. In addition, Jimmys are in negotiation regarding setting up accommodation for individuals who have completed a community alcohol detox in a hostel. 8.2 Mental health Studies have indicated that 75% of users of drug services and 85% 72 of users of alcohol services may experience mental health problems but such prevalence is not captured in data as many individuals are undiagnosed and untreated. Accessing treatment as a substance misuser can be problematic with mental health services reluctant to assess a client who is currently engaged in drug and/or alcohol treatment services. This leaves many clients in no mans land where they feel they are forced to continue to self-medicate to be able to function. Personality Disorders have not been singled out as requiring specific attention until recently. The Bradley Report 73 estimated the prevalence of Personality Disorders at 66% in the prison population and 5.3% in the general population. Whilst neither figure accurately suggests the prevalence in substance misusing populations, it is useful contextual data Local response Local data on prevalence of mental health problems does not give a complete picture of the situation. This is due to reporting being based on an individual having a diagnosed condition. This is a small group compared with the numbers of substance misusers with non identified or diagnosed conditions. Many of these are low level, but require primary health care support. The lack of data on this group means that partnership response may be compromised Dept Health (2009) The Bradley Report; Lord Bradley s review of people with mental health problems or learning disabilities in the criminal justice system. 43

44 Of data reported, NDTMS indicates that 24% of all adults in drug treatment and 13% of all adults in alcohol treatment were also receiving care from mental health services. This is considerably lower than the 21% reported nationally in relation to the alcohol service. It is important to note that this is not an indication of the prevalence of mental health problems in these client groups, rather the smaller percentage actually receiving specific support. Mental Health data has been requested from the CCG, Public Health and Hostels, but at the point of writing had not been received The treatment profile for individuals with personality disorders is increasing and will be addressed in the next Dual Diagnosis Strategy. In 2012 specialist ex offender accommodation services were commissioned in Huntingdon and Cambridge with open access to offenders with substance misuse issues who are engaged in treatment in the community. A 10 bed unit is now provided in Cambridge City and Four 2 bed units in Huntingdon alongside a further 2 bed unit in Huntingdon and another 2 bed unit in Wisbech specifically for substance misusing ex-offenders. The projects aim to work with statutory and non-statutory criminal justice services including Police Integrated Offender Management, Prisons and the New Probation Service to ensure offending behaviours are managed alongside substance misuse, debt, health and education and training needs to enable service users to eventually live independently within the community. CASUS team has a Consultant Psychiatrist who works with young people and their families who are affected by substance use disorders (SUD) or who suffer from co-morbid substance use and at least one other mental health diagnosis; as a result, prescribing can be delivered. Now in its third year of operating, a mental health pathfinder initiative in Cambridgeshire has placed mental health nurses within the county s Integrated Offender Management (IOM) teams. The aim is to identify and assess offenders with mental health needs, estimated at just below 40% and refer them to appropriate mainstream treatment. This cohort also has high prevalence of drug and/or alcohol misuse issues so a number of cases are dual diagnosis. The success of this model of working has resulted in the model being rolled out for victims of crime. 8.3 Education, employment and training Local response The Recovery Works pilot 74 has been running in the county; funded by the Department of Work and Pensions, it offers employers 2,000 for each substance misuser (drug and alcohol) in treatment that they successfully engage in work. Monitoring data 75 collects the status of drug misusers successfully completing treatment. The number of clients working more than 10 days in the last 28 days at exit numbered 36% 8.4 Recovery Champions Local response Recovery Champions has been running successfully for some years to assist and support vulnerable adults entering the treatment system and those already established but struggling in their treatment Diagnostic Outcomes Monitoring Executive Summary 2013/14 Quarter 4 44

