Adult Alcohol and Drug Needs Assessment

2015

This document provides an update to the previous needs assessment published for 2014/15, with a particular focus on a combined drugs and alcohol profile. This echoes the national merging of drug and alcohol treatment interventions The 2010 Drug Strategy and 2012 Alcohol Strategy remain pivotal to the work taking place in Derby now that the duty to provide drug and alcohol treatment has transitioned to Public Health within the Local Authority.

Supporting treatment planning priorities for 2015/16

Contents

1 Drug and Alcohol Priorities 2015/16.............................................................32 Executive Summary.....................................................................................52.1 Introduction – Alcohol................................................................................92.2 Binge drinking.........................................................................................102.3 Hospital admissions due to alcohol.........................................................122.4 Mortality and months of life lost..............................................................182.5 Alcohol and crime...................................................................................192.6 Alcohol Treatment System......................................................................262.7 Demographics and headline treatment figures.......................................272.8 Safeguarding...........................................................................................292.9 Employment and Benefits.......................................................................292.10 Housing and Homelessness....................................................................302.11 Drinking levels and additional substances used......................................312.12 Length of time in treatment....................................................................322.13 Treatment outcomes...............................................................................333 Introduction – Drugs.................................................................................343.1 Prevalence estimates..............................................................................353.2 Waiting Times.........................................................................................363.3 Treatment Engagement..........................................................................363.4 Routes into Treatment............................................................................373.5 Interventions...........................................................................................383.6 Employment and Benefits.......................................................................383.7 Housing and Homelessness....................................................................403.8 In Treatment Outcomes..........................................................................403.9 Successful Completions..........................................................................413.10 Residential Rehabilitation.......................................................................423.11 NPS and Club Drugs................................................................................433.12 Blood-Borne Viruses and Drug-Related Deaths......................................433.13 Safeguarding..........................................................................................443.14 Pharmaceutical Activity..........................................................................453.15 Conclusions............................................................................................53

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1 Drug and Alcohol Priorities 2015/16

Whilst the Crime and Disorder Act 1998 mandates the requirement to deliver substance misuse treatment, the National Drug Strategy 2010 and Alcohol Strategy 2012 remain pivotal in influencing the local delivery arrangements where the services are continuing to build upon the ethos of recovery from addiction. Funding for substance misuse now forms part of the Public Health Grant allocation within the Local Authority including some additional grant funding from the Police and Crime Commissioner to support criminal justice treatment activities. Public Health along with all areas within the Local Authority is expected to continue to deliver efficient and effective services against the backdrop of significant financial pressures. Despite these significant challenges there continues to be the commitment to deliver drug and alcohol treatment services in the City.

A new Integrated Drug and Alcohol Service began on 1st April 2015 bringing together drug and alcohol treatment services for the first time. A single point of entry and assessment process has been developed to ensure clients are assessed only once. This has reduced artificial barriers through the development of a person centred approach to care in order to maximise the client journey.

The opening of a ‘step down’ provision at St Peters Churchyard and other community venues are now in use to ‘widen the door’ to non-traditional drug and alcohol using populations, with an expected rise in the numbers of non-complex clients accessing treatment at these locations.

A revised recovery model of service delivery, bringing elements of sustainable recovery and behaviour change to the start of the treatment journey, will be implemented. To further support recovery there is a commitment to continued partnership working to improve access to wider support for drug and alcohol clients to maintain recovery and improve wellbeing maintaining links with sport and leisure, housing, welfare and debt advice as part of the Universal Delivery of Local Support pilot, employment and education and opportunities to engage in mutual aid groups, such as AA and NA, and other peer support activities.

A key focus for 2015-16 will be to grow the existing mutual aid provision in the city, through the offer of the use of facilities at St Andrews House to hold groups and the training and awareness of staff of the benefits of engaging clients in mutual aid support. A follow up audit of services in respect of mutual aid will be undertaken by PHE later this year.

Local drug trends reflect the national picture with the number of clients presenting to services having used new and emerging substances continuing to increase. It is key that the treatment system remains flexible and responsive to the needs of this population group and continues to provide high quality harm minimisation advice and evidence based treatment programmes tailored to new substances. A local 3 year partnership strategy has been developed focusing on intelligence, regulation, treatment and awareness-raising of the harms caused by New/Novel Psychoactive Substances (NPS) underpinned by a multi-agency action plan.

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The on-going commitment to reduce re-offending in the city will be maintained including custody suite activities, court assessments and support for the effective delivery of court orders to tackle offending which is driven by drug and alcohol use. The revision of existing criminal justice pathways to maximise the outcomes for this client group will underpin the criminal justice client journey.

Recent National guidance in relation to the dispensing of Naloxone advocates for the need to promote the wider availability of the product, including the availability of information on the risks of overdose and how to respond to emergency overdose situations appropriately. This guidance and locally devised dispensing protocols will also be implemented over the coming year focusing on high risk groups such as prison leavers and those opiate users not stable in treatment in order to prevent or reduce the risk of overdose.

The on-going commitment to continue to deliver efficient and effective services for the residents of the city, alongside the findings from the needs assessment will inform the treatment planning priorities for the forthcoming year.

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2 Executive Summary

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5

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2.1 Introduction – Alcohol

The alcohol section of the Needs Assessment (NA) was produced using data from NDTMS (including the 2013/14 JSNA support pack), the Local Alcohol Profiles for England (LAPE) and Hospital Episode Statistics (HES). The health harms associated with alcohol consumption in England are widespread, with around 9 million adults drinking at levels that pose some level of risk to their health. The current UK government recommends that adult men should not regularly drink more than 3-4 units of alcohol a day, and that adult women should not regularly drink more than 2-3 units of alcohol a day. After an episode of heavy drinking, individuals should refrain from drinking for up to 48 hours to allow tissues to recover. Because of the breadth of the problems associated with alcohol, this document provides a range of alcohol related data in relation to levels of harm and the local alcohol treatment system's response. This NA presents key performance information about alcohol clients in the Derby City treatment system alongside national data for comparison. The data relates to clients in England who are in treatment primarily for alcohol misuse.

