Joint strategic needs assessment

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Adult drug users (2015)

Topic titleAdult Drug Use
Topic ownerCDP Executive Group
Topic author(s)Caroline Keenan, Clare Fox and Jane Bethea
Topic quality reviewedDecember 2015
Topic endorsed bySubstance misuse strategy group
Topic approved byCDP Executive Group
Current versionDecember 2015
Replaces version2012
Linked JSNA topicsAlcohol, Children and Young People substance misuse, smoking, adult mental health, domestic violence
Insight Document ID161968

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Executive summary

Introduction

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Drug misuse is associated with a range of psychological, physical and social issues and addressing these remain a key national and local priority. Whilst solid progress has been made in improving the impact of drug misuse, the changing nature of drug misuse represents further challenges for the City.

This JSNA chapter describes local need in relation to drug misuse, outlines services in place to address misuse issues in adults and also identifies unmet needs and gaps in provision.   

This JSNA chapter focuses on drug misuse in adults.  A chapter on substance misuse in young people can be found here.

Unmet needs and gaps

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·         Evidence suggests 18-24s are more likely to frequently use illicit drugs yet this age group is underrepresented within structured drug treatment populations.  This suggests that more work is required to understand the needs of this group and ensure their access to effective treatment.

·         Some BME groups are underrepresented within Nottingham’s treatment system.

·         The prevalence of drug misuse is increased within homeless people and a lack of stable accommodation is often considered a barrier to recovery.

·         Drug treatment has been shown to have a positive impact on families affected by drug misuse.

·         This JSNA relies heavily on data sourced from the National Drug Treatment Monitoring System which excludes unstructured treatment. It also relies on extrapolated national level data to inform levels of local need.

·         The use of novel psychoactive substances (NPS) represents an emerging risk and the extent of the impact of these substances is not yet fully understood.

Drug misuse is associated with a range of mental health problems and the causal pathway of these factors is somewhat unclear.

Recommendations for consideration by commissioners

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The assessment has identified the following recommendations for commissioners:

·         Commissioners should ensure that 18-24 year olds who would benefit from a treatment intervention have the necessary access to services. It is also recommended that work is undertaken to understand why this age group appear to be underrepresented within the treatment population.

·         Treatment should be easily accessible for BME groups and again barriers to access need to be better understood to inform local service provision

·         Commissioners should continue to ensure that treatment services provide outreach to homeless people who misuse drugs and work with partners to improve access to stable accommodation.

·         Effective family interventions should continue to be commissioned and provided.

·         Commissioners should ensure that drug treatment interventions continue to address psychological health as well as physical health. Access to mental health support should be clearly visible within treatment pathways.

·         Consideration needs to be given to how unstructured treatment data could be collated and analysed using a more robust methodology.

Efforts should be made to increase local knowledge on the prevalence of NPS use and the associated health and social impact of use.

What do we know?

1. Who is at risk and why?

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National Prevalence and Trends in Illicit Drug Use

In 2013-14, 9% of 16-59 year olds in England and Wales used illicit drugs in the last year (Home Office, 2014).  Figure 1 shows that illicit drug use has reduced significantly over the last ten years.  Despite this downward trend in drug use in the long term, a significant increase in 2013-14 compared to the previous year indicates that illicit drug use continues to be a considerable national challenge. The most commonly used illicit drug type is cannabis, followed by powder cocaine and ecstasy. 

Figure 1: Proportion of 16 to 59 year olds reporting use of drugs in the last year (2011-12 to 2013-14)

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Notes: 'Any drug' comprises powder cocaine, crack cocaine, ecstasy, LSD, magic mushrooms, ketamine, heroin, methadone, amphetamines, methamphetamine, cannabis, tranquillisers, anabolic steroids, amyl nitrite, any other pills/powders/drugs smoked.

'Any stimulant drug' comprises powder cocaine, crack cocaine, ecstasy, amphetamines, amyl nitrite and methamphetamine. 

'Any Class A drug' comprises powder cocaine, crack cocaine, ecstasy, LSD, magic mushrooms, heroin, methadone and methamphetamine. 

Frequent use refers to use of any drug more than once a month in the past year.

Source: Home Office (2014).

National Demographic Profile

In the UK, 36% of 16-59 year olds have used an illicit drug at least once during their lifetime (Public Health England, 2014).  The use of illicit drugs exists across a broad spectrum of demographic profiles, but there is evidence of higher levels of use in some groups:

Age

Younger adults are more likely to use illicit drugs and to use them on a frequent basis.  Frequent drug use is defined as the use of any drug more than once a month in the past year.  In 2013-14, 60% of people who used illicit drugs frequently were aged 20-34 years.  As shown in Figure 2, adult illicit drug use is most common within the 20-24 age group and consistently depletes thereafter (Home Office, 2014). 