45 journey. Using service users who have recovered from their drug misuse, peer support is offered in a more informal that encourages retention in the treatment system and improvements in health and wellbeing resulting in better outcomes in the treatment system. It will also empower individuals both the individual in treatment and the peer, to achieve their personal goals which will build selfconfidence and help combat fear. The Inclusion Alcohol Treatment Service and Inclusion Drug Treatment Service are represented by both Community Recovery Champions (service users) and Therapeutic Recovery Champions (staff members) and are involved in many recovery initiatives such as developing links and partnerships with other organisations, developing care pathways and promoting recovery in other ways. 8.5 Families and carers Having a relative or friend who is a drug misuser is an extremely stressful experience, which can affect individuals physical health and psychological wellbeing, finances, social lives, and relationships with others. These impacts often mean that families, kinship carers and other carers need help in their own right, to enable them to cope better with what are usually ongoing, long term issues Local response The following groups are meeting the needs of families and carers: Parents and carers groups: The drug treatment service runs groups for parents and carers around the county in Cambridge, Huntingdon, Chatteris and Ely. In addition, one to one sessions are offered as necessary and phone support. Information sessions: Inclusion also offer information sessions to groups such as the Women s Institute and village groups. Countywide support groups: A number of groups are also available, run by independent charities and also provide support for families and carers of substance misusers, such as Centre 33, Crossroads Care and Family Anonymous. Key findings: Cross Cutting themes a. Children of substance misusing parents: Snapshot data shows very high numbers of children living with substance misusing parents in treatment; there are concerns that these children may be hidden and their needs not met. b. However, new roles of child link worker posts at Inclusion, and a worker at CASUS to encourage young carers to access support are in place, but the numbers involved highlights the need for maintained and monitored provision to meet the needs of this vulnerable group. c. Prevention/ Early Intervention: Data on young people s hospital admissions for alcohol misuse and onset of treatment for adults suggests further preventative and early intervention work. IBA has been rolled out in all custody suites; a new liaison nurse role in Addenbrookes will link patients with community services. d. NPS is of concern nationally, but local figures are, as yet, not showing similar trends; however a local strategy has been agreed between the DAAT and the Safer Peterborough Partnership on how to proceed. In addition, a recent survey has been conducted to ascertain legal high use, and the situation is being closely monitored. 45

46 e. Harm reduction: Uptake of BBV treatment figures, do not compare well with national averages; the move to offering vaccination immediately is welcomed. High rates of alcohol related and specific hospital admissions and deaths are of concern. f. Transitions: In order to ensure that young people do not dis-engage when they reach 18 and were historically supposed to transition to the adult service, they now can remain in the young people s service. When transition is necessary, this is closely backed up by joint working. g. Victims of domestic abuse: Cambs DAAT and Domestic Violence work closely together recent work is encouraging increased information sharing and referral where appropriate. h. Support for recovery: The new post detox house for hostel residents who have undergone community based detox will increase chances of maintaining abstinence. In addition, ex offender accommodation services have been commissioned for Cambridge and Huntingdon. E. CONSULTATIONS Cambridgeshire DAAT has undertaken a number of consultations in the last year. Key points emerging will inform future service provision. 1.0 NPS During September 2014 a consultation took place to identify local patterns, prevalence and trends in NPS use across Cambridgeshire, and thus, what responses and interventions are required to prevent harm from NPS use. Whilst the sample was selected in that the interviews were conducted at night time venues, nevertheless, the consultation gives a valuable insight regarding the current situation. 100 Cambridgeshire residents aged over 18 years were interviewed at night time venues in Cambridge, Ely, Peterborough, Huntingdon, March and Wisbech. Most respondents were aged between 18 and 34 years and included slightly more males than females. When were respondents were asked if they used illegal drugs, almost half answered yes. When asked if they used legal highs, just under 30% said yes. The main types of legal highs used were stimulants, followed by hallucinogenics. These were described with a wide range of names. Over 50% of users cited home as the place they used legal highs, followed by party and club. When asked how often legal highs were used, almost 40% of respondents said once a month ; 15% said every week and less than 10% said every day. The source of the drugs was varied and included friends, local dealer, shops and online. 1.1 Key findings of the consultation Many NPS users are young people in clubs, but use is much wider. 46