Throughout the NA comparisons are made against a national benchmark and using a nearest neighbour approach. The nearest neighbour approach groups each local area with 15 other areas that are similar across a range of demographic, socio-economic and geographic variables. Utilising a nearest neighbour approach allows for like-for-like comparisons of areas and can reveal patterns in the data that would not otherwise be seen when only making comparisons against a national benchmark. It is therefore important to consider both national and nearest neighbour comparisons when interpreting the data. All data has been divided in to four groups (quartiles) in order to allocate levels of harm. Quartile one, shown on the figures in dark green, is indicative of lower levels of alcohol related harm compared to the benchmark. Groups two and three indicate increasing levels of harm respectively, and areas in quartile four (shown in red) have the highest levels of harm compared to the benchmark.

Where cells appear with “s”, small numbers have been suppressed to prevent disclosure. The areas identified as the 15 nearest neighbours for Derby are:

Coventry, Dudley, Darlington, Calderdale, Walsall, Stoke-on-Trent, Bolton, Stockton-on-Tees, Kirklees, Wolverhampton, Peterborough, St Helens, Swindon, Rotherham, Doncaster.

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2.2 Binge drinking

Binge drinking is associated with a wide range of health problems, including brain damage, alcohol poisoning, chronic liver disease, breast cancer, skeletal muscle damage, mental ill-health and social problems. Alcohol misuse also has a major role in many accidents, acts of violence and other instances of criminal behaviour.

In Derby, 19% of adults engage in binge drinking (Public Health England, 2007-08). This is comparable with the national average (20%). In men, binge drinking is defined as having consumed 8 or more units of alcohol on the heaviest drinking day in the previous seven days. For women the cut-off was 6 or more units of alcohol. In 2009, 19.6% of adults in Derby were classified as increasing risk drinkers (North West Public Health Observatory). Increasing risk drinking is defined as the consumption of between 22 and 50 units of alcohol per week for males, and between 15 and 35 units of alcohol per week for females.

Figure 1: Percentage of binge drinking adults aged 16+ grouped by middle super output area – 2007-2008; Source: Local Health Profiles

This map demonstrates that the MSOAs with the highest proportion of binge drinking adults in 2007-2008 were clustered in the upper central areas of Derby. In particular, 36% of adults within an MSOA in Mackworth (E02002806) were estimated to be drinking at harmful levels. Other areas of concern are located within the Darley, Abbey and Arboretum wards.

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Figure 2: Proportion of adults who drink alcohol once a day or more grouped by ward – 2014; Source: Mosaic Public Sector

It is interesting to note that we are provided with a different geographical picture when considering the proportion of adults who reported drinking alcohol once a day or more in 2014. Figure 2 highlights Allestree (11.2%), Mickleover (9.3%) and Littleover (9.2%) as having the highest proportions for this indicator. It is conceivable that these areas are characterised by moderate, healthy levels of drinking that are guarding against alcohol abuse, since none of these areas featured within the highest regions for binge drinking for 2007-2008.

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2.3 Hospital admissions due to alcohol

Hospital admissions can be a result of casual regular alcohol use above lower-risk levels as well as chronic heavy drinking, and are most likely to be found in increasing-risk drinkers, higher-risk drinkers, dependent drinkers and binge drinkers. The rate of Alcohol-Related Hospital Admissions is used as an indicator in the Public Health Outcomes Framework. Some alcohol-related hospital admissions are specifically caused by alcohol while others are contributed to by alcohol (attributable).

Figure 3: Hospital admissions due to alcohol in Derby

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The data in figure 3 reflects the general impact of alcohol on population health. Alcohol-related hospital admissions can be a result of regular alcohol use above lower-risk levels as well as chronic heavy drinking and are most likely to be found in increasing-risk drinkers, higher-risk drinkers, dependent drinkers and binge drinkers.

Health conditions in which alcohol plays a causative role can be classified as either 'alcohol-specific' or 'alcohol-related'. The first two indicators above refer to ‘alcohol specific’ conditions, where alcohol is causally implicated in all cases, e.g. alcohol poisoning or alcoholic liver disease. The following four indicators are for ‘alcohol-related conditions’ which include all alcohol-specific conditions, plus those where alcohol is causally implicated in some but not all cases, for example high blood pressure, various cancers and falls.

Although Derby performed better than its neighbour group for under-18s, alcohol-specific and hospital admissions for alcohol-related conditions, it performed worse than the national group. Alcohol-related hospital admissions (broad measure) provide an indication of the totality of alcohol health harm in the local adult population. Derby falls within the upper quartile amongst its nearest neighbour group, and therefore has the least amount of harm in relation to this comparator. Derby has lower levels of harm than the national average on this indicator (i.e. sits within the second quartile). Derby performed worse than its nearest neighbour and the national group on both of the narrow measures for alcohol-related hospital admissions and admission episodes for alcohol-related conditions. Taken together this evidence suggests that Derby is underperforming around a range of hospital related outcomes, particularly in comparison with the national average.

Figure 4 shows under-18 hospital admission trends. The rate of under-18 hospital admissions has declined in Derby over recent years. Although Derby is lower than its family average and equal to the national average, it remains above the regional average. However, since Derby has a relatively wide confidence interval for this period, this difference is not statistically significant. Since 2008/09, Derby has shown a substantial drop in the rate of under-18s admitted to hospital with alcohol specific conditions.

