SEEING PAST THE DRUGS Your fortnightly magazine | jobs | news | views | research

Are GPs treating the patient or the addiction?

DRUGS STRATEGYVernon Coaker wants fresh ideas and focus

YOUNG WOMEN NOWListening is the key tobetter health and life

TOP PLANS TO DELIVERLaunching a new client monitoring system

21 May 2007 www.drinkanddrugs.net

21 May 2007

News Round-upGovernment challenged over alcoholconsultation • Review follows surge inEuropean cocaine use • Campaign onketamine • UN supports random drug drivetests • Action on Addiction merger poolsresources • Discrimination still an obstacleto HIV prevention • Media watch 4

Features

Cover storyLooking beyond the drugsGPs often treat a drug problem without seeingthe person beneath. Tony Birt shares hisexperiences; doctors Chris Ford, Linda Harriesand Francis Labinjo suggest improvements to the primary care landscape. 6

Looking for fresh ideasWe invite Home Office minister Vernon Coaker to share his approach to revising the Drugs Strategy. 8

Monitor to deliver Will the new client monitoring system ‘TOP’ restore faith in data collection byshowing real outcomes? DDN reports. 10

Now tell us what you want..!Harninder Athwal tells DDN about a newmovement that aims to divert young womenfrom drugs and destructive behaviour. 12

Curing bad paperworkDoctors Adrian Flynn, Rupert White and Omair Khan found a way of streamlining their patients’ journey into drug services. 13

Inside innovatorsPrison staff share their ideas for tacklingprison drug problems. as DDN reports. 14

RegularsLetters and commentCommonsense, and fear and bureaucracy. 9

Background briefingProf David Clark continues his look at whattreatment could look like if it were based on the best science possible (part 3). 15

Q&AMore time to answer the last question! 4

Jobs, courses, conferences, tenders 16

Drink and Drugs News

Whatever you feel about existing data collectionsystems – and we know that many of you feel verystrongly that they have taken over your job andburrowed into client time – there is no doubt thatthe NTA has consulted carefully before introducingthe new Treatment Outcomes Profile system (page10). Its designers, addiction researchers Dr JohnMarsden and Dr Michael Farrell, have taken onboard the need to combine time-saving onbureaucracy with the goal of improvingcareplanning.

With recent DDN letters pages in mind, itseemed worth including feedback from thesystem’s testers – in case it helps you at theteething stage. Many of the stakeholders at thelaunch conference were optimistic that it wouldgive greater efficiency alongside the much called-for monitoring of progress – as well as abarometer of the effectiveness of individualservices, that would strengthen and steer

commissioning. The real test will be seeing howeasily teams adapt, particularly keyworkers, tousing it to its much-needed potential.

In a week when the charity Mind warns ofunnecessary prescribing, we shine our torch intothe doctor’s surgery to find Tony Birt (page 6). Fiveyears ago he was dying from lack of holistic care.These days he is a passionate advocate for bettertreatment, and particularly understanding for drugusers within primary care.

We know there are doctors out there who careabout drug users. As well as those who spoke atthe RCGP conference recently (page 7), there areinspiring examples around the country, such as theCornwall group who carried out an audit to improvetheir referral process (page 13).

There’s plenty of inspiration in this issue: foryoung women through the Young Women Nowmovement (page 12), and for prison workerslooking for an excuse to innovate, on page 14.

Editor’s letter

In this issueEditor: Claire Brownt: 020 7463 2164e: claire@cjwellings.com

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News | Round-up

www.drinkanddrugs.net4 | drinkanddrugsnews | 21 May 2007

The government last week came

under fire for its refusal to carry out

a full consultation on its new

alcohol harm reduction strategy,

due for release later this summer.

Securing a private member’sdebate in the House of Commons lastWednesday, Conservative MP DavidBurrowes criticised the government’sapproach, saying it denied key stake-holders – such as service providersand people addicted to alcohol – anopportunity to improve strategy thatwas ‘too limited’. This lack of consul-tation, he continued, was further evi-dence that alcohol was ‘still the poorrelation in drug and alcohol policy’.

The current strategy, released in

2004, was too narrow in its approachand focused too explicitly on bingeand chronic drinkers. With the all theeconomic, health and social damageattributable to alcohol, the governmentneeded to review its approach, he said.

