JSNA Substance Misuse Introduction 9.1. Substance misuse causes less damage to health in absolute population terms than tobacco or alcohol. However, its association with crime and antisocial behaviour means drug use poses particular challenges to public health as it a significant impact on the wellbeing of individuals, their families and communities. The Home Office estimates that Class A drug use generates an estimated 15.4 billion in crime and health costs each year, of which 99% is accounted for by problem drug users1. The illegal nature of drug use makes it difficult to engage users in treatment and a large proportion have significant unmet health and social care needs. 9.2. Approximately 1% of those who have ever used drugs are or will become a problematic drug user (PDUs). However, the majority of drug use can be deemed recreational and although still harmful to health will have limited social impact to the user. Defining problematic drug use is difficult as it could be dependant or recreational in that it is not the frequency of use but the effect that it has on an individuals life. In terms of substance misuse services a problematic drug users refers to someone who uses opiates (heroin, morphine, codeine and /or crack cocaine). This includes people who use other substances in addition to these, even if these are the primary drug of use.1 While this is useful for planning drug treatment services as the majority of drug use is deemed non problematic users are unlikely to ever come into contact with services although the public health implications of nonproblematic drug use are significant and include low level mental ill health, accidents, crime and antisocial behaviour. Mortality and morbidity associated with substance misuse 9.3. All drugs have adverse consequences on health. Cannabis is associated with an increased risk of cancer, possibly higher than smoking tobacco alone due to the concentration of carcinogenic chemicals in cannabis. Cannabis can also cause a range of mental ill health, from short-term anxiety, depression and paranoia to more serious psychosis. If smoked with tobacco it can lead to nicotine addiction. Cocaine is a highly addictive stimulant which acts on the central nervous system. Crack Cocaine is cocaine that has been neutralised by an acid to produce a hydrochloride salt resulting a rock-like crystal which relapses vapours when heat that are smoked. Both cause the coronary arteries to constrict, raising blood pressure and reducing blood supply to the heart, which can result in heart attacks and seizures. When Cocaine is mixed with alcohol, a third substance cocaethylene is produced which increases the toxicity of both substances and increases the risk of sudden death. Long term use of
cocaine and other stimulants puts stress on the cardiovascular system and increases the risk of stroke and heart problems. Heroin is a highly addictive opiate made from morphine which slows body functioning and reduces physical and psychological pain. It can cause respiratory depression, and overdose is often fatal. 9.4. It is not only the substances themselves but also the method used to administer them which pose serious threats to health. Nasal inhalation over a long period causes degradation of nasal cartilage. Smoking can cause a range of respiratory conditions, including lung cancer. Injecting causes vein damage and has a high risk of infection from blood born viruses such as HIV and Hepatitis B and C, and bacterial infections including wound botulism. 9.5. PDUs are often also dependant on alcohol, which not only causes its own health problems but also aggravates drug related health conditions and adversely affects treatment outcomes. PDUs who are also alcohol dependant are more likely to overdose, have abscesses and vein scaring. 1 Drug related mortality 9.6. Heroin / morphine account for the majority of drug-related deaths and although drug related deaths are reducing, overdose remains the most common cause of death amongst problematic drug users. The annual standardised excess mortality rate amongst heroin users is twenty times that of the general population. 1 In London the proportion of drug-related deaths due to heroin/morphine is lower than in England and Wales while the proportion of deaths due to cocaine is twice as high. 1 9.7. Men are more likely to die from drugs than women and the median age at death is increasing; from 29.7 years in 1999 to 36.4 years in 2008. 1 9.8. Southwark has a higher age standardised rate of mortality from drugs than London, however deaths from drugs are falling, in line with national trends. Figure 9.1: Age standardised mortality rates from drug misuse in Southwark, Lambeth and Londonwide 10 Age standardised mortality rates due to drug misuse 1995-99 and 2000-05 with 95% confidence interval 9 8 Age standardised mortality rate 7 6 5 4 3 1995-99 2000-04 2 1 0 Southwark Lambeth London