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Figure 4: Under 18s admitted to hospital with alcohol-specific conditions (Source: Local Alcohol Profiles for England)

Figure 5 reflects local, regional and national trends for people admitted to hospital with alcohol-related conditions (broad measure). This includes episodes where an alcohol-related condition lies within the primary diagnosis or any secondary diagnosis field. Locally, Derby has moved from being the highest amongst its comparators to within the lowest few groups. As a result, it has shown the greatest levels of improvement, reflected in the percentage drops in figure 6.

Figure 5: Persons admitted to hospital with alcohol-related conditions (Broad; Source: Local Alcohol Profiles for England)

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Figure 6: Percentage change in rate of persons admitted to hospital admissions for alcohol-related conditions (broad)

The narrow measure includes alcohol-related conditions in the primary diagnosis field or any secondary diagnosis with an external cause. Derby remains above the national and regional averages for this indicator, although there have been significant reductions in the rate of admissions since 2011/12. Figure 8 accentuates this, and highlights that local improvements exceed those of the comparators.

Figure 7: Persons admitted to hospital with alcohol-related conditions (Narrow; Source: Local Alcohol Profiles for England)

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Figure 8: Percentage change in rate of persons admitted to hospital admissions for alcohol-related conditions (narrow)

Figure 9: Standardised admission ratio of hospital admissions for alcohol attributable harm grouped by middle super output area – April 2008 – March 2013; Source: Local Health Profiles

Figure 9 depicts the standardised admission ratios for alcohol related harm by middle super output area. The areas with the highest standardised admission ratio (SAR) of alcohol attributable harm are

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located within the upper central MSOAs of Derby. These are situated within the Abbey, Arboretum and Normanton wards. Other MSOAs of concern are located within the Derwent, Alvaston, Boulton and Sinfin wards.

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2.4 Mortality and months of life lost

Figure 10 reflects the level of chronic heavy drinking in the population and is most likely to be found in higher-risk drinkers and dependent drinkers. High rates of alcohol specific mortality and mortality from chronic liver disease are likely to indicate a significant population who have been drinking heavily and persistently over the past 10 – 30 years. In terms of months of life lost due to alcohol related conditions, in males Derby performs worse than both its nearest neighbour and the national average. In females, Derby performed better than its neighbour and amongst the worst nationally. The data for this indicator provides an estimate of the increase in life expectancy at birth that would be expected if alcohol-attributable deaths amongst under-75 year-olds were prevented. With males, an average of 13.99 months of life are lost, while in females an average of 6.04 months of life are lost. Derby performed worse than its neighbour and the national average on alcohol specific mortality and mortality from chronic liver disease. For alcohol-related mortality, Derby performed better than its neighbour group and worse than the national group. There was a general trend for Derby to underperform when compared to the national group on months of life lost, alcohol specific mortality, chronic liver disease mortality and alcohol-related mortality.

To address the harm reflected in this data, successful plans will employ what is known to work in terms of: effective prevention; health improvement interventions for those at risk; treatment and recovery services for dependent drinkers; and action to reduce binge drinking and reduce the harm caused by binge drinkers.

Figure 10: Months of life lost due to alcohol

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2.5 Alcohol and crime

The data below reflects the level of crime linked to drinking in the population in 2012/13 and is most likely to be found in binge drinkers, higher-risk drinkers and dependent drinkers. Higher levels of alcohol-related recorded crimes and violent crimes are likely to be significantly linked to binge drinking and the night-time economy. It is not possible to determine whether these drinkers are increasing risk, higher risk or dependent drinkers, however they are evidently drinking problematically.

In Derby there were 7.37 alcohol-related recorded crimes per 1000 in 2012-13. This is significantly higher than both the national average and nearest neighbour group. Similarly, with alcohol-related violent crime, Derby performed worse than its neighbour and national groups.

Figure 11: Alcohol and crime in Derby City

The series of tables and charts below provide a summary of criminal activity associated with alcohol consumption within Derby city and Derbyshire county as a whole. In total there were 4,628 alcohol-related incidents within the county and 1,779 incidents in the city in 2014/15. The number within the city is markedly higher than that provided in the previous needs assessment for the period of March 2012 - February 2013 (759). This can be explained by a recent performance-related drive to ensure that the alcohol flag is used in reporting, which means that the data provides a more accurate reflection of alcohol-related crime.

Table 1: Breakdown of crime by type - City

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Table 2: Breakdown of crime by type – County

As expected, violence against the person formed the majority of alcohol-related incidents in both the city and county. This was followed by criminal damage/arson and theft offences.

Table 3: Breakdown of crime by month

Figure 12: Monthly pattern of alcohol-related incidents

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The monthly pattern of alcohol-related incidents is very similar for the city and county. Both areas are characterised by an increase from May to June, as well as a rise from July to August. These peaks are likely to be due to the warmer weather, which can encourage people to drink sociably. However, the city showed a sharper increase in alcohol-related incidents over December, which may highlight a degree of local vulnerability to alcohol-related crime.

Table 4: Breakdown of crime by time

Table 4 provides a breakdown of the number of alcohol-related incidents by time. The city and county similarly show a u-shaped pattern, although this is more defined for the county, which displays a sharper drop between 02:00am – 05:00am. It is interesting to note that at 09:00am, both the city and county show a sharp increase in the number of alcohol-related incidents. In the evening, the number of incidents gradually increases as anticipated.

The Derby city offender level data revealed that the majority (82%) of offenders were male. Table 5 provides a breakdown of the count and percentage of offenders.

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Table 5: Breakdown of crime by gender of offender

Table 6 demonstrates that the majority of offenders were within the younger age categories of 25-34 (35%) and 16-24 (33%).