Figure 2: Proportion of adults who frequently used illicit drugs by age (England and Wales, 2013-14)

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There a number of factors that have been suggested as reasons why drug use is more prevalent in younger people, including:

·         Enjoyment: evidence suggests drug misuse is often considered pleasurable by young people;

·         Environment: drug production and misuse often thrives in communities suffering from multiple deprivation including high levels of unemployment, low quality housing and poorly resourced local services and infrastructure;

·         Curiosity: young people are often keen to experiment and this occasionally manifests in drug misuse;

·         Coping mechanism: drug misuse can be used as a mechanism to distract from physical and emotional pain;

·         Rebellion: Drug misuse may be used as a mechanism to provoke the attention of others;

·         Cost: The price of cannabis, for example, might be considered favourably in comparison to other substances such as alcohol (DrugScope, 2005).

Gender

Illicit drug use is not equally distributed by gender either in the UK or internationally, although variations in the magnitude of male to female ratios do exist across different countries within the European Union.  Males are more likely to use illicit drugs and to use drugs at a higher frequency, in larger doses and earlier in life compared to females (European Monitoring Centre for Drugs and Drug Addiction, 2005).  In 2013-14, 76% of national frequent drug users were male (Home Office, 2014).

Gender differences in risk-taking may provide an explanation for increased prevalence of drug misuse in males. Men appear to be less likely to consider the risks associated with drug misuse.  This hypothesis was supported in a survey which found that 27% of men thought it was safe to smoke cannabis compared to 15% of women (Home Office, 2013). 

Ethnicity

Drug use also varies according to ethnicity. Data from the Crime and Drugs Survey suggests that highest levels of drug use in the last year are reported by adults with dual heritage (17.1%), whereas the lowest levels of use are reported in adults who are Asian or  Asian British (3.4% report drug use in the last year). In terms of use in other groups, 9.1% of adults who identify as white (including white British and any other white background) and 5.8% who identify as Black or Black British report use in the last year.  Reference: https://www.gov.uk/government/statistics/tables-for-drug-misuse-findings-from-the-2013-to-2014-csew.

 

Sexual orientation:

In terms of sexual orientation, the highest levels of use in the last year are reported by people who identify as gay or bisexual. Overall 28.4% report use in the last year, and this is higher in males (33.0% of males compared to 22.9% of females). Overall 8.1% of people who identify as heterosexual report use in the past year, and again this is higher in males (11.1% of males compared to 5.1% of females). Reference:
https://www.gov.uk/government/statistics/tables-for-drug-misuse-findings-from-the-2013-to-2014-csew.

 

Factors Associated with Risk of Drug Use
The following factors have been linked to increased risk of drug use (National Institute on Drug Abuse, 2004):

·         Troubled family life: The risk of drug misuse is increased in households in which neglect, drug misuse and/ or emotional or physical abuse has taken place;

·         Mental health: Mental health problems including depression, anxiety and attention deficit disorder are associated with drug misuse;

·         Employment and educational attainment: Unemployment, vocational problems and failures in education are associated with increased risk of drug use;

·         Social groups: Socialising with people who use drugs increases an individual’s risk of using drugs themselves;

·         Previous drug use: Using drugs early in life has been shown to increase the likelihood of misusing drugs; and

·         Biology: Those who report positive effects from drug misuse are more likely to continue using.

Health and Social Consequences of Drug Misuse

Drug misuse is linked to a number of physical and psychological health outcomes.  The method of administration, such as inhalation or injection, can also impact on how the drug affects the user. The physical and psychological outcomes associated with misuse are given below:

Physical Health Consequences

Breathing problems
Smoking cannabis irritates the lungs and those who smoke cannabis on a frequent basis are likely to develop lung problems that are similar to tobacco smokers.  Consequences of frequent cannabis smoking can include coughing, lung illness and increased risk of lung infection (National Institute on Drug Abuse, 2015).

Heart problems
Smoking cannabis increases the heart rate for up to three hours and thereby increases the risk of heart attack (National Institute on Drug Abuse, 2015).  Cocaine also leads to increased heart rate and can lead to heart attacks and strokes which may cause sudden death (National Institute on Drug Abuse, 2013).  Chronic heroin use can lead to collapsed veins, heart lining infections and pulmonary complications (National Institute on Drug Abuse, 2014).

