here - National Treatment Agency for Substance Misuse
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here - National Treatment Agency for Substance Misuse
Drug health harms December 2013 A briefing for Directors of Public Health, commissioners, service providers and needle and syringe programmes from the second meeting of the National Intelligence Network on the health harms associated with drug use, held in London on 10 October 2013. About the network The National Intelligence Network on the health harms associated with drug use is convened by the alcohol and drugs team of Public Health England’s Health and Wellbeing Directorate. The network’s aim is to improve the sharing and dissemination of intelligence on blood-borne viruses, new and emerging trends in drug use, and drugrelated deaths, and to explore how to use this intelligence to improve practice. Public Health England activity Dr Vivian Hope, Dr Fortune Ncube and Dr Koye Balogun updated the network on recent PHE activity around blood-borne viruses and infectious disease related to drug use. Pete Burkinshaw updated the network on recent programme work in PHE’s alcohol and drugs team. Infectious disease A second suspected case of botulism in England among injecting drug users has been identified. There is nothing to suggest the two cases are linked as they occurred at significantly different times and in different locations. An updated briefing on botulism, tetanus and anthrax was subsequently circulated by PHE.1 1 Severe illnesses due to anthrax, botulism and tetanus in people who use drugs: update October 2013, PHE http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C /1317140125941 A future network meeting will include a session on PHE surveillance and the processes for disseminating information. Blood-borne viruses PHE has published the ‘Hepatitis C in the UK’ report for 2013.2 It is estimated that there are 215,000 individuals in the UK chronically infected with the hepatitis C virus (HCV). The vast majority (around 90%) of new hepatitis C infections are among people who inject drugs (PWID). The Unlinked Anonymous Monitoring Survey of People who Inject Drugs (UAM) for 20133 showed that half of injecting drug users in England are infected with HCV. Hepatitis B surveillance data for 2012 has been reported.4 554 cases of acute infection were established and only five (1.5%) of the cases with known exposure were attributed to injecting drug use – lower than the 13 reported last year. In recent years there has been a significant increase in the uptake of hepatitis B vaccinations among people who inject psychoactive drugs and access treatment services. 2 Hepatitis C in the UK, 2013 Report, PHE http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C /1317139502302 3 Data tables of the Unlinked Anonymous Monitoring Survey of HIV and Hepatitis in People Who Inject Drugs http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C /1317139450473 4 Health Protection Report: Volume 7 Number 35 Published, PHE http://www.hpa.org.uk/hpr/archives/2013/hpr3513.p df Drug health harms December 2013 However, there are different rates of blood-borne viruses among different groups. The risk tends to be higher in groups who inject image and performance enhancing drugs (IPEDs) and there should be extra attention paid towards this group. Furthermore, PHE plan to scope the monitoring of unstructured interventions as part of a long-term data review. Men who have sex with men PHE alcohol and drugs convened the first roundtable on men who have sex with men (MSM), sexual health and drug use with a second meeting scheduled for early in the New Year. It included stakeholders from statutory and thirdsector treatment services, leading sector charities, local government and government departments. There is also a high risk of blood-borne virus infection among people who inject new psychoactive substances (NPS). Needle and syringe programmes (NSP) Results from the NSP survey, produced in partnership by NICE, PHE and the National Needle Exchange Forum (NNEF), indicate that an increasing number of users of IPEDs are accessing needle and syringe programmes (NSP), and they are in the majority at some programmes. The stakeholder group aims to improve the monitoring of this cohort by linking existing datasets. The group will also assess what appropriate service provision would look like and consider offering guidance for commissioning to address the needs of this population, and examples of evidenced interventions. While the results from the survey are likely unrepresentative as a whole, due to a low response rate, PHE is considering whether to make them available on its alcohol and drugs website. Alcohol and problematic drug use Dr Ed Day, Clinical Senior Lecturer in Addictions at King’s College London presented on the clinical impacts of alcohol in problematic drug users. The Home Office requested that PHE alcohol and drugs assist them with monitoring the provision of foil for smoking drugs from NSP. This is in accordance with the conditionality set out by the Home Secretary.5 Brian Eastwood, Outcomes Manager in the alcohol and drugs team at PHE presented alcohol data from the Treatment Outcomes Profile (TOP). New data fields will be added to the Needle Exchange Monitoring System (NEXMS) to record the number of users taking foil and the sheets of foil taken. Problematic alcohol use by opioid users Excessive drinking among problem drug users is common. Problematic alcohol use can develop for people currently receiving opioid substitution treatment and those who cease treatment. Alongside these changes to monitoring NSP activity, PHE is considering a costbenefit analysis of creating a system which enables the upload of NSP data from local systems to NEXMS. Heavy use of alcohol in this population can be associated with considerable morbidity and mortality. Poly-substance misuse (of alcohol and other drugs) is