‘A more strategic approach isneeded, recognising the impact ofprice, regulation and availability andgiving alcohol misuse the same publichealth status that tobacco and obesitycurrently have,’ said the Enfield MP.

The government had to give thecountry’s alcohol problems the samepriority it gave drug problems. In thesame way that the government hadset clear targets for getting problemdrug users into treatment, targets on

getting problem drinkers into treat-ment also needed to be set. Theimbalance between drugs funding andalcohol funding needed to be urgentlyredressed, he said.

‘In 2006-07, of the 39 primary caretrusts that supplied separate figures foralcohol and drugs services, the aver-age spent on alcohol was £424,500,compared with the average of £3.83mthat is spent on drug treatment. So,alcohol receives about 11 per cent ofthe amount that is allocated to drugtreatment,’ Mr Burrowes said.

Responding to the criticisms,public health minister Caroline Flintsaid that although a formal consultationwas not being carried out, there had

been a ‘series of detailed discussionsthat have informed [the government’s]thoughts and views on how to take thestrategy forward’. Once the strategywas published, there would be furtheropportunities for stakeholder input.

She defended the government’strack record, stating it was becomingclear that the mechanisms put in placein 2004 were beginning to have apositive effect. And, she said, most ofthe commitments in the previousstrategy had been delivered on –particularly underage sales andalcohol related violence. ‘That is not tosay we should be satisfied by wherewe are, but the indications are thatsuch offences have fallen,’ she said.

Government challenged over consultation

A comprehensive literature review on theeffectiveness of current treatments for problematiccocaine use has been published by the EuropeanMonitoring Centre for Drugs and Drug Addiction.

The review followed a surge in cocaine usethroughout the Europe, with the drug responsible for8 per cent of all EU drug treatment demands. Cocainewas now the third most common reason for people toseek drug treatment.

The report concluded that treatment of cocainedependence still frequently included the use of anti-depressants, despite the low level of evidence that theywere actually effective. More promising results wereexperienced from topiramate and other anti-epilepticdrugs. However the report stated that, to date, the ‘mostinnovative treatment’ currently being tested was thecocaine vaccine, which aimed to block the desired effectsof cocaine and thereby reduce its potential for abuse.

However the lack of 100 per cent effectivepharmacological treatments meant that Europeanprofessionals relied heavily on psychosocialinterventions, particularly drug counselling andcognitive behaviour therapy. A therapy developed inthe US, known as contingency management, wasincentive-based and offered rewards for those whowere able to demonstrate abstinence from drugs.Despite positive trial results, there were questions overwhether this therapy was effective in the long term.

The review also called for urgent research intopoly-drug use, noting it had now become the rule,rather than the exception. Multiple substance useoften had a negative impact on treatment outcomes,the review stated, and there were ‘important gaps inour knowledge’.

Treatment of problem cocaine use is online atwww.emcdda.europa.eu/ ?nnodeid=18945

Review follows surge in European cocaine use

Random drug testing should be introduced to curbthe incidence of drug-related accidents on the roadand at work, according to Antonio Maria Costa,executive director of the United Nations Office onDrugs and Crime.

Speaking at the 14th Mayors’ Conference ofEuropean Cities Against Drugs, Mr Costa said it wouldnot be hard to win over public opinion, given thatmost were already in favour of alcohol testing –which had been proven to be an effective deterrent.

‘No one wants to be killed or maimed by a drunkdriver. So society accepts police controls to check ifsomeone has been drinking,’ he said. ‘Public opinionis waking up to the fact that some people are drivingcars, public transport, operating heavy machinery oreven flying aeroplanes while on drugs. Road testing

works for alcohol, it will work for drugs.’He particularly praised efforts by the UK, the US

and Australia to introduce such measures. However,he noted that any efforts to apprehend those withsubstance misuse problems had to be matched byefforts to provide them with the best possibletreatment. UNODC was building up TREATNET – aninternational network of drug dependence treatmentand rehabilitation resource centres, with 20 branchesaround the world. ‘But I want to see 100 times morecentres in this network,’ Mr Costa said. ‘I urge you toidentify well-run drug treatment and rehabilitationcentres and link them up to the TREATNET.’