Drug misuse in pregnancy
Approximately 70% of infants born to drug dependent mothers are affected in some way (Nottingham Neonatal Service, 2014).  Heavy use of cannabis during pregnancy can cause babies to startle more easily (Nottingham Neonatal Service, 2014).  Use of amphetamines and ecstasy may lead to decreased birth weight and increased risk of cleft palate and heart defects (Nottingham Neonatal Service, 2014).  Cocaine may be associated with placental abruption, prolonged rupture of membranes, intra-uterine growth retardation and differences in organisational responses and interactive behaviour (Nottingham Neonatal Service, 2014).  Heroin use in pregnancy can lead to low both weight and premature birth (Nottingham Neonatal Service, 2014).  Infants may also show signs of heroin withdrawal which is treated with barbiturates and methadone (Nottingham Neonatal Service, 2014).

Blood borne viruses
Injecting drug users put themselves at risk of a number of blood borne viruses including HIV, Hepatitis C and Hepatitis B. The number of cases of HIV transmitted through injecting drug use in the UK has remained relatively low.  In 2011,122,000 HIV diagnoses had been documented in the UK since the beginning of the epidemic over 30 years ago.  Approximately 5% of diagnoses (5,600 people) are believed to have been infected through injecting drug use (NAT, 2013).  Based on extrapolated data (Public Health England, 2013) it is estimated that there are 20 HIV Positive injecting drug users in Nottingham, two of which may be undiagnosed. 

Hepatitis C remains a key area of concern in injecting drug users due to the levels of infection, transmission, the lack of a vaccine, low levels of treatment engagement and the serious effects that it has on health. It is estimated that between 130 and 150 million people globally are infected with chronic hepatitis C (World Health Organisation, 2015).

Injecting drug use remains the main route of hepatitis C infection in the UK, with 90% of those acquiring the infection having done so through injecting drugs. Approximately 50% of injecting drug users in England have been infected with hepatitis C. Around 25% of these will go on to clear their infection naturally, it is therefore estimated that around two in every five injecting drug users in the UK currently have a hepatitis C infection.  Furthermore, Public Health England estimates that around half of the injecting drug users in the UK who are infected remain undiagnosed, either because they have not been tested or have been infected since their last negative test.

In England, only 3% of those who have a hepatitis C infection access clinical treatment. It is estimated that in the UK, 215,000 individuals have a chronic hepatitis C infection and hospital admissions and death as a result of hepatitis C are rising. This equates to approximately 2,000 people within Nottingham with a chronic hepatitis C infection. The rate of infection is highest in those aged 25-44 and is higher in males; these characteristics accurately reflect the local opiate using population (Public Health England, 2014).

Drug-related mortality
In 2012 there were 1,613 notifications of drug-related deaths in the UK and Islands (Corkery et al., 2013).  In Nottingham between 2011-2013 11 drug-related deaths were recorded.  A process for recording and investigating drug-related deaths within Nottingham City continues to be co-ordinated by the Crime & Drugs Partnership.  The local investigator receives reports of potential drug-related deaths occurring within the City and liaises with the Coroner’s office to establish the cause of death, and where a death is found to be drug related; investigate the circumstances and background that led to the death.

All deaths are reported to the Confidential Inquiry Review Group; a multi-agency group that receives the investigation reports and identifies any learning points that might arise from them.  All learning points are widely circulated across a range of treatment services and partner agencies in order to allow them to be implemented and acted upon to prevent further deaths in future.

Mental health

Mental health problems directly affect 25% of the population during any given year (Singleton, et al., 2001) which equates to approximately 76,000 Nottingham citizens (according to the Census, 2011).  For people dependent on drugs or alcohol, the prevalence of mental health problems is significantly increased to 30% and 45%, respectively (Coulthard, et al., 2002).  A known psychiatric condition was also evident in more than half of cases who died a drug-related death in Scotland in 2012 (Hecht, et al., 2014).

Schizophrenia
A considerable proportion of people with schizophrenia also smoke cannabis, although for many years the temporal relationship was not known, evidence suggests that cannabis consumed in high doses may lead to mental illness and psychosis (McLoughlin, et al., 2014). 

Hallucinations
Smoking cannabis has been linked to temporary hallucinations which manifest as sensations or images that seem to be real (National Institute on Drug Abuse, 2015).  Hallucinations may lead to increased risk of accident or injury.

Paranoia
Cannabis smokers often experience a sense of paranoia which leads sufferers to distrust others (National Institute on Drug Abuse, 2015).  Feelings of paranoia may lead to increased risk of injury of both the sufferer and those around them.

Social Consequences

Aggression
Research has shown that the use of cocaine and alcohol is significantly associated with aggression.  The causal pathway of cocaine use, alcohol use and violence is currently unclear however; this evidence suggests that people who use these substances are more likely to display aggressive behavior (Macdonald, et al., 2008).  