not 5 Written statement to Parliament from the Rt Hon Theresa May MP: https://www.gov.uk/government/speeches/drugparaphernalia 2 Drug health harms December 2013 widely studied and can be missed in practice. other substance use, injecting and sharing behaviour, days of employment, physical health rating and housing status. Alcohol is often the first intoxicating substance used by heroin users. It also remains the most frequently used additional substance among heroin users throughout their using career. These outcomes data for alcohol users can prompt commissioners of services to offer interventions to help this group of clients with related problems. At client level TOP data can assist clinicians and keyworkers with questions about their drinking levels. Studies show that in the period between one and six years after treatment drug use decreases overall but alcohol use increases.6 Also, patients on methadone maintenance who relapse to illicit drug use are more likely to test positive for alcohol than those who do not relapse.7 NB Preliminary data was presented at the meeting and is not available for publication. Alerts and early warning systems Alcohol use needs to be specifically addressed in drug treatment programmes. If it is not then recovering drug users may be at risk of poor outcomes and health-related harm. Michael Linnell, co-ordinator of the UK DrugWatch group, gave an overview of their work including a pilot project in Salford. Charlotte Davies, from UK Focal Point, talked about how intelligence is fed up to EMCDDA. Clinicians working with drug misusers require: an awareness of alcohol misuse; competence at detecting it; ability to give harm reduction messages; and ability to manage alcohol misuse alongside OST. DrugWatch UK DrugWatch is an informal online professional information network (PIN) set up in November 2010 by a group of professionals working in the UK drugs sector. Treatment Outcomes Profile Through Treatment Outcomes Profile (TOP) data, collected by the National Drug Treatment Monitoring System (NDTMS), PHE can identify levels of alcohol use (problematic or otherwise) among the population in treatment primarily for illicit substance use. Although a number of national and European-wide drug early warning systems (EWS) already exist, the founders of DrugWatch wanted to create a new system based on shared intelligence to identify, risk assess and respond to localised outbreaks of new psychoactive substances and adulterated drugs. TOP can highlight the variable impact alcohol use can have on an individual’s progress in other domains like levels of Example: UK DrugWatch asked for help after the night manager on a mental health ward spotted a cluster of four cases in the preceding two weeks requiring accident and emergency admission. 6 Simpson DD and Lloyd MR (1978) Alcohol and illicit drug use: follow-up study of treatment admissions to DARP during 1969-1971; Am J Drug Alcohol Use 1978; 5(1):1-22. 7 Stenbacka M, Beck O, Leifman A, Romelsjo A and Helander A (2007) Problem drinking in relation to treatment outcomes among opiate addicts in methadone maintenance treatment; Drug Alcohol Rev 2007;26(1):55-63 Symptoms were similar and UK DrugWatch asked for more details from 3 Drug health harms December 2013 the A+E duty manager. This information was posted on the UK DrugWatch network. Toxicologists then asked for a report from the duty manager and posted a request for information on the network. producing a joint report on the risk assessment can mean that control decisions are slow. The phenomenon of new psychoactive substances exists across Europe but there are differences in the type of substances used, the method of use and the harms associated with use. Within days DrugWatch provided an information briefing for professionals while harm reduction advice for patients was supplied to local treatment services through the local partnership. Drug-related deaths Information from the DrugWatch group can help identify real risks and harms, as well as flag-up potential risks. Local alerts which feed into a national alerts system can establish a more co-ordinated approach. Robert Wolstenholme from the alcohol and drugs team at PHE presented the latest 2013 ONS data on drug-related deaths. Malcolm Roxburgh, National Drug Treatment Monitoring System Programme Manager at PHE, talked about developing a new drugrelated deaths monitoring strategy European Early Warning System The UK Focal Point provides the UK component of the European Early Warning System (EWS) and is responsible for providing information to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) on the manufacture, trafficking and use of newly identified substances. Official statistics Official figures from the Office for National Statistics (ONS) for 2012 showed heroin and morphine deaths were similar to 2011. Methadone deaths fell in 2012 but this is against a general increasing trend. 1000 800 The UK network comprises forensic scientists, academics, law enforcement officials, government officials and clinicians. The network shares information on fatalities and intoxications. 600 400 200 0 2011 2009 2007 Heroin and morphine Cocaine All benzodiazepines 2005 2003 2001 1999 1997 1995 1993 The European Database on New Drugs (EDND) is a collection point for alerts information, health risks and case reports. Methadone All amphetamines Fig 2: Number of drug-related deaths where selected substances were mentioned on the death certificate, England and Wales, deaths registered between 1993 and 2012; ONS, 2013 For example, 25I-NBOMe is a derivative of the phenethylamine hallucinogen 2C-I and was first reported in Sweden in June 2012. Non-fatal intoxications followed in Belgium and UK. The substance is under a temporary class drug order (TCDO) in the UK and is subject to a formal risk assessment. The system provides a useful national and international information exchange network. However, ONS published statistics for the first time in 2012 concerning deaths where novel psychoactive substances were mentioned on the death certificate. These were backdated for previous years. There were 52 deaths where NPS were mentioned registered in 2012, up from 29 in 2011. 