Table 6: Breakdown of crime by age category of offenders

Derby City public health team have successfully implemented the ‘Cardiff Model’, which ultimately aims to reduce instances of alcohol related violence. This involves utilising anonymised information from A&E patients about the precise location, time and nature of alcohol-related assaults. This should enhance the effectiveness of targeted policing and reduce the incidence of alcohol-related violence, thus easing the existing burden on emergency services.

In Derby, there were 183 recorded alcohol-related assaults between April 2014 and February 2015. The purple flag metric filters these incidents by those that took place on a Friday or Saturday between 8pm and 5am within the city centre. There were 61 purple flag incidents recorded between April 2014 and February 2015. Overall, half of the recorded offences took place on the road/pavement. The second most common location type was a bar/pub/club. In contrast there were a near identical number of purple flag offences that took place on the road/pavement (27) and in a bar/pub/club (32). Table 7 below compares the location types of all assaults and purple flag incidents.

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Table 7: Location types of all assaults and purple flag incidents

Location type Number of incidents overall

Number of purple flag incidents

Road/pavement 92 27Bar/pub/club 65 32Shop 8 *Home 5 *Restaurant * *Park * *Care establishment

* *

School * *Grand Total 183 61

* Primary and secondary suppression have been implemented in order to protect the confidentiality of cells that pose an unacceptable risk of disclosure.

Table 8 indicates that the most common method of assault was the fist. This is also the case with purple flag incidents.

Table 8: Method of assault

Method of assault Number of incidents

Fist 99Not known/refuses to say 15Combination of body parts 10Other 9Feet 9Bottle 7Any blunt object 6Pushed 6Head 5Glass 5Other weapon *Knife *Other bladed or sharp object *Firearms *Chemicals *Grand Total 183

* Primary and secondary suppression have been implemented in order to protect the confidentiality of cells that pose an unacceptable risk of disclosure.

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There were seasonal fluctuations in the number of alcohol-related assaults (depicted in figure 13). This highlights notable peaks over the warmer months of July and August, as well as December. The latter can inevitably be explained by the Christmas holiday period.

Figure 13: Monthly pattern of alcohol-related incidents

When the data was grouped by day of occurrence, it became apparent that the number of recorded offences increased as the week progressed, with a notable peak on Sunday. This is demonstrated in figure 14 below.

Figure 14: Alcohol-related incidents grouped by day

Figure 15 demonstrates that when grouped by 5-digit postcode sector, the majority of assaults arose within the central areas of Derby, as expected. The incidents were especially prominent in the DE1 1 area of the Abbey, Arboretum, Darley and Mackworth wards, (52 incidents), and the DE1 3 area of Darley and Arboretum (22 incidents).

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Figure 15: Number of alcohol-related incidents grouped by postcode sector

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2.6 Alcohol Treatment System

The following section provides detailed information on individuals who are in contact with structured alcohol treatment. The data has been taken from the National Drug Treatment Monitoring System (NDTMS), and refers to individuals who were in treatment during 2013-14 and cited alcohol as their primary problematic substance. Nationally, women make up 36% of the adults in alcohol treatment. Women presenting to treatment often experience poor mental health, domestic violence and for mothers, who make up 54% of women in treatment, the challenge of being a lone parent. Some of the data presented here is split by gender to help local planning consider and meet women’s needs in recovery services.

Waiting TimesThis section provides information relating to the length of time clients waited to access alcohol treatment for the first intervention they received. People who need alcohol treatment need prompt help if they are to recover from dependency and keeping waiting times low will play a vital role in supporting recovery from alcohol dependency. Figure 16 below demonstrates that Derby performs better than the national average for both waiting times indicators. The proportion of individuals waiting under three weeks to start treatment (94%) exceeds the national average. The proportion of individuals waiting over six weeks to start treatment (1%) is marginally lower than the national average.

Figure 16: Waiting Times in Derby City

Routes into TreatmentThe table below shows the routes into alcohol treatment. Understanding these gives an indication of the levels of referrals from criminal justice (and other sources) into specialist treatment. Criminal Justice System (CJS) means referred through an arrest referral scheme, via an Alcohol Treatment Requirement (ATR), prison or the probation service.

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2.7 Demographics and headline treatment figures

In 2013/14, 65% of adults in alcohol treatment were male. The national average age of clients in alcohol treatment is 43 and although there are more men than women in treatment, the age distribution for both genders is very similar.

This section shows information about people who were in alcohol treatment in 2013-14. Specifically: all those in treatment; those who started in the year; the number of people in drug treatment who also have an alcohol problem; a gender split; the number of pregnant women and the number being treated for a co-existing mental illness.

Figure 17 shows the number of people who were in alcohol treatment in 2013/14 and whether they commenced treatment in that year or were already in treatment at the start of it. In Derby, 11% of adults in drug treatment cite additional problematic alcohol use. This is below the national average of 22%.

Figure 17: Demographics and headline treatment figures

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It should also be noted that mental health problems are common amongst those needing treatment for alcohol misuse. The data below shows the proportion of people who, when assessed for alcohol treatment, were receiving treatment from mental health services for reasons other than substance misuse. This is compared against the national, regional and nearest neighbour groups.

Table 9: Comparison data for concurrent contact with mental health services and substance misuse services for alcohol misuse (2013/14); Source: Public Health England

Concurrent contact with mental health services and substance misuse services for alcohol misuse (% - as a proportion of all individuals in specialist alcohol misuse services)

Derb

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22.09 8.37 37.47 17.12 21.84 21.18

Number 218 64 338 1,807 2,002 114,787

Table 9 demonstrates that although Derby exceeds the national, regional and nearest neighbour groups, this difference is not significant when confidence intervals are taken into account.