Crime
Drug misuse is associated with crime in a number of ways.  People who are dependent on drugs may steal in order to fund their addiction, and it is estimated that for this reason up to half of all acquisitive crime is drug-related (DrugScope, 2015).  Violent crime is also often associated with drug and alcohol misuse (DrugScope, 2015).  Research has shown that effective treatment interventions significantly reduce drug-related offending (Keen, et al., 2000).

Homelessness
Drug misuse is a known cause and consequence of homelessness.  The misuse of drugs can be a causal or contributing factor to becoming homeless and drug misuse can also be used as a coping mechanism for dealing with homelessness (Crisis, 2011).  The prevalence of drug misuse is considerably increased amongst homeless people; approximately 80% of people who become homeless start using at least one new drug.  Furthermore, the misuse of drugs and alcohol accounts for more than a third of deaths amongst homeless people (Crisis, 2011).  The lack of stable accommodation is considered a barrier to recovery for many homeless people and this group is recognised as more difficult for intervening services to access (Crisis, 2011).

Families
Drug dependent parents can pose a risk to both themselves and their children.  Drug misuse can reduce a parent’s capacity to provide the necessary practical and emotional care to their children and this may result in reduced educational attainment, mental health problems and increased risk of drug misuse in the child (The National Treatment Agency for Substance Misuse, 2012).  Whilst living with a child has been considered a preventative factor for developing severe drug misuse problems, drug misuse treatment has been shown to be effective in improving the lives of the families affected (The National Treatment Agency for Substance Misuse, 2012).

2. Size of the issue locally

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Local Prevalence and Demographic Inequalities

The prevalence of substance misuse in Nottingham can be estimated using a number of sources.  In most cases it is necessary to accept estimates based on data collected through large national surveys as local level information does not exist.  Local estimates for opiate and crack use are available and have been utilised in this assessment. 

Nottingham has similar levels of substance misuse compared to other major cities in the country.  For example, there are an estimated 2,615 opiate and crack users in Nottingham, this is the lowest rate of the three cities in the East Midlands (including Nottingham, Leicester and Derby) and mid-table within the eight Core Cities (Liverpool John Moores University, 2014).

Cannabis

Despite an overall increase in the last fifteen years and remaining the most prevalent drug, national lifetime cannabis usage has reduced slightly from 31% of 16-59 years olds to 29% in the last two years, as shown in Figure 3 (Home Office, 2014).

Figure 3: National proportion of 16 to 59 year olds reporting use of cannabis ever in their lifetime

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Opiates

It is estimated using regional prevalence rates produced by Liverpool John Moores University and based on 2011 census population data, that there are an estimated 1,534 opiate users in Nottingham City (Liverpool John Moore’s University, 2014).  In terms of change over time, it is estimated that there were 1,575 opiate users in Nottingham in 2009/10 (University of Glasgow 2010), 1,496 in 2010/11 (Liverpool John Moores University 2011) and 1,534 in 2011/12 (Liverpool John Moores University 2014). 

The use of opiates in 15-24 year olds and 25-34 year olds reduced in the period 2009/10 to 2010/12, whereas opiate use in 35-64 year olds has consistently increased in the last three years (Liverpool John Moores University, 2014).  This suggests that Nottingham has a cohort of entrenched and also ageing opiate users.

Injecting

The level of injecting in the cohort of drug users accessing treatment is stable.  In the last three years, 14-15% (97 to 117 clients) of those starting a new treatment journey currently injected, 25-27% (163-189 clients) previously injected and 58-60% (380-454 clients) had never injected.  A cohort of ageing injecting drug users is associated with increased physical health problems.  A number of people continue to access specialist needle exchanges; last year 1,347 clients accessed the local specialist needle exchange provider.

Cocaine

The number of crack cocaine users in Nottingham has reduced in the short-term (-7.4%, Liverpool John Moores University, 2014).  Using the Census 2011 population figure for Nottingham, the crack using cohort in Nottingham equates to 0.7% of citizens.

Figure 4 below shows crack cocaine prevalence nationally over the last fifteen years (Home Office, 2014).  The overall trend in crack cocaine use is increasing, although since 2011/12 use appears to have declined. Whether this decline is sustained is uncertain. In the previous five years crack cocaine use has reduced however, prevalence increased significantly between 1996 and 2014.

