Evolving need and practice FDAP 15th June 2016 Peter Burkinshaw PHE- Alcohol, Drugs and Tobacco Division

Outline Meeting diverse need Effective interventions and competence Effective OST NPS and a focus on core skills Drug and alcohol related deaths Supporting the workforce Coming soon FDAP, 17/6/16

FDAP, 17/6/17

Meeting need – not without challenges Growing cohorts with multiple and complex needs – incl. frequent alcohol related hospital admissions and co-morbidity Ageing cohorts of drinkers and opiate users - multiple chronic health conditions require combined responses Pressure on risk management; healthcare & pathways Increase in drug related deaths New and growing patterns of drug use incl. new psychoactive/medicines/Chemsex Young people with multiple vulnerabilities, including self-harming, offending, mental health; domestic abuse & CSE The doors need to be wide open - requiring different pathways, partnerhips and responses FDAP, 17/6/16

FDAP, 17/616

Staff equipped to achieve better outcomes Evidence suggests: Workers who have clear techniques and belief in them achieve better outcomes Supervision and governance are key Outcomes are greatly influenced by the quality of the working alliance Wampold (2001), Bell (1998), Moos (2003) FDAP, 17/6/16

Competencies FDAP, 17/06/16

Common components of effective treatment SUPPORT, STRUCTURE & GOAL DIRECTION REWARDS & REWARDING ACTIVITIES Effective treatment ABSTINENCE-ORIENTED NORMS & MODELS SELF-EFFICACY & COPING SKILLS Moos R (2007) Theory-Based Processes that Promote the Remission of Substance Use Disorders. Clin Psychol Rev 27(5): 537-551 FDAP, 17/06/16

Adaptive treatment Plan, review, optimise (measure) Phases: Engagement and stabilisation Preparation for change Active change Completion Layers (of intensity): Standard Enhanced Intensive Evidence to practice: Medications in recovery and The recovery diagnostic tool (RDT)

OST Quality FDAP, 17/06/16

Mutual aid

The DRD inquiry ONS official statistics, registrations of drug misuse deaths in England increased by 17% in 2014, following an increase of 21% in 2013 64% increase in heroin-related death registrations since 2013 (England and Wales) Public Health England’s (PHE) inquiry, expert working group convened to: review evidence; scope further investigation; develop findings; publish conclusions and recommendations Five ‘regional’ stakeholder events (attended by approximately 500 stakeholders) gathered intelligence on current local practice in relation to preventing drug-related deaths, including what was effective or needing to be improved. FDAP, 17/06/16

Work leading up to the inquiry FDAP, 17/06/16

Alcohol harm Alcohol has been identified as a causal factor in more than 60 medical conditions, including mouth, throat, stomach, liver and breast cancers; cirrhosis of the liver; high blood pressure; and depression. Alcohol is the leading risk factor for deaths among men and women aged 15-49 years in the UK (Global Burden of Disease, 2010) Alcohol-related deaths Based on attributable fractions- latest year (2013) – 22,481 Based on specific causes of death-Latest year (2013) – 6592 Deaths from chronic liver disease (alcohol is a leading cause of liver disease) (2011-13) – 17,432 Source: LAPE, PHE FDAP, 17/06/16

Prevalence Smoking and substance misuse Compared to the general population much higher smoking prevalence among people with mental health problems and substance misusers (and staff!) Significant contribution to premature mortality amoungst opiate users (COPD) Smoking may affect tx outcomes by: Causing subjective symptoms of methadone inadequacy Impeding cognitive recovery after alcohol abstinence Requiring higher doses of some benzodiazepines/opiates Audit across addiction services in or with a connection to SLaM: Blackfriars, Lantern Hall, Beresford Project, Lorraine Hewitt House, AAU, Clouds House, and Ley Community FDAP, 17/6/16

Synthetic cannabinoids Stimulants Sedatives/ Dissociatives Hallucinogens Synthetic cannabinoids Groups more important than specific drugs New psychoactive substances, 22nd September 2015

Challenge for specialist drug services Knowledge that needs to be updated, but built on a foundation of core competences. ‘technical’ knowledge (what are the drugs, how do they work) ‘cultural’ knowledge (who is using, how are they using) ‘clinical’ knowledge (how to clinical manage acute/chronic presentation) ‘service’ knowledge (when and where to refer) FDAP, 17/06/16

FDAP, 17/06/16

FDAP, 17/06/16

Next Working with Health Education England on the inclusion of substance misuse in their work programme. Drug Strategy PHE evidence review Alcohol expert working group Alcohol prevalence estimates FDAP, 17/06/16

‘The future….., the future is already here, it is just unevenly distributed.’ William Ford Gibson FDAP, 17/06/16