He also urged ‘cities to help other cities’ andsuggested exchange programmes where expertsdiscover new and better way to tackle drugs and crime.

UN support for random drug tests on drivers

A new information leaflet on the dangers of the drugketamine has been produced by the Forest of DeanCrime and Disorder Reduction Partnership.

The leaflet – believed to be the first of its kind inthe UK – was developed after the drug was identifiedas an escalating problem in the area.

‘The dangers of this drug are not widely knownas it is fairly new on the drugs scene,’ said MelanieGetgood, chair of the CDRP’s substance abuse actiongroup. ‘This leaflet is specifically aimed at youngpeople and provides essential information aboutwhat ketamine is and what makes it so dangerous.’

The drug – which is a type of anaesthetic – cancause death and makes users vulnerable to beingrobbed or sexually assaulted.

Campaign on ketamine

The latest readers’ ‘question and answer’ featurehas been held over to appear in our next issue.Please continue to send answers to the questionbelow, by a deadline of Tuesday 29 May, to appearin the next issue. Please email answers to theeditor: claire@cjwellings.com

Reader’s question: I used to have a drug problem,but since getting clean have enjoyed my job as adrugs worker. A few months ago I relapsed forthe first time. I took leave from work and bookedmyself into treatment, determined to sort myselfout. My problem is that my counsellor at rehab isthreatening to tell my employer about myrelapse, saying that she has a duty to protect myfuture clients. I am horrified, as I thought myconfidentiality was protected when I went intotreatment. Please can anyone advise me on myposition? Amy, by email

Q&A next issue

Injecting drug users are being denied access tobasic HIV prevention and treatment services,according to a UNAIDS senior official.

Opening the International Harm ReductionAssociation (IHRA) 18th Conference on Drug-Related Harm, held in Poland, UNAIDS regionaldirector for Asia and the Pacific, Prasada Rao, tolddelegates that of the estimated 13 million peopleglobally who inject drugs, just 8 per cent had accessto some kind of HIV prevention service. Access toantiretroviral treatment in particular wasunacceptably low. Mr Rao blamed exclusion, lack ofinformation, stigma and discrimination for thesituation.

Yet this exclusion came despite the knowledgethat injecting drug use was a major mode of HIVtransmission. ‘About 10 per cent of all new HIV

infections worldwide are attributable to injectingdrug use – if you exclude Africa, that figure rises to30 per cent,’ Mr Rao said. ‘Evidence shows that HIVprevention programmes are particularly effectiveamong people who inject drugs but they areregularly denied access to information and services.’

He said that in regions where injecting drug useis driving the Aids epidemic – such as south-eastAsia, central Asia and Eastern Europe – focusedharm reduction programmes which reach injectingdrug users had to be built into national Aids plans.

He held up Portugal as an example of goodpractice. Here, in recent years harm reductionprogrammes and information campaigns aimed atinjecting drug users were significantly scaled up,and the result was a drop of almost one-third innew HIV diagnoses between 2001 and 2005.

Scottish police forces have launched a new strategyaimed at the social conscience of the middle-class,to deal with the growing increase of cocaineconsumption. This follows concerns that publicitycampaigns that focus on the health implications andillegality of cocaine, are having little impact onScotland’s young. According to Gill Wood, thenational drugs co-ordinator for the Scottish Crimeand Drug Enforcement Agency (SCDEA), youngprofessionals should be informed of the ‘horrendousviolence’ associated with the supply of the drug –murders, serious organised crime and exploitation ofwomen and children. SCDEA plan to get thismessage across through an ethical trade anti-drugscampaign at summer music festivals. The Scotsman, 14 May

The number of Britons being prescribed antidepress-ants has increased dramatically in recent yearsdespite warnings, from a leading mental healthcharity, that many patients may not need them.Mind’s report highlights more than 31m prescrip-tions written by doctors for antidepressant drugs lastyear, with Seroxat and Prozac increasing by 10 percent – despite guidelines from the National Institutefor Health and Clinical Excellence, over reliance andpossible side-effects. According to the charity, adultpatients with moderate depression should insteadbe offered counselling and cognitive behaviouraltherapy. But many GPs kept prescribing because ofthe lack of alternatives to antidepressants,insufficient funding and patient demand for the drug.The Times, 14 May