Figure 4: National proportion of 16 to 59 year olds reporting use of crack cocaine ever in their lifetime 

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The national prevalence of powder cocaine over the last fifteen years is shown below in Figure 5.  Overall, powder cocaine use has significantly increased and has consistently accounted for the vast majority of any cocaine use.  In the short-term (2013-14 compared to 2012-13) powder cocaine use has increased by 0.6 percentage points (Home Office, 2014). 

Figure 5: National proportion of 16 to 59 year olds reporting use of powder or any cocaine ever in their lifetime

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Ecstasy

In 2013/14, based on national data, 9.3% of 16-59 year olds reported use of ecstasy.  This is a short-term increase, compared to 8.3% in 2012/13.  Also over the last five years ecstasy use has increased by one percentage point.  These findings are indicative of overall and consistent increase in ecstasy prevalence (Home Office, 2014).

Hallucinogens

The prevalence of hallucinogens has been broadly maintained.  Approximately 9% of 16-59 year olds are estimated to have used hallucinogens in their lifetime (Home Office, 2014).

Amphetamine

Amphetamine prevalence in 2013/14 was 11.1% which is a reduction in the long-term (compared to 2009/10, 0.6 percentage points) and the medium-term (compared to 2011/12, 0.5 percentage points); although there has been a small increase in the short-term (compared to 2012/13, 0.5 percentage points, Home Office, 2014).  The prevalence over time of ecstasy hallucinogens and amphetamine is shown below in Figure 6.

Figure 6: National proportion of 16 to 59 year olds reporting use of ecstasy, hallucinogens or amphetamine ever in their lifetime

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3. Targets and performance

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The Public Health Outcomes Framework reports on three drug-related indicators as part of health improvement Successful completion and no representation within six months of opiate users (indicator 2.15i); successful completion and no representation within six months of non-opiate users (indicator 2.15ii); and people entering prison with substance dependence issues who are not previously known to community treatment (2.16).

In 2013, 10% of Nottingham opiate user clients successfully completed treatment and did not represent within six months.  As shown in Figure 7, This is the second highest rate in the East Midlands, higher than the average for the East Midlands and higher than the national average.  Despite a slight reduction between 2012 and 2013, performance on this measure has shown improvement over time.  Over the previous two years Nottingham’s performance has been significantly better than the national average (Public Health England, 2015)

Figure 7: Successful completion of drug treatment (opiate users)

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In terms of non-opiate clients, in 2013 36.5% of Nottingham clients successfully completed treatment and did not represent.  Nottingham is similar to the national average on this measure (Public Health England, 2015).

Figure 8: Successful completion of drug treatment (non-opiate users)

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Since 2012-13, The Public Health Outcomes Framework has also reported on the proportion of clients entering prison with substance dependence issues who are not previously known to treatment (indicator 2.16).  Although a low level of treatment na├»ve clients in prison could be considered positive as it may mean that the treatment system has intervened in an individual’s substance misuse at an earlier stage, it may also be an indication that the earlier interventions have been unsuccessful.  As such interpreting this measure is difficult. The performance of Nottingham, together with the East Midlands and England, is shown below in Figure 9.  In Nottingham, three of every five new receptions have already experienced substance misuse treatment intervention at a structured level.  Nottingham’s performance is similar to the average for England and the East Midlands (Public Health England, 2015).

Figure 9: People entering prison with substance dependence issues who are not previously known to treatment

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4. Current activity, service provision and assets

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Service provision

Current community drug treatment in Nottingham is delivered by a consortium of providers working from one City centre base. This service delivers interventions for all adult clients requiring unstructured and structured (pharmacological and/or psychosocial) treatment regardless of the drug of choice or complexity.  It offers a single point of access, assertive and proactive engagement of drug users into treatment, brief interventions, evidence based structured treatment and harm reduction interventions including blood borne virus testing and vaccination.  The service also provides outreach into the night time economy and advice and training for professionals.

Anyone entering the service receives an assessment, recovery plan and package of care designed to meet their individual needs. They will also have access to recovery support which may include help with benefits and housing, mutual aid and reintegration interventions including basic skills, education and training needs, physical and psychological health and risk behaviours. Community drug treatment also provides assessment and referral to inpatient and residential rehabilitation services and has pathways and joint working arrangements with mental health, alcohol treatment services, criminal justice and family support.

There are also structured interventions delivered in primary care settings by Shared Care (Specialist GPs working with specialist drug treatment workers) to those largely stable drug users.  This is an effective way of combining primary healthcare with specialist assessment and interventions.

A specialist needle exchange and harm reduction service is also delivered in the City providing  interventions such as harm reduction and health promotion advice and information, needle and syringe exchange, blood borne virus testing and vaccination. Pharmacies across the city also deliver a needle exchange service as well as supervised consumption of opioid substitute medication.