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2.8 Safeguarding

Approximately one in three of England's alcohol treatment population has a child living with them at least some of the time. The 2004 Alcohol Harm Reduction Strategy for England estimated that 1.3 million children under 16 in England are affected by parents whose drinking is classified as either harmful or dependent. An estimated 2.6 million children (22%) in the UK are living with parents who are drinking hazardously and 705,000 (6%) are living with dependent drinkers (Manning et al, 2009). Derby is slightly above the national average with the proportion of adults receiving alcohol treatment who are living with children. This is of particular concern since parental alcohol misuse can reduce the capacity for effective parenting. Public Health England note that the children of parents or carers who are dependent on drugs or alcohol are at more risk of behavioural problems, low educational attainment and substance misuse problems. It is therefore imperative that a robust protocol between alcohol treatment services and local safeguarding and family services is maintained. This is fundamental in protecting vulnerable children from harm, and providing them with the support to succeed.

In Derby, 56% of adults in structured alcohol treatment are parents and/or live with children (source: NDTMS, 2013/14). Locally, the proportion of adults living with children (27%) is equal to the national average. However, when combined with the proportion of parents not living with children, the proportion of adults in contact with children in Derby constitutes 56% of the treatment population. This narrowly exceeds the national average of 54%.

2.9 Employment and Benefits

In Derby, the proportion of clients in regular employment (22%) is virtually equivalent to the national average of 21%. However, the percentage of clients who are unemployed or economically inactive is lower than the national average (34% compared to 40% nationally). Conversely, the proportion of long-term sick or disabled clients (35%) exceeds the national average. This is reflected in the higher percentage of individuals recorded as being on disability living allowance (23% compared to 16% nationally).

Employment is key to sustaining recovery. However, employment outcomes for clients exiting treatment remain low at both a local and national level. Improving job outcomes for this group requires improved multi-agency responses; achievable through good joint working between Jobcentre Plus and Work Programme Providers.

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2.10 Housing and Homelessness

There is a high local need for stable housing, with 7.6 per 1000 households accepted for homelessness applications. In addition, a significantly higher proportion of clients have non-urgent housing problems (14% compared to 9% nationally).

A safe, stable home environment enables people to sustain their recovery; insecure housing or homelessness threatens it. Addiction and homelessness do not exist in isolation. People experiencing both are likely to have a range of needs cutting across health and social care, substance use and criminal justice. The Joint Strategic Needs Assessment (JSNA) and Joint Health and Wellbeing Strategy (JHWS) can be used to identify and commission across these interdependencies. Engaging with local housing and homelessness agencies can help ensure that the full spectrum of homelessness is understood and picked up: from statutorily homeless; single homeless people, rough sleepers and those at risk of homelessness.

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2.11 Drinking levels and additional substances used

This section shows the number of people drinking at higher risk levels, the number of units consumed in the 28 days prior to treatment and the number of people using additional substances to alcohol. Higher risk drinking is defined here as ‘women drinking more than 140 units per month’ and ‘men drinking more than 200 units per month’ and is in line with the Government's definition of weekly higher risk consumption levels (50 units per week for men and 35 units per week for women). Drinking at higher risk levels increases the risk of alcohol related disease. For example, the risk of liver disease is increased by 13 times. Risk of coronary heart disease is increased by 1.7 times for men and 1.3 times for women. Although the majority of clients cite using alcohol in the month prior to treatment, 7% nationally cite no alcohol use. There are several reasons why this could be the case: they may have been referred to treatment directly from the criminal justice system or they may be in treatment to maintain abstinence and prevent relapse. Additional use of opiates and crack are mentioned here as they are often used by clients with the most complex problems. Cannabis is also shown separately as it is the most common additional substance cited by alcohol clients in treatment.

79% of clients are drinking at higher risk levels in the 28 days prior to entering treatment, which is marginally above the national figure of 77%. A significant proportion of clients cite cannabis use in addition to alcohol, (17% locally compared to 10% nationally). In addition, 6% are also using opiates or crack, and 12% are using other drugs. This highlights the need for a holistic approach to the treatment journey.

Figure 18: Drinking levels and substance use in those in contact with treatment

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2.12 Length of time in treatment

NICE Guidance (CG115) suggests that harmful drinkers and those with mild alcohol dependence might benefit from a package of care lasting three months while those with moderate dependence might need a six month package and those with severe dependence or those with complex needs may need a package of care lasting up to a year.

The length of a typical treatment period was around 6 months, although nationally 10% of clients remained in treatment for more than one year. Retaining clients for their full course of treatment is important in order to increase the levels of successful treatment completion and reduce rates of early treatment drop out. Conversely, having a high proportion of clients in treatment for more than a year may indicate that they are not moving effectively through and out of the treatment system.

Figure 19: Length of time in treatment

Figure 19 above demonstrates that 57% of clients spend less than 3 months in treatment, which is markedly higher than the national average of 38%. However, there is conflicting evidence regarding how length of treatment affects outcomes. While observational studies have found that a longer inpatient stay resulted in better outcomes in therapeutic communities, halfway houses and hospitals, randomised clinical trials have found that longer inpatient stay has not resulted in better outcomes for patients being treated for alcoholism. Despite these mixed findings, it is important that the client’s treatment episode is sufficient in preventing re-presentation.

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2.13 Treatment outcomes

Figure 20 relates to clients completing their period in treatment in 2013-14, and whether they completed successfully and did not return within 6 months. The Government's alcohol strategy states that increasing effective treatment for dependent drinkers will offer the most immediate opportunity to reduce alcohol-related admissions and costs to the NHS. Although there is no single measure of effective treatment for alcohol dependency, the following data demonstrates how well the current system is working in treating those who are receiving structured treatment.

The first data item in figure 20 indicates a significantly higher proportion of individuals leaving alcohol treatment as a proportion of all clients in treatment in 2013-14 (83% compared with 65% nationally). Despite a higher completion rate for Derby’s alcohol clients, the percentage of individuals leaving alcohol treatment successfully was virtually equal.