Drug related morbidity 9.9.Mental Health The prevalence of mental ill health within the drug using population and the prevalence of substance misuse within the mental health population are both high. Families and carers of problematic drug users have higher rates of mental ill health than the general population. 9.10. Communicable diseases Injecting drug users (IDUs) are vulnerable to a range of blood born viruses and bacterial infections including botulism and staphylococcus aureus. Overall the prevalence of HIV amongst IDUs is low, with approximately one in ninety infected. Within London this rises to one in twenty and around one in a hundred will become infected within three years of injecting. 1 Hepatitis C is the most significant viral infection facing IDUs and over 90% of laboratory notified cases report injecting drug use as a risk factor. The prevalence of hepatitis C and HIV with London s IDUs is high with a prevalence of 43.7% of IDUs testing positive for hepatitis C and 4.3. 1 Injecting drug use is the primary risk factor for hepatitis B and one in six IDUs in the UK have been infected. Despite an effective vaccine hepatitis B transmission continues and reports indicate it may have even increased since the 1990s. A survey amongst recent IDUs of antibodies to hepatitis B core antigen (anti-hbc a marker of current or past infection) found that prevalence increase from 3.4% in 1997 to 10% in 2006, although fell to 4.8% in 2007. 1 Infections at the site of injecting are common with a third of IDUs reporting an abscess, sore or open wound within the last year. Prevalence of drug use 9.11. Population surveys are considered a useful way of measuring certain behaviours in a population and have provided reliable and valid data on tobacco and alcohol use. A large proportion of data regarding drug use comes from the British Crime Survey (BCS), although caution is required when interpreting these figures. Firstly, the illegality of substance misuse means that people are reticent about disclosing past or current drug use thus prevalence is likely to be an underestimation. There is no information about how those who do not respond to the survey differ from those who do which makes it difficult to extrapolate the data to population level, despite its large sample size. Finally the BCS only includes people living in private households, excluding the majority groups who are likely to have higher rates of drug use than the general population, such as the homeless and those living in hostels. A second method of calculating prevalence uses data on those in contact with drug services and through a variety of statistical and modelling techniques estimate the total numbers of problematic drug users in the general population. More robust estimates use a combination of methods and data sources.
London 9.12. London has the largest open drugs market in Europe and self reported drug use is higher in the capital (11.2%) than England as a whole (10.5%). 1 Class A drug use is significantly higher in the capital with 4.1% of Londoners saying they have used cocaine in the past year compared to 2.4% across England and Wales. 1 Within London there are significant differences in the prevalence of drug use. The eight inner London boroughs (Camden, Hammersmith and Fulham, Islington, Kensington and Chelsea, Lambeth, Lewisham, Southwark and Westminster) have higher rates (1.7% compared to 0.40%) in the four most outer boroughs of Harrow, Hounslow, Ealing and Brent. 1 9.13. Young people (16-25) in London report lower substance misuse overall but higher use of Class A drugs. It is postulated that these lower overall rates are attributable to the lower levels amongst ethnic minorities of which young people constitute a higher proportion. Studies have found that young Londoners are more likely to misuse glue, gas and solvents, paan and khat. Southwark 9.14. There are an estimated 4810 PDUs in Southwark and 89% of use crack and 71% use heroin, demonstrating that poly drug use is the norm in Southwark 1. Using the Office of National Statistics 2008 mid year population estimate of 278,000 residents this gives a problematic drug user prevalence in Southwark of 1.73%. Figure 9.2: Prevalence of problematic drug use in Southwark compared with rates in Inner and Outer London Prevalence of Problematic Drug Users with 95% Confidence Intervals 3.5 3 2.5 Prevalence 2 1.5 1 0.5 0 Outer London Inner London Southwark Area