Aftercare services are provided for those leaving treatment successfully and drug free. They offer relapse prevention work, diversionary activities, psychosocial interventions advice and support around housing, benefits, education and training.

Clients within the criminal justice system access drug treatment within the integrated criminal justice substance misuse service whether subject to a licence/order or voluntarily. The service delivers drug testing, assessment, advice and support to those who meet criteria in the custody suite; tracking and monitoring of those in the courts who tested positive in the custody suite and contribute to court reports.  Within the service they provide assessment and recovery planning; pharmacological and brief and structured psychosocial interventions and harm reduction advice including blood borne virus testing and vaccination.

 

Treatment Penetration

Analysis of treatment penetration into the substance misusing population in Nottingham is a key measure of treatment impact as it assesses the extent to which drug treatment services are meeting the need of those who have the capacity to benefit from it.  The Census 2011 states that Nottingham’s population is 305,680 and that 201,926 citizens (66% of the population) are aged 16-59.  If we accept the national estimate that 3.1% of 16-59 year olds use drugs on a frequent basis (Home Office, 2014), approximately 6,260 citizens (2% of Nottingham’s population) might require a drug intervention.

In 2013-14, 2,559 adults accessed structured treatment and it is estimated that a further 1,706 accessed unstructured treatment.  Of these clients, 3,015 adults accessed substance misuse treatment for drugs, which equates to an estimated treatment penetration rate of 48%.  This penetration rate provides an annual snapshot but does not account for clients already known to treatment services prior to 2013/14.  It is not currently possible to quantify this cohort although if these clients were included the penetration rate would be higher.

The local and national treatment penetration rate for opiate and crack users, opiate only users, crack only users and injecting drug users is shown in Figure 10 (Public Health England, 2015).  Nottingham’s penetration rate is similar to the national average and exceeds the national average for injecting drug users and crack only users.

Figure 10: Treatment penetration

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Unmet Need in Treatment

Assessment of the demographic categorisation of frequent illicit drug users against the treatment population reveals noteworthy differences between need and provision.  Nottingham has a higher than average young adult population which indicates that the city may be at a comparatively greater risk of young adult illicit drug use compared to other areas in England and Wales.  Based on the age breakdown of frequent illicit drug users nationally and then applied to Nottingham’s demographic breakdown which is significantly younger compared the national average, it is estimated that 46% of frequent illicit drug users in Nottingham are aged 20-24 whereas this demographic represents 8% of the drug treatment population, signifying a considerable underrepresentation.  Although not all of this estimated number are likely to have a treatment need, many would benefit from health promotion and brief interventions.

In contrast to the underrepresentation present in the 20-24 demographic, drug treatment clients aged 30-44 appear to be overrepresented compared to frequent drug user demographics.  In 2013-14, 59% of clients in structured treatment in Nottingham were aged 30-44 whereas it is estimated that 23% of frequent drug users in Nottingham fall into this demographic. 

Data used to assess the demographic breakdown of the local and national treatment population is sourced from the National Drug Treatment Monitoring System (NDTMS) which reports on structured treatment.  The effect of excluding demographic information on unstructured treatment may provide a partial explanation for the underrepresentation of the 20-24 demographic in drug treatment and the overrepresentation of the 30-44 demographic.

It should be taken into consideration that the demographic categorisation of the drug treatment population in Nottingham is similar to that of England and, therefore, the same age differences between estimated need and provision exist at a national level.  This might suggest that the incongruity between the age of frequent drug users and the drug treatment population is a result of another factor upon which local service provision has little control; drug type.  Structured treatment is currently dominated by opiate users who make up approximately 70% of clients accessing drug treatment services.  The demographic profile of opiate users is consistent with an ageing population.  Furthermore, the proportion of opiate clients in Nottingham who are known to treatment is higher than it is for other drug types, such as cannabis.  Structured treatment also lends itself more robustly to opiate treatment because it often involves a pharmacological intervention, a type of intervention that is very common in drug treatment for opiate use and much less common in drug treatment for any other drug type.  Notwithstanding data limitations which prevent exploring the effect of drug type on this identified demographic inequality, current literature does recognise that age and substance type have a key role to play in understanding illicit drug use (UK Drug Policy Commission, 2010).

The assessment of differences in ethnicity reveals that White British drug treatment clients are overrepresented in Nottingham.  Despite the data limitations already explored in the interpretation of this information, this evidence suggests a need to re-evaluate the pathway into drug treatment for minority ethnic groups.