The successful completions data provides an indication of the effectiveness of the treatment system in Derby. A high number of successful completions and a low number of re-presentations to treatment indicate that the treatment services are responding well to the needs of those in treatment.

Figure 20: Adults completing treatment

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3 Introduction – Drugs

This section provides key performance and recovery outcomes information about the drug treatment system with national data for comparison. It presents data from the National Drug Treatment Monitoring System (NDTMS), the Treatment Outcomes Profile (TOP), the Drug Interventions Programme (DIP), matched data from NDTMS and local market system data used by Jobcentre Plus and estimates of the prevalence of opiate and/or crack cocaine use. Although drug treatment services treat dependence for all drugs, heroin users remain the group with the most complex problems, thus separate data is provided for them. Nationally, women constitute 27% of the adults in drug treatment. Locally, the proportion of women in drug treatment is marginally lower at 24% (NDTMS, 2013/14). Women presenting to treatment often experience poor mental health, domestic violence and for mothers, the challenge of being a lone parent. Some of the data presented here is split by gender to help local planning consider and meet women’s needs in recovery services.

Data within this section presents outcomes for clients during their time in treatment and also longer-term recovery outcomes. The outcomes achieved while in treatment can be demonstrated to be very good predictors of successful completion and non re-presentation especially housing and employment and abstinence from illicit drug use. In addition, the latest successful completion and non re-presentation rates are a very good indicator of future performance in the PHOF indicators 2.15i and 2.15ii.

http://www.phoutcomes.info/public-health-outcomes-framework#gid/1000042/par/E12000004/ati/102/page/0

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3.1 Prevalence estimates

The estimated number of opiate and/or crack users (OCU) and injectors in Derby is set out below. Collectively, they have a significant impact on crime, unemployment, safeguarding children and long-term benefit reliance.

Table 10 provides the estimated number of opiate and/or crack users (OCU) and injectors in Derby City. OCUs have a significant impact on crime, unemployment, safeguarding children and welfare dependency. The rate of OCUs per 1000 in Derby is 14.52, which is almost double the national estimate of 8.40. When looking at opiate and crack separately, Table 10 suggests that the rate of opiate use in Derby is higher than the national rate (12.81 and 7.32, respectively). Similarly, the rate of crack use is higher than the national rate (6.47 and 4.76, respectively).

Table 10: Prevalence estimates for Opiate/Crack users (OCU) and Injectors

Figure 21 provides a bullseye view of Opiate and/or Crack Users for all in treatment (total prevalence estimate: 2,374).

Figure 21: Bulls Eye - OCUs

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217

343

898Currently in treatment

In treatment during financial

Known to treatment but not treated in the last year

Not known to treatment

916 (total 2,374)

3.2 Waiting Times

The majority of clients wait under three weeks to start treatment (98%), whilst a small minority wait over six weeks to start treatment. This is consistent with the national patterns. Drug users need prompt help if they are to recover from dependence. Local efforts to keep waiting times low mean that the national average waiting time is less than one week. Keeping waiting times low will play a vital role in supporting recovery in local communities.

3.3 Treatment Engagement

When engaged in treatment, people use less illegal drugs, commit less crime, improve their health, and manage their lives better – which also benefits the community. Preventing early drop out and keeping people in treatment long enough to benefit contributes to these improved outcomes. As people progress through treatment, the benefits to them, their families and their community start to accrue. Figure 22 shows the proportion of adults in 2013-14 who have been in treatment for three months or more – a measure for effective treatment engagement. The proportion of opiate clients effectively engaged in treatment (96%) has dropped by 5% since 2012-13, but remains above the national average. Re non-opiate clients, there has been a 15% increase in the proportion of adults engaged in effective treatment, although this is currently below the national average (81% and 88% respectively).

Figure 22: Adults effectively engaged in treatment

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3.4 Routes into Treatment

The figure below conveys the routes into drug treatment in Derby and at a national level. Understanding these provides an indication of the levels of referrals from criminal justice (and others sources) into specialist treatment. ‘Referred through CJS’ indicates referrals through an arrest referral scheme, or via Drug Rehabilitation Requirements (DRR), prison or the probation service. In Derby, self-referral is the most common route into drug treatment (59%), followed by referrals through the criminal justice system (31%). This corresponds with national trends, although there are a higher proportion of self-referrals locally than nationally (the latter of which is 43%).

Analysing the routes into drug treatment can also provide an insight into whether there are co-existing problems in the drug treatment population. In particular, mental health problems are common amongst those in treatment for drug use. Table 11 shows the proportion of people who, when assessed for drug treatment, were receiving treatment from mental health services for reasons other than substance misuse. This is compared against the national, regional and nearest neighbour groups.

Table 11: Comparison data for concurrent contact with mental health services and substance misuse services for drug misuse (2013/14); Source: Public Health England

Concurrent contact with mental health services and substance misuse services for drug misuse (% - as a proportion of all individuals in specialist drug misuse services)

Derb

y Pe

rfor

man

ce

agai

nst n

ation

al

Derb

y Pe

rfor

man

ce

agai

nst

near

est

neig

hbou

r

Derb

y Pe

rfor

man

ce

Derb

y

Leic

este

r

Notti

ngha

m

Nea

rest

ne

ighb

our

Regi

on

Engl

and

Sign

ifica

ntly

lo

wer

than

na

tiona

l ave

rage

Not

sign

ifica

ntly

di

ffere

nt

Sign

ifica

ntly

lo

wer

than

re

gion

al a

vera

ge

10.42 10.20 10.08 13.31 13.22 17.51

Number 145 153 179 2,444 2,022 33,843

Derby is comparable with its nearest neighbour group (due to wider confidence intervals), and has a significantly lower proportion of people with concurrent contact than the national and regional comparators.