The UK’s first drug and alcohol court will belaunched in Camden, Islington and Westminster toprovide a specialist service for the many substancerelated care cases in these areas. The court willoffer same-day referrals for help, advice and supportin cases where children face going into care as aresult of their parents’ substance misuse, and willinclude a judge, substance misuse specialists andsocial workers. This scheme is successfully usedacross the USA and has enabled more children incare to return home. The court is part of a three-year pilot scheme due to start in January next year. Community Care, 15 May

Scottish children as young as 12 can now be pre-scribed nicotine replacement therapy (NRT) under NHSguidance to help them quit smoking. According toofficials at NHS Health Scotland, young people havejust as much right to the treatment as adults. GPsurgeries and chemists are being issued with anupdate on good practice, which includes offering NRTpatches and gum to teenagers. Originally NRT treat-ment was not recommended between the ages of 12-18 as their brains are still developing and could makethem more vulnerable to addiction. However theCommittee on the Safety of Medicines approved itsuse following research in 2005 that indicated therewas no evidence it will be misused by adolescents.Tobacco researcher, Dr Linda Bauld, believes this newguidance will make it very clear to reluctant GPs that itis now acceptable to prescribe NRT to young people. The Herald, 10 May

Media Watch

News | Round-up

www.drinkanddrugs.net 21 May 2007 | drinkanddrugsnews | 5

Three well-known addiction charities, Clouds, theChemical Dependency Centre and Action on Addictionhave merged, taking their name from the latter.

The relaunched Action on Addiction announcedat a reception at the House of Lords this week thatthey were pooling resources and expertise to offertreatment and rehabilitation on the 12-step model,prevention, education, professional education, andfamily support. The charity’s chair, DominicCastlewood, said that ‘many a story in addictionhinges on taking a risk’ and praised the individualsinvolved for putting their clients first. New joint chiefexecutives are Nick Barton of Clouds and Lesley King-Lewis of the former Action on Addiction.

Public Health Minister Caroline Flint praised a‘brave but grown-up approach’ and said she wasimpressed by how the voluntary sector had kept upwith policy changes, in working out how best to

respond to individuals’ needs. She looked forward toworking with Action on Addiction ‘on issues thataren’t always on top of everybody’s agenda’.

Former client Emma explained her lifetransformation from attending Clouds and Hope House– a journey that had begun with recreational drug useat 15, progressed to crack and heroin use by 18, andsaw her paralysed from the neck down for threemonths, after speedballing. Specialist care at rehab had‘slowly put [her] back together’ so that she completed athree-year degree and now worked in the field.

Action on Addiction’s chief executivesemphasised their determination to continue helpingpeople like Emma. ‘We are not very good in thiscountry at getting people into treatment when theyneed it,’ commented Lesley-King Lewis.

Action on Addiction’s website iswww.actiononaddiction.org.uk

Action on Addiction merger pools resources

HIV: discrimination still an obstacle

Caroline Flint: ‘Brave but grown-up approach.’

6 | drinkanddrugsnews | 21 May 2007

Cover story | The patient experience

www.drinkanddrugs.net

All too often busy GPs treat a drug problem withoutseeing the person beneath. Tony Birt (pictured right)brings the patient experience alive, while doctors ChrisFord, Linda Harris and Francis Labinjo suggest how GPscan use changes in the primary care landscape to improve the patient experience.

Looking beyond the drugs

Five years ago I was dying – quite literally andrapidly, on the waiting list for secondary carefor my chronic, severe and enduring opiatedependency and chaotic poly drug use. The

three reasons I’m still here to tell my tale are TheAlliance, evidence-based practice and a vital mission toimprove drug treatment in primary care – to normaliseit, de-stigmatise it and reach a holistic approach.

Unfortunately I have to admit that primary carehas absolutely nothing to do with me being alivetoday, but it is the reason I’m calling for change. Fiveyears ago while on ‘death row’ – the waiting list – for15 months, I was told time and time again by my GPthat: ‘We are a non-prescribing practice Tony and Iwould love to help you but…

- My partners would never stand for it, you see.- I am not permitted to prescribe for you.- We have to follow the protocols.- I just don’t know what to do for the best.- I only had an hour drugs training and I was awaythat day, I think I had a cold or something…’

This list could go on. The point is that there areTonys out there, all over the country – and still morewho never saw the sunrise this morning becausetheir GP, or anyone else with the professionalcapacity would not, or could not, help. Would wemake such judgement calls anywhere else in thehealthcare field? Would it be stood for?