Figure 11: Demographic breakdown of frequent drug users and structured treatment populations

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aBased on Crime Survey for England and Wales (CSEW) data

bBased on CSEW data adjusted for Nottingham population

cBased on data from the National Drug Treatment Monitoring System which includes structured treatment only

dCSEW data is unavailable for those aged over 59 years

5. Evidence of what works (what we should be doing)

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Nottingham is committed to commissioning services that have harm reduction and recovery as core objectives and deliver interventions based on evidence and best practice.   Including evidence presented in the national drugs strategy. National (2010)

Commissioning for recovery: drug treatment, reintegration and recovery in the community and prisons (NTA, 2010) in department of health guidance Drug (Department of Health, 2007 and in NICE clinical guidelines such as Drug Misuse: Psychosocial Interventions; Drug Misuse: Opioid Detoxification; Drug Misuse: methadone and Buprenorphine; Public Health Guidance on Needle and Syringe Programmes http://www.nice.org.uk/guidance/cg/published/index.jsp?p=off

A Summary of the Health Harms of Drugs, (Department of Health, 2011)

Hepatitis C: guidance, data and analysis (PHE 2013)

6. What is on the horizon?

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New Psychoactive Substances

The use of new psychoactive substances is considered to be a growing issue; however, the impact of these substances is yet to be felt either in national surveys or in Nottingham’s substance misuse treatment system.  Use of new psychoactive substances is also not currently seen among the criminal justice cohort.  It must be noted, however, that there is little empirical research in this area.  

National and local evidence suggests that the new psychoactive substances presenting the greatest challenge to the city are synthetic cannabinoids.  In response, the Crime & Drugs Partnership is facilitating both a New Psychoactive Substances Working Group and a Synthetic Cannabinoids Working Group to address this issue and develop appropriate interventions and harm reduction advice. 

A significant gap in knowledge exists around the use of new psychoactive substances and criminal behaviour and it is recommended that this information is collected when clients are arrested.  There is some local evidence to suggest that white powder falsely believed to be cocaine has a role to play in offending, particularly with violence and criminal damage.

Misuse of medicines

Nationally, there is a gap in data for misused prescribed medications, however, a recent survey in a university concluded that one third (33%) of students and one quarter (24%) of staff members had used prescription drugs that were not prescribed to them (Holloway & Bennett, 2012). This mainly consisted of pain relievers and sedatives.

Over the last 12 months, a range of providers in Nottingham, including substance misuse treatment services, hostel staff and prison workers have expressed increasing concern about the growing levels of misuse of a range of medicines. The problematic misuse of these substances was frequently highlighted as being an escalating issue and a major area for concern.

By nature, the misuse of medicines is, to a large extent, hidden.  Locally in 2013-14, only 130 structured drug treatment clients cited medications as problematic, which equates to 7% of the structured treatment population.

 

The Nature of Drug Use

Following a number of heroin seizures and recent deaths across the county, it is suspected that heroin purity is increasing in strength. This will have implications for harm reduction messages and treatment services. There is also increasing use of psychoactive substances nationally and locally which are having adverse effects. This again has implications for harm reduction messages and treatment services including emergency departments. Work is under way to address these issues through a number of working groups.

 

Local System Change

Following a commissioning review work is currently underway to develop a new treatment system model based on consultation and evidence. Nottingham City will go out to tender during 2015/16 for these new services.

 

Hepatitis C Treatment

There are a range of new oral treatments for Hepatitis C becoming available (National Institure for Health and Care Excellence, 2015).  The new treatments are better tolerated than current treatments and have been shown to be effective in curing hepatitis C. A number of these treatments are being evaluated by the National Institute for Health and Care Excellence (NICE). Further guidance will be published during 2015.

Transforming Rehabilitation

Government plans to reduce the rate of re-offending include extending rehabilitation services to offenders released from short term custodial sentences where no provision had previously existed. This will impact on substance misuse services as part of the “Through the Gate” agenda which allows for sentence planning for all prison releases for additional supervision and interventions for a minimum period of twelve months. The “through the Gate” agenda was introduced across the area in May 2015 and has yet to be fully implemented. At the time of writing the full effect as not yet been realised; but we do perceive an increase in those who have to access substance misuse interventions as part of their top up supervision, this will mainly be delivered by Criminal Justice substance misuse services.

Projected Service Use

Current and projected service use of structured drug treatment services are shown in Figure 12 broken down by substance type.  Based on the fact that increases in clients accessing treatment for opiate use have been observed in recent months, and including Statistical Process Control in the methodology utilised to inform future projections, it is anticipated that service use for opiate clients will regress to the mean.  A similar method has been utilised to project service use of non-opiate drug treatment clients.  It is therefore estimated that the number of people accessing treatment for opiate and non-opiate drug use will match or exceed that recorded in April 2012 within the next three years.