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3.5 InterventionsIt is evident that the types of intervention delivered to service users will have an impact on their achievement of recovery outcomes. The majority of high-level interventions (95%) are delivered in a community setting. There are also a substantial proportion of interventions delivered in primary care settings for pharmacological interventions (14%), which more than doubles those for other interventions.

3.6 Employment and BenefitsIn Derby, 48% of clients were unemployed/economically inactive at the beginning of treatment, which is marginally lower than the national average of 53%. It should also be noted that an employment status of “other” may highlight a data quality issue where the information does not fit into other options of the core data set. In Derby, 28% of clients have a recorded employment status of “other”, which is markedly higher than the national figure of 3%. This indicates a significant level of hidden need due to an under-reporting of information.

The benefit profile of the treatment population in figure 23 reveals that over half of the clients in drug treatment on 31st March 2012 were recorded as being on benefits. The most common type of benefits were Employment Support Allowance (22%), followed by Income Support (17%). It is also notable that the median length of time on benefits was the greatest for incapacity benefits (7.05 years), followed by income support (5.64 years).

Employment is a key element in sustaining recovery. However, employment outcomes for clients exiting treatment remain low both locally and nationally. Improving job outcomes for this group requires improved multi-agency responses; achievable through good joint working between Jobcentre Plus and Work Programme Providers.

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Figure 23: Benefit profile of the treatment population

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3.7 Housing and Homelessness

Although the majority of clients do not have a housing problem (73%, n=317), 15% do and 10% have an urgent problem. In addition, the local need for housing is higher than the national rate, with 7.6 per 1000 households accepted for homelessness applications.

A safe, stable home environment enables people to sustain their recovery; insecure housing or homelessness threatens it. Addiction and homelessness do not exist in isolation. People experiencing both are likely to have a range of needs cutting across health and social care, substance use and criminal justice. The Joint Strategic Needs Assessment (JSNA) and Joint Health and Wellbeing Strategy (JHWS) can be used to identify and commission across these interdependencies. Engaging with local housing and homelessness agencies can help ensure that the full spectrum of homelessness is understood and picked up: from statutorily homeless; single homeless people, rough sleepers and those at risk of homelessness.

3.8 In Treatment OutcomesData from NDTMS suggests that clients who stop using illicit opiates in the first six months of treatment are almost five times more likely to complete successfully than those that continue to use.

Figure 24: Treatment outcomes

Abstinence from drugs reflects the number and proportion of clients who reported using a drug at the time of their start TOP (28 days before treatment) that have stopped using it by the time of their treatment review TOP (conducted in 3 month cycles) in 2013/14. Derby is currently exceeding the national average for abstinence from opiates, crack, amphetamines, cannabis and alcohol (adjunctive use).

There have also been significant reductions in drug use, particularly in opiate clients (28% of users) and alcohol clients with adjunctive drug use (22% of users). A significant reduction in drug use is defined as the number and proportion of clients who reported using a drug at the time of their start TOP that have reliably improved (i.e. reduced their frequency of use by a set number of days) by the time of their treatment review TOP in 2013/14. The reliable change index provides a conservative measure that requires a specified number of days’ reduction for a client to be considered “reliably improved”. The threshold varies between substances – for example, 13 days’ reduction is required for opiate use.

Figure 24 highlights that Derby performs comparably with the national average for adults successfully completing treatment and no longer reporting a housing need (88%). In addition, the

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proportion of adults no longer injecting at review is higher than the national average (68% and 57% respectively).

3.9 Successful Completions

The data below shows the proportion of drug users who complete their treatment free of dependence, the progress Derby has made on people successfully completing treatment, and those successfully completing who do not relapse and re-enter treatment. The drug strategy asks local areas to increase the number of people successfully leaving treatment having overcome dependence. Although many individuals will require a number of separate treatment episodes spread over many years, most individuals who complete successfully do so within two years of treatment entry.

Also below is the proportion of adults who have been in treatment for more than two years – the data suggests that the likelihood of clients completing treatment and not re-presenting decreases the longer they remain in treatment over 2 years.

Figure 25 demonstrates that Derby performs relatively similarly to the national average across the majority of indicators. More notably, there has been a 61% growth in successful completions in non-opiate clients since 2012-13, which greatly exceeds the national figure of 7%.

Figure 25: Successful completions

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3.10 Residential Rehabilitation

Figure 26 shows the number of adult drug users who have received residential rehabilitation during their latest period of treatment (as a proportion of the whole treatment population and against the national proportion). The proportion of adults who attended residential rehabilitation is equal to the national average (2%).

Drug treatment mostly takes place in the community, near to users’ families and support networks. Residential rehabilitation may be cost effective with someone who is ready for active change and a higher intensity treatment at any stage of their treatment, and local areas are encouraged to provide this option as part of an integrated recovery-orientated system.

Figure 26: Number of adults who received residential rehabilitation

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3.11 NPS and Club Drugs

Locally, mephedrone is the most common and virtually sole club drug amongst adults new to treatment. Nationally, this drug is used by approximately half of the treatment population, with smaller proportions citing the use of other club drugs such as ecstasy, ketamine etc.

Opiate users still dominate adult treatment, and generally face a more complex set of challenges and are much harder to treat. Non-opiate-using, adult club drug users typically have good personal resources – jobs, relationships, accommodation – that mean they are more likely to make the most of treatment. From April 2013 NDTMS collected information on additional new psychoactive substances, and will report these next year.