Without real primary care involvement andcommitment we will surely return to the bad old daysof just two, three, four years ago, where theproblematic substance users’ only hope was the 12-week ‘beggar’s option’ – 12 weeks’ treatment, thenback out to face the world – that sent me reelingback into chaos most of my life.

There are many people in my community who aredependent on benzodiazepines – just as I was, inthe days when I was known as ‘Benzo Birtie’. How isit that these very vulnerable people cannot getsupport through a prescription with their GP, butthere are another hundred in the same town, eventhe same surgery, who get the supplies to sell to‘Benzo Birties’ all over the country?

Would it not be more sensible – and safer for thecommunity – to prescribe for, and look after the ones

that are problematic and chaotic with these ‘killer’drugs (that were introduced by the medical field inresponse to barbiturates)? At the age of 15 I wasprescribed benzos (lorazepam – which was thenmarketed as Ativan) for barbiturate dependency –but there was no ongoing support when I transferredmy addiction to the benzos.

The problematic substance user needs to be ableto trust, accept and believe in primary care. This wouldbe a huge step towards ending their isolation andkeeping them in the net of long-term holistic care.

Tony Birt

Working with the patient not the drug Drug treatment has traditionally focused on controlof substances rather than considering the person asa whole and understanding the use of drugs in theirlife. This focus has led to the development ofservices which are sometimes difficult to access andoften appear antagonistic to the people that they aredesigned to serve.

People with drug problems are often viewed asuntrustworthy and incapable of recognising their ownneeds – a pervasive belief and a destructive gener-alisation that reduces the effectiveness of services atevery level. It is counterproductive for both patientsand staff, and leads to fear in staff and patients.

Patient-centred care challenges our attitudes andprejudices towards our patients and their drug use. Itscore principles are listening, trusting and empower-ment. We need to listen and patients need to beheard. We need to believe what patients say and workwith them – at the stage they are at, and not where wethink they ought to be. We need to increase theperson’s sense of power over their own life and havetransparency about what we are doing to help themand why, explaining how the system and law works andsharing information. We should help the patients workout their own care plan so they can decide what’s bestfor themselves. Rather than just attempting to coercethe person to stop taking drugs, we can empowerthem to take control of their own lives.

In doing this, we can attempt to move clinicalpractice beyond fear and control and care for theperson rather than just concentrating on the drug. Wemust be mindful to deal with them as an individual,

A different outlookPeter Bates suggests a fresh approach for primarycare into treating drug users, based on his workwith the National Development Team.

As always in working with people, attitudes matter aswell as technologies. We are regularly told that thereis no community to join, or that this (non-existent)community will close ranks to keep out people withunattractive, criminal or incomprehensible behaviour.

We are also sometimes told that it is not thetask of health professionals to assist people toretain or rebuild social roles and relationships, andsometimes even that health professionals can dotheir work without knowing anything about theordinary aspirations of their patients.

The National Development Team (NDT) vigorouslyopposes such blind pessimism by finding out whathelps, by pointing out the myriad examples of hope,and by defiant enthusiasm. Founded in 1976 NDThas had a key role in promoting socially inclusive

practice by undertaking research; developingconceptual frameworks and resources; andconducting service evaluation and staff training.

Tools are available to train staff in inclusioncapabilities, specify inclusion interventions, auditinclusion practices, and measure inclusionoutcomes. Promoting social inclusion has been akey feature of services for adults with learningdisabilities since the 2001 White Paper ValuingPeople and of adult mental health services since the2004 report from the Office of the Deputy PrimerMinister Mental Health and Social Exclusion.

We suspect that it may be possible to adaptsome of these resources for use with drug users andin primary care - indeed, many of the ‘inclusion onprescription' projects have been doing similarthings for years. We would be glad to hear fromanyone interested in a further conversation andmutual learning.