47 Some users made informed decisions about what they were taking and accepted the risks involved; the majority had no idea of what they were taking and minimized the risk. Dealers were taking advantage of this situation. Most respondents said they were reluctant to access traditional drug services due to the stigma attached; this meant they were receiving no information or support from this resource. 1.2 Recommendations from the consultation Education and harm reduction information. Training for professionals, and the development of strong links between treatment, health and sexual health. Increased use of outreach volunteers trained in targeted interventions. 2.0 Service user consultation During October 2014 a consultation took place with current / previous and treatment naïve service users, in order to explore their views about the current substance misuse treatment system. 45 Cambridgeshire residents aged over 18 years were interviewed across the county; Cambridge, Ely, Elm and Wisbech. Most respondents were aged between 35 and 59 years and included slightly more males than females. When the respondents were asked whether they were involved with the Drug or Alcohol Services, 78% are currently involved, 20% were previously involved and 7% had never been involved. Just under half the respondents were currently engaged with Inclusion Alcohol Service and 38% were currently involved with Inclusion Drug Treatment Service. Out of the 15 respondents that stated that they currently had an opioid substitute prescription, 60% still reported to be using on top citing boredom and using on payday as the main reasons. 2.1 Key findings of the consultation The majority of respondents reported that they had been involved in developing their care plan and had signed it. When the respondents were asked whether they used the Local Pharmacy, 40% of respondents stated that they did for prescription pick up and needle exchange services. Every respondent was happy with the service that they received. The majority of respondents reported that they were happy with their accommodation, those that were not did report that the treatment service that they were engaged with had been very supportive to try and move them to more suitable accommodation. When asked if the treatment service had provided information and support regarding training / employment information, 62% reported that they had received this information. The majority of those that had reported no, stated that this was either their choice, was unable to work or was already working. 2.2 Recommendations from the consultation Ensure that every service is given information regarding Blood Borne Virus, with particular emphasis on asking whether they would like to be tested and vaccinated against Hepatitis B and tested for Hepatitis C. 47

48 To continue to improve the pathways between Mental Health Services and Drug and Alcohol Services. Improve the waiting times for initial assessment Better access to Inpatient Detoxification Publicize services more so people know where they can access help. APPENDICES Appendix 1: Service user consultation 1.0 Background The DAAT carried out a service user consultation in September - November 2014 as part of our Needs Assessment process. 45 current/ex-service / treatment naive users around the county were interviewed. Summary of respondent profiles were as follows: - Just under half of them were females. - A half of the interviewees were in 35s-59s age group, 33% were in 18s-34s age group and 9% were over 60 (4 individuals). - 2% were Eastern European, 93% were White British (4% did not give ethnicity) - 17% have children under 16s living with them. - 77% respondents live in Cambridge, 13% in Wisbech, 4% in Ely and 4% did not provide an answer. 2.0 Summary of the feedback Service engagement Of 45 respondents, 7(16%) said they used to a have problem with drug/alcohol. The remaining use drugs or alcohol, 31(69%) of these respondents are engaged with either the Drug or Alcohol Treatment Service. Of those 31, 23% stated that they use heroin, either as the primary drug or alongside other drugs, 13% stated that they drink alcohol either as the primary drug or alongside other drugs. Of those 45, 12 respondents reported that they had previously or never accessed treatment. 48

49 Using on top Of 35 drug and alcohol users, 12 (34%) of them are currently on scripts. Service users 35 Of those 12, 7 (58%) said that they use on top. The substances used on top were mainly heroin and crack. Service users on scripts Use on top Reasons for leaving treatment There are 7 individuals who had previously involved with treatment services but have now left. The leaving reasons were: - Successfully stopped using - When came out felt that support offered was not suited to personal circumstances. - Didn t attend appointments so my script was stopped - No intention of stopping [drinking] - The below comments are particularly worth mentioning: "Didn t feel key worker was helping at all. Seemed just want you to attend Doctor s appointments Was discharged, as didn t attend for a while. Felt little was done to find out why this was, just got a letter discharging me. Reasons for not involving with the treatment When asked why they were not involved with the treatment system, the majority of respondents admitted that they did not want to ask for help or were sceptical about the treatment. Only drink and use at parties. Might be excess, but not affecting life. Don t know where Drug and Alcohol Services are Not felt necessary but wouldn t know where service was anyway. Would go to GP if felt had a problem. No real perception of where the Alcohol and Drug services are in Wisbech. Felt they were only for full blown addicts. Not really a problem. If felt out of control would talk to GP. 91% interviewees confirmed that they don t feel there is any barrier in accessing treatment services. Services at Pharmacies We asked for feedback on specific services including needle exchange, supervised consumption or medication pick up. All of those respondents that used this facility were happy with the services provided at their local pharmacies. 49