Recorded drug offences 9.15. In 2006/07 there were 2458 recorded offences for drug trafficking in Southwark, 2122 offences for drug possession and 323 for drug trafficking and 13 for other drug related offences, making Southwark the borough with the fourth highest number of recorded drug offences in London. Trends in drug use 9.16. Patterns of drug use in London mirror national trends although they are at higher levels across all substances. Across the UK cannabis remains the most commonly used drug followed by cocaine, while heroin is the most common primary problematic drug of users in treatment. However, categorising PDU according to primary drug used does not reflect contemporary patterns of substance misuse and the majority of people seeking treatment misuse multiple substances, including alcohol 1. Over the past decade there has been a general trend towards poly drug use. A quarter of those who inject drugs share needles and syringes and while this is declining it remains higher than in the mid-1990s 1 9.17. There is increasing evidence of an aging PDU population. Healthier lifestyles, opioid maintenance treatment, and anti-retroviral treatment following the HIV/AIDS epidemic of the mid-1980s has contributed to increased life expectancy amongst PDUs. The average age of drug related death rose from 29.7 in 1999 to 36.4 in 2008 and the proportion of those aged over 50 increased during the same period from 0.1% to 4.2%. 1 An aging opioid using population has implications for substance misuse services and health and social care providers. Figure 9.3: Hospital admissions for drug misuse in Southwark, Inner and Outer ondon and nationally 2002-2007 Age standardised hospital admissions due to drug misuse 2002/03-2006/07 45.0 Age standardised rate per 100,000 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 2002/03 2003/04 2004/05 2005/06 2006/07 Southwark Inner London London England Year
Substance misuse and inequalities 9.18. Deprivation Deprivation can be both a causal factor and consequence of substance misuse. Some groups have been identified as being more vulnerable to not only developing substance misuse problems but also being affected by its consequences though, actual or fear of, crime and antisocial behaviour. There is a strong link between homelessness and substance misuse and over 60% of homeless people in London cite drug or alcohol use as the primary factor in becoming homeless. Homelessness also exacerbates existing substance misuse problems with four out of five people reporting that they had started using at least one new substance since becoming homeless. 9.19. Children and Young People Children who are defined as vulnerable, for example whose parents misuse substances, looked after children and children not in education, employment or training are most at risk of developing problematic substance misuse. 9.20. Women Reported drug use is lower in women than men and starts at a later age. However the average age at which women enter treatment is the same as men, indicating that their drug use impacts more severely on them. The ratio of male to female PDUs is Southwark is 3.28 to 1.0. 1 9.21. Ethnicity Ethnic groups experiences of substance misuse differs according to faith and cultural and social norms. Rates of substance misuse amongst ethnic groups are generally lower than the general population, although they are more likely to experience the negative consequences of substance abuse. Tackling substance misuse in Southwark National policies 9.22. In March 2008 the Home Office launched its new ten year drug strategy, Drugs: Protecting Families and Communities. The strategy has four main strands: Protecting communities through robust enforcement to tackle drug supply, drug-related crime and anti-social behaviour Preventing harm to children, young people and families affected by drug misuse Delivering new approaches to drug treatment and social re-integration Public information campaigns, communications and community engagement. 9.23. Southwark Drug and Alcohol Action Team is a partnership consisting of representatives from local authorities (education, social services, and housing) health, probation, the prison service and the voluntary sector who are accountable to the Home Office for delivering the national drugs strategy within the borough. Their responsibilities include commissioning treatment services, monitoring and reporting on performance and communicating plans
and activities to stakeholders. The Southwark Drugs Intervention Programme (DIP) in established in 2003 challenges the link between crime and drug use by linking drug using offenders into treatment. Recommendations Significantly increase the profile of cannabis and crack services amongst male PDUs under the age of 34. Significantly increase the profile of cannabis and crack services amongst Black African and Black Caribbean men as the figures suggest low levels of service uptake and very high levels of testing negative for Class A drugs on arrest. Train all substance misuse workers to become competent in identifying and managing poly drug use within their client populations. Assess the needs of aging opioid using population and the impact this will have on services. Increase Hepatitis B vaccination coverage amongst PDUs. Increase service uptake and retention amongst Black African and Black Caribbean men.