Peter Bates can be contacted atpbates@ndt.org.uk; www.ndt.org.uk

21 May 2007 | drinkanddrugsnews | 7

Cover story | The patient experience

www.drinkanddrugs.net

and not generalise, when we discuss their choices andbehaviour. We need to build and maintain a patient-centred relationship, which can be used to support thewhole spectrum of care, including harm reduction,abstinence and substitute prescribing.

How can we do it? We need to listen, ask and trustour patients. It’s a win-win approach that removes thebarrier of fear.

Dr Chris Ford

A changing landscapeThe provider landscape is changing and almost everypublic sector organisation and agency is facing wholesystem change.

In the substance misuse field we have always hadto use the strength of evidence based practice toensure patients get the best deal.

But GPs and primary care practitioners have anopportunity to be involved in shaping a ‘brave newworld’. The baton for commissioning is being passedto them, and PCTs are being urged to broaden thebase of care and widen patient choice.

By engaging in the commissioning process GPs canhelp PCTs, through their knowledge, leadership andchampionship, to understand how public healthinterventions and prevention can make huge returnson quite small investments now. The battle is to getthem to listen, so that drugs and alcohol are movedup the list of competing priorities.

For the entrepreneurs, there are opportunities tomove ‘beyond prescribing’ by the creation of alliances,a move toward a business – and dare I say it – acustomer focused approach, to deliver on the socialdeterminants of care.

The world is changing, but I remain optimisticthat primary care will continue to dominate thesubstance misuse treatment field. I hope that as weenter this watershed between strategies, we canreflect and plan how we are to take a central role inreshaping the future of care for our patients.

Dr Linda Harris

Adapting to change I firmly believe that substance misuse services shouldbe delivered within primary care, with other specialists,including hepatologists and psychiatrists, brought in as

“There are many people in my communitywho are dependent on benzodiazepines – justas I was, in the days when I was known as‘Benzo Birtie’. How is it that these veryvulnerable people cannot get support througha prescription with their GP, but there areanother hundred in the same town, even thesame surgery, who get the supplies to sell to‘Benzo Birties’ all over the country? “

needed. United we stand; divided we fall, fail, or both. Every individual has the potential to make a

difference to the service that they are working in andare committed to, and teams of patient-centredindividuals can truly transform the way they work.The Department of Health Guidance, New Ways ofWorking for Psychiatrists (NWW), has implications forthe risk exposure of GP addiction specialists and forshared care, as consultant psychiatrists will nolonger see follow-ups or cases other than complexones, making more use of advice and consultancy tothe multi-disciplinary team for less complex cases.

There are emerging new challenges. Moreaddicts are growing into older age, with many over65. At the other end of the scale we are finding anincreasing number of younger people with Attention-deficit hyperactivity disorder (ADHD) and autismspectrum disorders such as Aspergers’, who aregrowing up to become young adults with substancemisuse problems.

If we are to reduce drug taking, harmful behaviourand drug-related deaths, we need to promote betterengagement with service users.

Better Ways of Working can help to improve thequality of drug treatment within primary care, but weneed common ownership of the agenda and to identify‘change champions’, communicate better, co-ordinatereferrals, record outcomes and change our workingculture, which is currently too territorial.

We need a united approach between mental health,primary care, criminal justice agencies and theindependent sector, under the steer of the NTA, and Ibelieve that future training of addiction specialistsshould involve spells of experience in both addictionpsychiatry and general practice.

Dr Francis Labinjo

Contributors to this article were all speakers at the

RCGP 12th national conference on the management

of drug users in primary care, held in Birmingham.

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Comment | Vernon Coaker

www.drinkanddrugs.net8 | drinkanddrugsnews | 21 May 2007

This week I am looking forward to nationaltackling drugs day, a chance to celebratethe wonderful work that often goes on,often unsung, around the country. On

Wednesday, groups in places as diverse asCamden, Durham, Blackburn, Milton Keynes andCeredigion will highlight the dangers posed by drugsand the work that goes on to tackle this menace.

A drug treatment centre will be officiallyopened in Barking and Dagenham, there will beinformation stalls across the country and Gates-head will host a concert with a song, called ‘KickIt’, written and performed by a former drug user.