50 Needle exchange In general people were happy with the needle exchange system and the packs thought to be good. There was a suggestion that there could be more support equipment and condoms provided with the packs. The majority of people thought that providing more bins and keeping the exchange open for longer would encourage people to discard needles safely. Accommodation Of 45 people answered the question about accommodation, 9 (20%) stated that they were not happy with their current accommodation arrangements. However over half has received support from Inclusion and Access Surgery with finding alternative suitable accommodation. Carer/family support Over half of the respondents said that they were aware of family/ friends or carers support groups. The feedback shows that the family support service is well promoted and offered in Cambridgeshire. What would you like to change? We asked what changes people would want to make to improve the drug/alcohol treatment system and support services. Availability and access especially when you are on the streets rather than use A and E. Vulnerable people can be ignored. St Neots not very well served. More aftercare after Rehab could improve communication especially initial phone answering and ensuring messages get through to appropriate people. Try to keep key workers consistent, build a rapport and then use it to keep it as consistent as possible. More supportive in early stages of recovery. Seem to want to rush you out of door once recovered. Needs more aftercare support. Better inter-relationship between Alcohol service and Mental Health. Not simply discharging people due to temporary lack of contact. More publicity about where to go. Better support for those leaving prison. Better understanding of Mental Health and Drugs. Better detox facilities, easier to get initial assessments. More late night opening. More quicker Rehab facilities, less time to lapse. More information to young people about where the services are and who they are. 50

51 Feedback can be listed under the four main themes: Improve availability and access. Improve aftercare support. Improve access to Inpatient Detox and Rehab. Better interaction between Mental Health and Substance Misuse Services. Appendix 2: NPS 1.0 Background A NPS survey was carried out in order to explore and identify local patterns, prevalence and trends in NPS use across Cambridgeshire. 100 respondents around the county were interviewed. Summary of respondent profiles were as follows: Just under half of them were females. Just over half of the respondents were in the 18s 24s age group, 32% were in the 25s 34s age group and 9% were over 35 years old. 37% of the respondents lived in Cambridge, 17% in Ely, 10% in Huntingdon, 12% in Wisbech, 17% in Peterborough and 6% in March. 2.0 Summary of the feedback Do you take drugs? Of 100 respondents, 26 (27%) said that they take Novel Psychoactive Substances. Just under half of all the respondents said that they took illegal drugs. What type of drug is it? 69% had tried a stimulant 39% a Hallucinogenic 15% another substance 12% a depressant 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% What type of drug was it? Stimulant Depressant Hallucinogenic Other (please specify) 51

52 What did the substance look like? What did it look like? Powder Crystal Capsule Pill Herbal type Liquid Canister Other (please specify) 39% said it was a powder 39% said that it did not look like any of the substances listed. 8% said that it was a herbal type 8% said that it was a liquid 4% said that it was a pill 4% said it was a canister. How did the respondent use it? How did you use it? Sniffed it Swallowed it Smoked it Injected it Other (please specify) 46% said that they sniffed it 27% said that they used it in another way such as cheeked it or put it in a balloon 19% swallowed it 8% smoked it. 52

53 Where do you use it? Where did you use it? Club Pub Home Party Other (please specify) 42% of the respondents said that they used the substance at home 27% at a party 15% at a club 15% specified other, which included in the street and at a festival. When did you last use them? When did you last use them? In the last week In the last month In the last six months In the last year Longer than a year 39% stated that they had last used NPS in the last 6 months 30% in the last week 27% in the last month 4% in the last year 0% longer than a year 53

54 How often do you use Novel Psychoactive Substances? How often do you use legal highs? Every day Every week Once a month Once every six months Once a year 39% of the respondents stated that they would use NPS once a month 19% said that they would use it once every 6 months 15% said that they would use it every week 15% said that they use it less often than a year 8% said that they use it every day 4% said that they used it once a year. Appendix 3: Cambridgeshire Constabulary s Criminal Justice data 1.0 Background On the 23 rd December The members of the Joint Commissioning Group were asked to review the draft Needs Assessment. S Ward highlighted that the CJ section of the document did not detail the police data. It was agreed that the following four areas would be considered for inclusion in the Needs Assessment document: o Frequent Attendees to custody the countywide cost to the Constabulary for persons with substance misuse & mental health concerns returning to custody many times is approx. 3,000,000 in man hours of which 65% of these persons are not known to services 54

