The number of individuals engaged in structured drug treatment programmes in England has declined over recent years, but this has been a trend which has occurred alongside another development, that of an increasing number of drug related deaths (DRDs), culminating last year with ONS reporting the highest number of DRDs on record. Delivery of needle and syringe programmes (NSP) in England is not monitored in the same way as drug treatment programmes, at least at a national level, but local monitoring systems provide information which points to a different picture than that which national drug treatment programme data might suggest.
In the North West of England, NSP provision within the nine local authorities which cover Cheshire and Merseyside has been monitored for over 25 years by Liverpool John Moores University’s Public Health Institute (PHI), with comprehensive coverage for the last 10 years. Over 1.9 million needles and syringes were distributed across Cheshire and Merseyside during 2016/17, and of these over 1.25 million were to people who inject psychoactive drugs (including heroin), the highest number on record. When this data is matched to that from the National Drug Treatment Monitoring System (NDTMS), the proportion of individuals injecting psychoactive substances who were not in structured treatment within the past year was 80.1%. This is the first year that we have been able to match the data looking at this cohort only, so it is not yet clear whether this is a growing issue or consistent with other years. Either way, it appears that there is a substantial proportion of individuals injecting psychoactive substances who are not currently in structured treatment.
NSP services within Cheshire and Merseyside use a client attributor comprising of initials, date of birth and gender as part of PHI’s data monitoring, and one of the regular queries concerns the authenticity of this attributor. In theory, a random fictional attributor might be supplied by clients who fear their anonymity could be breached, particularly in the case of services where the NSP is located within the same building as the structured treatment provider. Two factors we’ve explored suggest that this may not be the case, or at least not extensively so. In the first place, research undertaken by PHI over the summer of 2017 surveyed agencies and pharmacies delivering NSP from across the spread of local authorities and asked them about this specific issue. Over two thirds (72%) responded by stating that they believed individuals using their service used the same consistent attributor on each visit. Moreover, as part of the drug related death monitoring process, operational in several of the same local authority areas, a substantial number of individuals whose personal details are confirmed to be correct by both the treatment service and the coroner have matching NSP records. This suggests that there is widespread use of genuine details, and that the numbers highlighted by the system will probably not be wildly over inflated. At the least, since the same model based on attributors has been used for counting the number of individuals using NSP for the last 25 years, the direction of travel is important. If we look solely at the number of NSP transactions without looking at individuals specifically, we can see that they have doubled over the last 3 years. With only 19.9% of NSP client attributors matching to data from NDTMS, even if this figure was doubled, it would still represent a majority of individuals using NSP who are not engaged in treatment.
The 2016 report from the Advisory Council on the Misuse of Drugs (ACMD) identified a number of potential causes of the recent upsurge in opioid related deaths, including the ageing drug using population, changes in the availability and purity of heroin at street level and socio-economic changes (i.e. increasing deprivation and cuts to support services in deprived areas). However, it also suggested that changes in the commissioning and provision of drug treatment might be a factor and it is accordingly vital that the large numbers of individuals outside of the treatment system do not go unnoticed by those commissioning services. With research showing that individuals using heroin become more vulnerable to death from overdose as they grow older, the increasing proportion of people who use NSP services that are older highlights the importance of ongoing engagement in order to encourage attendance in treatment services and monitoring numbers to ensure the problem is not becoming exacerbated. It is also important to note that treatment has been identified as a protective factor by Public Health England (PHE) and other bodies: “There are risks associated with the move towards abstinence. For example, there is a higher risk of death for heroin users who have left Opiate Substitution Therapy (OST) than for those who stay in it, especially in the first few weeks.” (ACMD, 2016, p31). While elements of the latest guidelines on clinical management of “drug misuse” focus on the importance of not being solely recovery focussed, the high number of individuals outside of the treatment population make them a vulnerable group, particularly in the light of funding cuts which the ACMD warned would result in a dismantling of the drug treatment system, citing the lack of resources as “short sighted and a catalyst for disaster.”
Continued monitoring of NSP provision by local authorities is more important than ever to provide a clearer picture of service need, and to gain a more rounded picture of the prevalence of injecting substance use compared with focussing solely on nationally reported treatment data. Given the increasing move from agency to pharmacy for NSP provision, it’s vital that those delivering NSP services in whatever setting are equipped with the expertise and integration to mainstream treatment services so they can offer individuals who inject the same quality of service. People who inject drugs have a right to be well and to be able to access the same health related interventions as those who have made the decision to go down the route of recovery. Being outside of the treatment system should not make those who inject outsiders from good quality healthcare.
Written by Mark Whitfield and Howard Reed
Mark Whitfield is the Intelligence and Surveillance Manager at LJMU’s Public Health Institute. He leads the PHI Intelligence team which manages the collection and analysis of data covering areas such as drug and alcohol use and A&E attendances across the north-west of England.
Howard Reed is the Intelligence & Surveillance Systems Manager at LJMU’s Public Health Institute. He manages the collection and analysis of data from a variety of agencies in the North West, and is the lead for Integrated Monitoring System which collects NSP data from neighbouring local authorities.