On Wednesday drug action team partnershipswill be organising events to support the day, frompolice crackdowns, information stalls in super-markets, sports activities for young people toballoon releases to mark the numbers of peoplein treatment, and football and rugby matchesfeaturing people involved in the effort to tackledrug misuse.

In all, six ministers will be out and about,demonstrating just how much of a priority thisgovernment places on tackling drugs andreducing the harms they cause. I will be leadingthe ministerial activity by opening a newtreatment centre in Barking and Dagenham.Alongside other ministers, I will be playing afootball match against Lambeth North PositiveFutures scheme and the Hull-based charity, DadsAgainst Drugs to launch the Tackling DrugsChanging Lives Awards 2007.

This isn’t just talk: since 1998, when welaunched our ten-year Drug Strategy, this govern-ment has made tackling drugs a top priority. Wehave backed our strategy with unparalleledinvestment of over £9 billion in enforcement,education, early intervention, and treatment.

We have spent this money well: overall drugmisuse has fallen by 16 per cent since 1998while the misuse of Class A drugs hasstabilised. I am particularly heartened that drugmisuse among young people has fallen by over afifth in the last ten years.

More and more people are entering andstaying in drug treatment. Nearly four-fifths of the181,000 people who underwent drug treatmentprogrammes in the last financial year completedtheir programmes.

Despite these successes, I am keenly awarethe debate over drugs remains highly charged andthe challenge for government is to navigate a waythrough competing demands. I fully understand thestrong emotions involved; but too often the debateis framed in extreme terms – some people arguefor legalisation while others argue for toughenforcement – leaving little space for a rationaldebate in the centre ground.

For example, in recent months we have heardfrom people who think drug legalisation would bethe answer to solving the social problemsassociated with drug misuse. On the other hand,I do not have to go far to hear from people whocall loudly for even tougher enforcement against

drug dealers and drug users. Others will refer todrug policies abroad, whether in the Netherlands,Sweden or the United States, and say we shouldadopt the extreme policies of zero-tolerance orlegalisation.

Each country has to tailor the drug strategy thatis appropriate to its own culture, history andtraditions. But the truth is that any drug strategycannot succeed without a comprehensive app-roach that focuses on enforcement, education,early intervention and treatment. Tough enforce-ment stops criminals and takes harmful drugs outof circulation; education empowers young peoplewith knowledge of the harms caused by drugs;early intervention with vulnerable groups in order toprevent them from becoming drawn into drugmisuse and treatment improves individual lives,and cuts crime and anti-social behaviour.

Our latest figures show that more than15,300kg of cocaine and 2,200kg of heroin weretaken out of the supply chain in 2005/06. Almost200 illegal criminal gangs were disrupted and £30million of drug related assets were seized. Thatmatters. I know, when I meet people in myconstituency and elsewhere, that people wanttough action on dealers, the people who dragdown their communities.

However, as a former teacher I know that drugeducation has a significant role to play. We nolonger wag the finger at young people and tell themsimply not to do drugs. Instead, through the multi-media FRANK campaign, we empower youngpeople by warning them of the harms caused bydrugs and the risks involved with drug misuse,targeting vulnerable young people who are most atrisk and providing specialist interventions for youngpeople with developing drug problems. Thisapproach has paid dividends with drug misusefalling among young people.

After a decade of success, we are looking torenew our Drug Strategy and will shortly consulton the way forward for coming years. I want tohear fresh ideas on how we can enhance thedrug strategy, but I am clear that I want to focuson what works: enforcement, education, earlyintervention and treatment.

In talking to drug treatment professionals it isevident to me that drug classification isimportant in setting out the legal framework fordrug control. It has stood the test of time and Iwant to focus on the most important aspects oftackling drug misuse: how we can enforce thelaw against dealers and supplies; how we canempower our young people with knowledge of theharms illegal drugs cause; and how we canprovide treatment most effectively so that evenmore drug misusers are treated for the benefit ofthem and their communities. This strategy hasworked and I want to enhance it.

I remain fully committed to our strategy ofenforcement, education, early intervention andtreatment, focusing at all stages on harmreduction. Working together, we can reduce evenfurther the harm caused by illegal drugs.

‘I want freshideas and afocus onwhat works’

We invite Home Office minister

Vernon Coaker to give us insight

to his approach to revising the

Drugs Strategy. He explains his

direction of travel.