55 o o o Drugs and substances seized by police data :this data will detail the new trends in the drug using market Custody referral forms data this data is persons in custody referred to services by police custody staff Drug testing data: This will inform the Needs Assessment on the number of Cambridgeshire residents (not including Peterborough resident data) drug tested for (cocaine, heroin and crack) 2.0 Frequent Attendees to custody Over the last 18 months the police have been monitoring persons who return to custody more than twice in a twelve month period. All the persons being monitoring have been highlighted as part of a risk assessment - that they have drugs, alcohol or mental health concerns in some cases the persons can have multiply concerns. This data is a rolling twelve months and captures persons with escalating offences and trends. You will note from the charts below, that many of these persons are not known to services and at present there is no direct custody pathway into treatments services (no commissioned intervention workers working in police custody suites). The data is divided into three areas: o o o Huntingdonshire Fenland Cambs city, Cambs South and Cambs East Each coloured block of cells represents a person, it identifies if they are male or female, known to services, not known to services, drugs, alcohol or MH markers, how many times they have been in custody in a rolling twelve months and age. Data period for all charts is: December November Some of the persons have returned in a short period of time and in some cases the crime type has escalated. This data only details the persons causing the most harm to themselves or their community. Countywide the Constabulary has more than 1,200 persons each month who are considered a frequent attendee. Huntingdonshire Thorpe Wood (TW) Custody Male yes yes yes Female no no no Known to Services yes Not Known to Services yes yes Drugs Marker yes yes yes Alcohol Marker yes yes Mental Health Marker yes How many times person being into custody in rolling twelve months Age

56 Fenland PIC custody Kings Lynn Male yes yes yes yes yes yes yes yes yes Female yes Known to Services yes yes yes Not Known to Services yes yes yes yes yes yes yes Drugs Marker yes yes yes yes yes yes Alcohol Marker yes yes Mental Health yes yes Marker How many times person being into custody in rolling twelve months Age Cambs city, Cambs South and Cambs East Parkside Custody Male yes yes yes yes yes yes yes yes Female yes yes Known to Services yes yes Not Known to yes yes yes yes yes yes yes yes Services Drugs Marker yes yes yes yes Alcohol Marker yes yes yes Mental Health yes yes yes yes Marker How many times person being into custody in rolling twelve months Age Cambs city, Cambs South and Cambs East Parkside custody cont../ Male yes yes yes yes yes yes yes yes yes yes Female Known to Services yes yes yes yes yes Not Known to Services yes yes yes yes yes yes 56

57 Drugs Marker yes yes yes yes yes yes Alcohol Marker yes yes yes yes yes Mental Health yes yes yes yes Marker How many times person being into custody in rolling twelve months Age Cambs city, Cambs South and Cambs East Parkside Custody cont../ Male yes yes yes yes yes yes yes yes yes Female yes Known to Services yes yes yes yes Not Known to Services yes yes yes yes yes yes Drugs Marker yes yes yes yes yes yes yes Alcohol Marker yes yes Mental Health yes yes yes yes Marker How many times person being into custody in rolling twelve months Age Cambs city, Cambs South and Cambs East Parkside custody cont../ Male yes yes yes yes yes yes yes yes yes Female yes Known to Services yes Not Known to Services yes yes yes yes yes yes yes yes yes Drugs Marker yes yes yes yes Alcohol Marker yes yes yes Mental Health yes yes yes Marker How many times person being into custody in rolling twelve months Age Cambs city, Cambs South and Cambs East - Parkside Custody cont../ Male yes yes 57