3.12 Blood-Borne Viruses and Drug-Related Deaths

Figure 27 depicts the drug users in treatment in Derby who have had a hepatitis B vaccination and current or past injectors who have been tested for hepatitis C. Although this is relatively similar to the national average, the proportion of adults who completed a course of vaccination is markedly higher at a local level. Drug users who share injecting equipment can spread blood-borne viruses. Providing methadone and sterile injecting equipment protects them and communities, and provides long-term health savings. Although local drug-related death data is not provided, understanding and preventing deaths is an important measure of how well the recovery-orientated drug treatment system is protecting people while increasing ambition.

Figure 27: Hepatitis B vaccinations amongst adult drug users

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3.13 Safeguarding

In Derby, 61% of adults in structured drug treatment are parents and/or live with children (source: NDTMS, 2013/14). Figure 28 demonstrates the number of drug users in treatment who live with children; users who are parents but do not live with children; and users for whom there is incomplete data. This last item is included to help areas consider the possible hidden population(s) of drug-dependent parents, or those with childcare responsibilities in contact with local treatment services. An estimated one in three of the English treatment population (60,949 people) has a child living with them at least some of the time. Locally, this is marginally lower (27%), whilst a markedly higher proportion of the treatment population are parents not living with children (34% compared with 24% nationally).

Figure 28: Proportion of treatment population in contact with children

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3.14 Pharmaceutical Activity

Needle Exchange Service

Since needle exchange patients are required to re-register every 6 months, this document provides the latest snapshot of registrations from the previous financial year. It is also important to note that the data may be an over-estimation of the actual number of registrations, since clients are able to register at different pharmacies.

Between October 2014 and March 2015, there were 853 new needle exchange registrations. Over this period, the number of new registrations declined and subsequently increased (figure 29). This could be explained by the fact that this is a relatively new scheme this year. The number of total transactions has gradually increased, which is displayed in figure 30. This alludes to a greater use of the needle exchange service by existing patients.

Figure 29: New registrations for needle exchange services

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Figure 30: Total transactions for needle exchange services

Figure 31 provides a monthly breakdown of the average number of needles per transaction. This has remained relatively steady this year.

Figure 31: Average number of needles per transaction

Male patients formed the majority (84.99%) of new registrations between October 2014 and March 2015.

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Figure 32: Gender breakdown of new registrations

Figure 33: Age structure of new needle exchange registrations

The mean age of patients who received new needle exchange registrations was 32.2. The age structure of male registrations appears to follow a normal distribution, whilst that of females could be described as a bimodal distribution. However, the latter should be interpreted with caution due to the relatively small number of registrations over this period.

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Table 12: Comparison of the age structure of new needle exchange registrations and clients currently in treatment

* Primary and secondary suppression have been implemented in order to protect the confidentiality of cells that pose an unacceptable risk of disclosure.

Figure 34: Age structure of new needle exchange registrations and clients currently in treatment

Table 12 and Figure 34 reveal that the age structure of clients with new needle exchange registrations and those currently in treatment is relatively similar. However, the proportion of clients in the younger adult categories of 20-24 and 25-29 is markedly higher in clients with new needle exchange registrations. Conversely, the proportion of clients in the older categories is greater for all clients in treatment; a pattern that was anticipated.

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When summarised by age and ethnicity, it is apparent that patients from a white, mixed or other background form the most common ethnic group (table 13). Those from the 25-34 age group comprise a large proportion of this population. The “not stated” group indicates a potential data quality issue with missing information.

Table 13: Ethnicity and age group of patients with new registrations

Age GroupWhite, Mixed

and OtherAsian or Asian

BritishBlack or Black

British Not stated Prefer not to say Grand Total16-24 140 * * 7 * *25-34 363 13 * 24 * *35-44 204 * * 11 * *45-54 61 * * * * *55-64 9 * * * * *65-74 * * * * * *75+ * * * * * *Grand Total * * * * * *

* Primary and secondary suppression have been implemented in order to protect the confidentiality of cells that pose an unacceptable risk of disclosure.

Re primary drugs, opiates were the most common drug overall, which was the case across the majority of months.

Table 14: Primary drugs grouped by month of registration

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Figure 35: Seasonal patterns in the intake of primary drugs

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Supervised Consumption Service

In Derby, 43 pharmacies are registered to deliver supervised consumption services, 36 of which provide this. Figure 36 demonstrates that, despite a peak in April, the number of new registrations subsequently dropped and remained relatively low for the succeeding months.

Figure 36: New supervised consumption registrations

Figure 37 similarly demonstrates a downward pattern, although the decline in the number of supervisions has been more gradual than that of new registrations.

Figure 37: Number of supervisions

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The mean age of patients newly registering for supervised consumption was 36.1. Although small numbers have been excluded, figure 38 conveys a normal distribution of ages. Here the majority of patients are classified within the mid-30s age range.

Figure 38: Age structure of new supervised consumption registrations

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3.15 Conclusions

This needs assessment has uncovered a range of issues that continue to arise within the drug and alcohol using populations. These include unemployment, housing problems and potential safeguarding issues associated with individuals who are parents and/or live with children. It is also evident that the impact of substance misuse is broad-ranging, with effects that can vary from hospital admissions, the use of pharmaceutical services such as needle exchange and supervised consumption and criminal activity (particularly violence). The above, in addition to the client’s primary condition, reflect significant challenges for the health and criminal justice systems.

2015/16 will see the onset of an Integrated Drug and Alcohol Service that will ensure a person-centred approach to care. There will also be a revised model of service delivery that will integrate elements of sustainable recovery and behaviour change at the start of the client’s treatment journey. Continued partnership working will facilitate the client’s access to wider support such as employment, education, housing and welfare and debt advice as part of the Universal Delivery of Local Support pilot. In addition, a revision of existing criminal justice pathways should effectively manage offending that is driven by drug and alcohol use.

The provision of these services coupled with a person-centred approach to care should ensure that the diverse needs of drug and alcohol users are successfully fulfilled.

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