The number of clients accessing services for consumption of both alcohol and non-opiates has increased significantly since February 2014 and services in this area continue to develop.  It is therefore assumed that this trend will continue in future years.

Figure 12: Actual and projected service use of drug treatment services by substance type

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Figures from 15/16 are projections based on trend analysis of historical service provision

7. Local views

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In July 2015, the Crime & Drugs Partnership carried out a consultation with 215 service users, service managers and staff, partner stakeholders, voluntary sector services, family and carers and the general public.  The results showed that over 50% of respondents felt that substance misuse services were either very or fairly easy to access and 60% of respondents felt that it was very or fairly easy to refer someone to the correct substance misuse service for the first time.  Figure 13 shows that fear, stigma and poor mental health were the most commonly cited issues that might prevent someone from accessing substance misuse treatment.

Figure 13: Response to consultation question on what might prevent people from accessing substance misuse treatment services

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The opinions of citizens in respect of anti-social behaviour issues are sought annually via the Respect for Nottingham survey.  The survey asks residents about their opinions on people using and dealing drugs both in their local neighbourhood and in the City Centre.  The results, summarised in Figure 14, show a general decline in the proportion of respondents who felt that drug use or dealing drugs was a fairly or very big problem in the local neighbourhood.  However, dealing and using drugs remains one of the highest public concerns city-wide.  

Figure 14: Proportion of Respect Survey respondents who felt that drug use and drug dealing was a fairly or very big problem in their local neighbourhood and in the City Centre

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What does this tell us?

8. Unmet needs and service gaps

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·         Evidence suggests that young people aged 18-24 are more likely to frequently use illicit drugs yet this age group is underrepresented within structured drug treatment populations.  This suggests that more work is required to understand the needs of this group and ensure their access to effective treatment.

·         Some BME groups are underrepresented within Nottingham’s treatment system.

·         The prevalence of drug misuse is increased within homeless people and a lack of stable accommodation is often considered a barrier to recovery.

·         Drug treatment has been shown to have a positive impact on families affected by drug misuse.

·         The use of novel psychoactive substances (NPS) represents an emerging risk and the extent of the impact of these substances is not yet fully understood.

·         Drug misuse is associated with a range of mental health problems and the causal pathway of these factors is somewhat unclear.

This JSNA relies heavily on data sourced from the National Drug Treatment Monitoring System which excludes unstructured treatment.

9. Knowledge gaps

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·         Statistics pertaining to drug and alcohol treatment reported by Public Health England via the National Drug Treatment Monitoring System (NDTMS) are restricted and, as a result, cannot be lawfully published prior to official release.   The information contained within this chapter includes data up until 2013-14 which means that more up to date information cannot be taken into account if the findings are to be shared in a public arena.  This issue represents a challenge and knowledge gap for commissioners.

·         In order to make a full assessment of whether or not demographic inequalities exist in the local adult drug treatment population it is necessary to scrutinise demographics according to drug type.  This information is not currently reported by NDTMS.

·         Mental health remains a significant issue for people dependent on drugs and alcohol. More work needs to be done to ensure effective pathways are in place for drug treatment clients requiring mental health interventions.

·         There is a lack of local information regarding substance misuse in Nottingham.  Whilst local estimates of opiate and crack use are available, the availability of statistics on use of other drugs is limited.

National and local knowledge and intelligence around NPS use is limited and as such planning any future services in relation to need is difficult.  A national survey around NPS is being developed but it is unlikely that this will produce any local level data for use in service planning. 

What should we do next?

10. Recommendations for consideration by commissioners

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The assessment has identified the following recommendations for commissioners:

·         Commissioners should ensure that 18-24 year olds who would benefit from a treatment intervention have the necessary access to services.

·         Treatment should be easily accessible for BME groups.

·         Commissioners should continue to ensure that treatment services provide outreach to homeless people who misuse drugs and improve access to stable accommodation.

·         Effective family interventions should continue to be commissioned

·         Consideration needs to be given to how unstructured treatment data could be collated and analysed using a more methodology.

·         Efforts should be made to increase knowledge on the prevalence of NPS and the associated impact of its use.

Commissioners should ensure that drug treatment interventions continue to address psychological health as well as physical health.

Key contacts

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Caroline Keenan, Senior Performance and Insight Officer, Nottingham City Council Caroline.Keenan@nottinghamcity.gov.uk

Clare Fox, Strategy and Commissioning Manager, Nottingham City Council, Clare.Fox@nottinghamcity.gov.uk

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Glossary