58 Female Known to Services yes Not Known to yes Services Drugs Marker yes Alcohol Marker Mental Health Marker How many times person being into 4 4 custody in rolling twelve months Age Drugs and substances seized by police data The police Drug Experts monitor the Cambridgeshire seizures these drugs are seized as part of arrest and complex drug cases. The list does not detail quantity or purity it is just to give you an understanding of the type of substances being used by the Cambridgeshire population. I would highlight the importance that any needs assessment and new substance misuse contracts should lead to the development of flexible services that can delivery intervention that reacts quickly to emerging trends. The present treatment service is very much opiates focus. Herbal Cannabis Heroin Cocaine Crack cocaine Cannabis plants MDMA Cathinones Methadrone Ketamine Amphetamine Cannabis resin Various NPS Please note that during 2014 No Khat or Methamphetamine was seized by Cambridgeshire Constabulary. 4.0 Custody referral forms data this data is persons in custody referred to services by police custody staff In April 2014 the Constabulary worked very closely with Addaction to support the IBA (Identification Brief Advice) training of all custody staff. This training and awareness of alcohol NHS misuse enabled the custody staff to complete a referral form and direct persons into services. This is not a mandatory referrals and persons detained in custody give consent for their personal details to be shared with services. The custody staff received refresher training in September 2014 and this was supported by Inclusion. Liaising with persons in custody and completing IBA and a referral form is only a small part of the custody staff role therefore we are aware that we do miss many persons. 58

59 Once Services receive the referral they work directly with the referred persons using varies methods of intervention support. April 2013 December 2014 data Drinksense Peterborough Aspire Peterborough Inclusion Cambridgeshire 50 referrals 36 referrals 88 referrals Please note that Peterborough (Thorpe Wood) Custody has intervention workers in the custody suite therefore this may be why the numbers of referrals are lower than the referrals from Parkside. 5.0 Drug testing data: This will inform the Needs Assessment on the number of Cambridgeshire residents (not including Peterborough resident data) drug tested for (cocaine, heroin and crack) Drug Testing at Thorpe Wood (TW) custody Peterborough is targeted intelligence drug testing. A person is only drug tested if there is evidence of drug use or intelligence of use. When Huntingdon custody was closed it was agreed that Huntingdonshire persons arrested, who attend TW custody would be considered for targeted intelligence drug testing. The kits test for opiates, cocaine and crack cocaine. Once a person tests positive there is a mandatory referral by the Custody Sgt for the person to attend an initial assessment and follow-up with the drug service. The table below details all the Huntingdonshire persons drug tested and the number of positives for opiates, cocaine and both Jan Feb Mar April May June July Aug Sept Oct Nov Dec Opiates Cocaine Both Number of Hunts persons tested Cambridgeshire Constabulary is part of a National working party that is working with the Home Office with the objective to develop drug testing. The development would be to test for other drug types, and the list detailed in 3.0 is the Cambridgeshire proposed list. 6.0 Conclusion The data included in this paper details some Cambridgeshire persons coming into police custody with highlighted substance misuse concerns. Working with our partners we have implemented some intervention pathways, and we are open to developing these pathways to support early intervention and prevention. 59

60 Appendix 4: START Criminal Justice referrals Table 1 (RA data) 60

61 1.0 This table provides a breakdown of the Constabulary Targeted Engagement (Required Assessment) outcomes at the substance misuse service provider level for the period December 2013 to December (Targeted Engagement or mandated drug testing in custody was a Home Office funded initiative for high crime areas served by an Intensive Drug Interventions Programme, to mandate drug misusing offenders to engage with drug treatment. Peterborough was established as an Intensive DIP and received the additional funding to facilitate this initiative, Cambridgeshire however was established as a low crime area and was funded as a Non Intensive DIP without the remit or resource to provide any drug testing in custody or arrest referral programme). It demonstrates that the referral process for the Required Assessment documentation between Constabulary and Inclusion START is robust with all 40 referrals having been identified by Inclusion during this period. It also demonstrates the attrition (drop out) rates from this mandatory referral pathway in respect of persons not attending their appointments and, most importantly from a treatment provider perspective, the conversion rate from referral to effective treatment engagement. (Effective treatment is regarded as engagement with structured Tier 3 treatment for 12 or more weeks). 61

62 Table 2 (CC data) 2.0 This table provides a quarterly breakdown from October 2013 to October 2014 for all Police Drug Conditional Cautions received by the Inclusion START service. It represents all Conditional Cautions issued across the 4 existing custody suites for Cambridgeshire detainees including Cambridge Parkside, Huntingdon, Peterborough Thorpe Wood and the Kings Lynn custody suite dealing with persons arrested in the Fenland area of the County. 62

63 The table represents the compliance to attend the treatment service as the main Condition of the Caution as well as demonstrating the conversion rate from referral via this pathway into effective treatment. Table 3 (Custody Referrals) 63

64 64