4 Drug health harms December 2013 ONS reported 20 deaths registered in 2012 where para-Methoxyamphetamine (PMA) was mentioned. Prior to this, two deaths involving PMA had been reported in the preceding nineteen years. Total amphetamine deaths (including MDMA) increased from 62 in 2011 to 97 in 2012, the highest number for four years. Priorities The group discussed priorities for health harms associated with drug use and suggested areas that the network should address at future meetings. The new public health landscape provides opportunities for the drug treatment sector to build on knowledge and good practice that has developed over the years. Deaths where tramadol was mentioned (which are usually not classed as drug misuse deaths) continue to increase, up from 154 in 2011 to 175 in 2012. Alcohol use and smoking are drivers of premature mortality among the drug using population, alongside hepatitis C and HIV. Developing a PHE drug-related deaths strategy PHE is looking at wholesale improvement of the quality of deaths statistics. There could be wider recording of deaths among people who use drugs, which could include deaths through injecting drug use and related chronic illness. Getting targeted health harms information to the right people quickly through reputable knowledge bases is vital. A ‘bottom-up’ approach can work where there is good local knowledge feeding into wider regional and national systems and this is to be encouraged. There have long been plans to utilise and collate data from the National Drug Treatment Monitoring System (NDTMS), Hospital Episode Statistics and ONS deaths data. It is expected that PHE will be in a position to utilise linked data soon. Credible alerts and public health messages are key to establishing an effective intelligence sharing system. Guidance which explains who is in charge of monitoring messages and working with people in drug using communities, with direct experience of health harms, can help with this. ONS is consulting on its future outputs and reporting, including statistics on drugrelated deaths. PHE’s decision on how to develop a surveillance system is partially dependent on the outcome of the ONS consultation. There are concerns in the field that services are providing shorter hours for needle exchange and pharmacies are doing the bulk of needle exchange provision. If PHE is to have greater involvement in the monitoring process, there may be an opportunity to look at a wider classification of drug-deaths than is currently reported. Data could also be examined alongside levels of naloxone provision, for example, to evidence best practice in preventing drug-related deaths. There were concerns among some network members that needle exchange and harm reduction components in provider contracts are much more limited than they have been before. Some local areas have suggested that a large harm reduction section in a tender is likely to make it unsuccessful. 5 Drug health harms December 2013 An English map of naloxone distribution would be welcomed by the field and its publication could be reinforced with good practice examples of naloxone’s use. The WEDINOS (Welsh Emerging Drugs and Identification of Novel Substances Project) system is an example which can be looked at for planning future information systems. Standards for drug toxicology screening can be collated and encouraged to improve intelligence. Local areas that have good data flows from coroners to local strategic partners should be protected and other areas should look to improve the data flows where possible. The treatment sector and their allies (including Directors of Public Health) can join forces and a strong relationship can influence contract commissioning to reflect the needs of the population. Key topics for future health harms network meeting were identified as: smoking among drug users and the provision of needle and syringe programmes. The next network meeting will take place on Wednesday 29 January, at Skipton House, 80 London Road, London SE1 6LH Presentations http://www.nta.nhs.uk/who-healthcare-drdbbv.aspx Attendees Dr Yusef Azad, National Aids Trust David Badcock, Addaction Dr Koye Balogun, PHE Jamie Bridge, National Needle Exchange Forum Nigel Brunsdon, Injecting Advice & HIT Pete Burkinshaw, PHE Emma Burke, PHE Jane Cox, Hepatitis C Trust Katelyn Cullen, PHE Dr Ed Day, University of Birmingham & Society for the Study of Addiction Charlotte Davies, PHE Selina Douglas, Turning Point Brian Eastwood, PHE Dr Simon Hill, National Poisons Information Service Dr Vivian Hope, PHE Neil Hunt, University of Kent Steve Jackson, Bristol Drugs Project William James, Swanswell Susan Johal, PHE Ian Joustra, Rotherham Doncaster and South Humber NHS Foundation Trust Dr Michael Kelleher, PHE Dr Ryan Kemp, British Psychological Society Andrew Kilkerr, CRI Michael Linnell, DrugWatch & Lifeline Liz McCoy, Pennine Care NHS Foundation Trust Jim McVeigh, Liverpool John Moores University Danny Morris, Royal College of General Practitioners Mike Naraynsingh, Greater Manchester West Mental Health NHS Foundation Trust Dr Fortune Ncube, PHE Simon Parry, MORPH John Ramsey, TICTAC & St George’s College, University of London Malcolm Roxburgh, PHE Harry Shapiro, DrugScope Carole Sharma, Federation of Drug and Alcohol Professionals Basak Tas, Release Steve Taylor, PHE Louise Wilkins, Nottinghamshire Healthcare NHS Trust David Wood, Guy’s and St. Thomas’ NHS Foundation Trust Tim Woolley, Addiction Dependency Solutions Robert Wolstenholme, PHE If you have any enquiries about this briefing, or the network in general, please contact Robert Wolstenholme: robert.wolstenholme@phe.gov.uk 6