Topic Report: Drugs and alcohol

Self-referrals are the largest route into tier three specialist treatment nationally. Self-referrals form a greater proportion of referrals in Buckinghamshire at 72% for drugs (compared to 59% nationally) and 66% for alcohol (compared to 63% nationally) in 2020/21. The proportion of referrals received in Buckinghamshire from the NHS is low (6% for drug treatment, and 16% for alcohol treatment) but similar to national figures (6% and 15%, respectively). The proportion of referrals from primary care has been increasing in Buckinghamshire however, from 2% in 2019/20 to 5% in 2020/21 for drugs, and from 8% in 2019/20 to 12% in 2020/21 for alcohol. Referrals from hospitals in Buckinghamshire have remained low at 1% for drugs and 4% for alcohol which are both below national levels (2% and 7%, respectively).

Local data provided by ORB (including both drugs and alcohol and all tiers of services) show a similar pattern with nearly three (2.9) times as many referrals received from GPs as from hospitals. While referral numbers from both groups were previously increasing, they decreased in 2021/22 (Figure 19).

Stakeholders highlighted that enquiring about alcohol consumption and screening for dependency are not currently part of routine clinical care within A&E at Stoke Mandeville Hospital, and that referrals from A&E to specialist treatment services for at risk drinkers could be improved. An Alcohol Care Team or Alcohol Liaison Nurse service is provided at Oxford University Hospitals, Frimley Health, and Royal Berkshire but is not provided in BHT. Alcohol care teams have been estimated to provide a return on investment of £3.85 for every £1 invested and it has been estimated that providing an Alcohol Care Team in every non-specialist acute hospital nationally would save 254,000 bed days and 78,000 admissions per year by year three (source: Public Health England).

The waiting time for the first tier three intervention following referral to drugs services was less than 3 weeks in more than 99% of cases, in line with national data.

Engagement with people with lived experience found that those who had self-referred into the service felt the process had been quick and easy. All had been contacted within 24 hours and arranged a time for an assessment. Some of those involved in the focus groups had been in and out of treatment over a number of years and all felt that it was easy to access services. The initial assessments were seen as being thorough and ‘holistic’, identifying other issues which may need addressing in addition to substance misuse such as housing, finance, employment, and personal circumstances.

All data relating to referral to, use of, and outcomes from specialist drug and alcohol treatment services are for tier three activity in 2020/21. They are taken from the Commissioning Support Pack unless stated otherwise. This pack was produced by the Office for Health Improvement and Disparities (OHID) using National Drug Treatment Monitoring System (NDTMS) data.

27 young people used Here4YOUth tier three services in 2020/21. The most common substance used is cannabis (89% of clients), followed by alcohol (33% of clients). Referral sources into specialist youth drug services are similar to nationally, with the most common being children’s services and education.

There were 978 adults receiving tier three specialist drug treatment in Buckinghamshire in 2020/21, of which over half (52%) had entered treatment during that year. An additional 514 adults received specialist alcohol-only tier three treatment in Buckinghamshire in 2020/21. Use of opiates form the majority of drug treatment places (65% in 2020/21) and also the majority of drug-misuse deaths (85% in 2017-19), in line with national data.

The demographic breakdown of drug treatment clients in Buckinghamshire in 2020/21 largely reflected the patterns observed nationally. Three quarters (74%) of adults in drug treatment were men. Approximately one third (37%) were 30-39 years old and another third (32%) were 40-49 years old. The majority (83%) of adults entering drug treatment in Buckinghamshire identified as white British, similar to the proportion of the general population in Buckinghamshire (81% in the 2011 Census) (source: Ethnicity in Buckinghamshire).

Adults entering specialist drug treatment are nearly four times more likely to smoke (42% entering treatment in 2020/21) than the general population (11% adults in 2019) in Buckinghamshire. However, fewer than 5 of the 126 adults identified as smokers on entering treatment in 2020/21 in Buckinghamshire were recorded as having received a smoking cessation intervention.

8% of clients receiving specialist treatment for use of illegal drugs in Buckinghamshire also report problematic use of over the counter (OTC) or prescription only medicines (POM). However, this is below the 14% level seen nationally.

Prescription drug misuse was identified as an issue by professional stakeholders. It was reported that prescription medicines are being seen more frequently in drug-related deaths locally. However, the drug and alcohol treatment service is not currently commissioned to provide treatment solely for misuse of prescription drugs (i.e. without concurrent use of illegal substances).

829 Buckinghamshire adults received tier three treatment for alcohol misuse in 2020/21 – of whom 514 were receiving treatment for alcohol only and 315 also received support for use of non-opiate drugs (covered above).

