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
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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
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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.
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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.
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Drug health harms December 2013
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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.
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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.
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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.
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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.
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Key topics for future health harms
network meeting were identified as:
smoking among drug users and the
provision of needle and syringe
programmes.
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The next network meeting will take place on
Wednesday 29 January, at Skipton House,
80 London Road, London SE1 6LH
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Presentations
http://www.nta.nhs.uk/who-healthcare-drdbbv.aspx
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Attendees
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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
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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:
[email protected]
6