The demographic breakdown of current clients who present to treatment for alcohol-only support in Buckinghamshire in 2020/21 largely reflects the patterns observed nationally. Just over half (54%) were men. Approximately one third (30%) were 40-49 years old and another third (28%) were 50-59 years old – these age bands are 10 years older than quoted for drug treatment clients. The majority (86%) of adults entering alcohol treatment in Buckinghamshire identified as white British, which is similar to the proportion of the general population in Buckinghamshire (81% in the 2011 Census) (source: Ethnicity in Buckinghamshire).

A greater proportion of adult alcohol-only treatment clients in Buckinghamshire had their level of dependence assessed and categorised (81%) than nationally (68%) in 2020/21. The levels of alcohol consumption reported locally were lower on entering treatment than seen nationally (Figure 20). A similar proportion of those in alcohol treatment in Buckinghamshire were identified as using/having previously used other drugs compared to nationally (38% versus 42%) in 2020/21.

Adult drug and alcohol treatment services in Buckinghamshire were reconfigured in 2017, moving from an approach in which multiple providers offered elements of the treatment to an integrated adult substance misuse treatment service. The majority of professional stakeholders agreed that the integrated service model works better than the previous approach. When asked, stakeholders did not identify any therapeutic gaps in services offered by the integrated service.

Family support sessions were described as “a lifeline for those supporting individuals in treatment”. One partner stated that having other people who understand what you are going through “gives you hope”. It helped them to understand addiction and how to support their partners. Most of the family members involved in the focus groups felt that they would benefit from structured sessions which provided details of what to expect and ‘do’s’ and ‘don’ts’ when it comes to supporting and managing a partner with an addiction. The partners of service users commented that, when seeking help for their partners from GPs and other services, they had been unaware that there were support services for families to access. It was only as a result to speaking with the service supporting their partners directly that they were made aware that they could refer themselves into services for support.

HCV infection is the most common blood borne virus among people who inject drugs in the UK (source: Shooting Up report). Over 90% of HCV infections in England are thought to have been acquired by injecting drug use. The proportion of people who inject drugs who have evidence of ever being infected by HCV is rising nationally – reaching 60% in 2020 (source: UK Health Security Agency). Despite this, significant advances in HCV treatment since 2015 have translated to reduced HCV-related mortality in those aged under 75 in England.

However, the COVID-19 pandemic has been associated with reduced access to clean needles and increased reported needle-sharing activity (source: Shooting Up report). There was also a 62% drop in HCV testing nationally during 2020 (source: Hepatitis C in England 2022). Screening for HCV continued in prisons throughout the COVID-19 pandemic – with an uptake of 46% in 2020/21 compared to 45% in 2019/20.

In 2019/20, the latest year before the COVID-19 pandemic, Buckinghamshire saw 62% of those recorded as eligible on entering drug treatment being tested for hepatitis C virus (HCV) infection, compared to 69% nationally. This fell during the COVID-19 pandemic, to 40% being tested in Buckinghamshire and 41% nationally in 2020/21 (Figure 21) (categories with fewer than 5 individuals are rounded up to 5 to prevent deductive disclosure.). As the total number of individuals presenting to services also fell during the COVID-19 pandemic, the number of active HCV infections identified fell sharply by a factor 13 between 2019/20 and 2020/21 in Buckinghamshire, compared to falling by a factor 5 nationally. However, a separate national data collection system as part of the ‘Hep C U Later’ programme has confirmed that the Aylesbury Hub has already achieved micro-elimination status and that data from August 2022 indicates Buckinghamshire may be the first countywide service to achieve micro-elimination status. Criteria for micro-elimination are shown in Figure 21.

A course of vaccination (three doses) against HBV is recommended for all current people who inject drugs, those who inject intermittently, those who are likely to ‘progress’ to injecting, non-injecting users who are living with current injectors, and family/household contacts of people who inject drugs (source: UK Health Security Agency). It is also recommended for all sentenced prisoners and new inmates entering prison in the UK.

In 2020, 12% of people nationally who have ever injected drugs were estimated to have had prior HBV infection. Nationally only two thirds (66%) of injecting drug users have been vaccinated (2020) (source: Shooting Up report).

In 2019/20, the latest year before the COVID-19 pandemic, Buckinghamshire saw 14% of those recorded as being eligible on entering drug treatment receiving a full course of vaccination. This is similar to nationally (12%) but despite a higher proportion of the eligible population locally recorded as having accepted the offer of HBV vaccination (50% versus 40%). By 2020/21, the proportion of those recorded as eligible on entry to drug treatment who completed HBV vaccination had fallen to 1% (just 6 individuals), compared to 3% nationally (Figure 22).

The provision of take-home naloxone, to reverse the effects of opiates during potentially fatal overdoses, is greater in Buckinghamshire than England and also marginally improved during the COVID-19 pandemic. In 2020/21, three quarters (76%) of those entering treatment for opiate use in Buckinghamshire were either issued with or confirmed pre-existing access to naloxone, compared to half (53%) nationally. Of all those in opiate treatment, nearly half (47%) in Buckinghamshire had naloxone compared to just over one quarter (28%) nationally.

Injecting drugs can also lead to bacterial infections. In 2020, over one in three people (38%) identified as injecting drugs in England, Wales and Northern Ireland reported having a sore, open wound or abscess related to an injection site (source: Shooting Up report). Injecting drugs may also lead to serious systemic bacterial infections. The number of cases of invasive Group A Streptococcal (iGAS) infection identified amongst people who inject drugs increased from 4 recorded cases in 2013 to 234 in 2019 in England and Wales. iGAS carries a fatality rate of 9.5% (source: Shooting Up report).

Nearly two thirds (65%) of adults who reported injecting drugs on entry to specialist treatment in 2020/21 reported no longer injecting drugs by 6 weeks (similar to the national proportion). However, compared to national data, Buckinghamshire had a higher proportion of opiate clients who have been in treatment for less than 2 years (57% versus 46%) and a higher rate of early unplanned exits (those who leave treatment in an unplanned way before 12 weeks) at 23% (50 individuals) versus 15%. Early unplanned exits are also twice as high in Buckinghamshire as they are nationally for the treatment of non-opiates with or without alcohol at 34% (98 individuals) versus 17%.

In 2020/21, 3.8% of opiate users successfully completed drug treatment and did not return to treatment within 6 months in Buckinghamshire – below the regional (5.7%) and national (4.8%) levels. However, safety is the primary concern and service users who are not abstinent may not represent a ‘failure’ of treatment services if they are being maintained on opiate substitute treatment (OST) – particularly during the early COVID-19 pandemic. The successful completion of treatment for non-opiate users (33%) was the same as regional and national levels.

The proportion of adults in specialist alcohol treatment who successfully completed and did not return to treatment within 6 months has been rising in Buckinghamshire for the past three years from 30% to 36%. This is now higher than the national average, which fell during COVID-19 from 38% to 35%.

Buckinghamshire has a higher rate of early unplanned exits from the programme at 23% (88 individuals) of those starting treatment in 2020/21 compared to 13% nationally.

A reduction of 44% in the number of people re-offending and a reduction of 33% in the number of offences in the two years after starting drug treatment has been found nationally, with the largest reductions for alcohol-only users (source: Public Health England and Ministry of Justice). Applying these findings locally provides an estimate of 60,000 offences committed by adults before accessing drug treatment and 900 offences committed by adults before accessing alcohol treatment in Buckinghamshire. These translate to a gross social and economic saving in Buckinghamshire for adults starting treatment in 2016/17 of £9.5 million for drugs and £200,000 for alcohol.

Drugs supply is often linked to Serious and Organised Crime (SOC). The police undertake activities to disrupt both these organised crime groups and drugs supply networks, at a local and regional level. Moderate disruptions relate to individuals in these networks that are arrested, or where drugs or criminal property is seized. Major disruptions relate to instances when a significant number of a gang’s members are arrested or multiple/large quantities of drugs or criminal property are seized, thus reducing the volume of drugs in circulation. Between January 2020 and October 2022, 30% of moderate and 20% of major SOC disruptions across the Thames Valley occurred in Buckinghamshire. There were more disruptions across the Thames Valley in 2021 than 2020 (Figure 23).

The criminal justice system was responsible for 16% of drug and 6% of alcohol adult treatment referrals nationally in 2020/21. A lower proportion of referrals from the criminal justice system were seen in Buckinghamshire compared to nationally for both drug (8% versus 16%) and alcohol (2% versus 6%) treatment. Just over one third (38%) of adults in Buckinghamshire with a need for substance misuse treatment successfully engaged with community-based specialist treatment within three weeks of release from prison (2020/21). Although this rate is the same as that seen nationally, it is lower than 10 of the 13 comparator authorities for which data are available (source: Office for Health Improvement and Disparities). Local data show this has risen to 44% in 2021/22. A new national stretching target of 75% by the end of 2023 is now in place.

A key gap identified by local stakeholders in relation to the criminal justice system was in the pathway from prison to community specialist drug treatment. It was reported that prisoners are often released at short notice and often on a Friday, impacting the ability of the community provider to deliver continuity of care. The onus for making contact with the community provider often rested with the individual, having been provided with a contact number and advised to self-refer. It was felt this contributed to non-engagement.