Notes from the AllianceMind your language!

Negative words can easilypervade our language withoutus realising the negative effect.Time to take stock, says Daren Garratt.

The recent RSA Commission on Illegal Drugs, Communities andPublic Policy report, Drugs – facing facts, highlights somethingthat many of us have known for years; many people are able tomanage their drug use and bring no harm to themselves orothers. Now, of course, I am not suggesting that drug usedoesn’t lead to harm because the effects can be blindinglydevastating, but it’s not inevitable.

Yet I wonder how many of us unknowingly contribute to thecontinued demonising of drug use and drug users by using wordsand phrases that allow such negative stereotypes to perpetuate?

I know I do it.I was talking to a colleague last week about the importance

of language and the messages we reinforce, when I was struckby how many times I’ve heard people – myself particularlyincluded – habitually juggle the words ‘dependent’,‘problematic’ and ‘chaotic’ when discussing an individual’sheroin use. I realised that they’ve become almostinterchangeable terms in this field, and that’s wrong.

I wouldn’t like to guess how many people reading thismagazine are dependent on a substance, but I’d suggest thatthe majority who admit it would in no way feel that their usewas in any way problematic. And for those who may have toconcede that, unfortunately, their using has started to have aworrying impact upon their health or social functioning, it’scertainly not a given that this is due, or contributing, to a lossof control and spiralling chaos.

We all fall into different patterns of use at different times,but the important thing to do is try and have an awareness ofthat fact, and to try and respond effectively should things startto get too much. At the end of the day, some people canregularly use drugs like alcohol and heroin in a controlled waywhile others sadly can’t, but that all depends on the individualand a myriad influences and reasons.

So why does the message that heroin users can be ‘normalpeople’ (or conversely, ‘normal people’ can be heroin users) stillseem to be getting lost?

Well, maybe by subconsciously equating heroin use withchaotic and problematic dependency, our language merely rein-forces the public’s stigma, ignorance and fear of what a user is.

Language is a social construct and the words we use influencethe image that society creates of us, therefore the terminologywe choose has the power to change that image and, in time,people’s perceptions and opinions. Be they positive or negative.

And I know that arguments rage on about whether it reallymatters if people use words like ‘detox’, ‘addict’, ‘clean’, or‘abuse’ when there are people dying on the (drug) war-tornstreets of Britain, but if it means that by using lazy languagewe reinforce the image of a drug user as something, toxic,powerless, dirty and abusive, I think it does.

Daren Garratt is executive director of the Alliance

www.drinkanddrugs.net 21 May 2007 | drinkanddrugsnews | 9

Letters | Notes from the Alliance

At last some common sense

Prof Howard Parker’s succinct assessmentof the current drug strategy and for hissuggestions for interventions that work,(DDN, 7 May, page 6) was a joy to read.

The Royal College of Psychiatristsdescribes alcohol as the nation’sfavourite drug. while estimating that twiceas many people become addicted to it ascompared with all other drugs combined.Other sources attribute 44 per cent of allviolent crime to alcohol abuse. The NTA’sdenial of alcohol as a drug, andprohibiting services to record alcohol asthe primary problem, while simultaneouslyclaiming to use evidence-based practice,highlights the hypocrisy that emanates sofrequently from that source.

Professor Parker’s comments on theNTA’s obsession with the ‘numbers intreatment’, without any correspondinggoal for numbers in recovery, echoes thefindings of Liverpool John MooresUniversity which concluded that the higherthe numbers in treatment, the greater thedrop-out rate. When one considers thatthere are no goals of drug free recoveryand rehabilitation in the current strategy,such conclusions are not surprising.

In the same issue (page 4), a neworganisation, the Drugs and HealthAlliance (DHA), which is made up of anumber of familiar names, urges us tohave a drug policy embracing publichealth. It is therefore puzzling thatnotwithstanding the holistic soundingname, and their declared claim to turnthe escalating addiction problems of thiscountry into a health issue, which itsurely is, there is no mention that thetreatment for all which is urged, shouldembrace drug free recovery orrehabilitation. Surely the objective of allhealth treatment should, insofar aspossible, be recovery? The latter in thecases of addiction is not possible withoutbecoming drug free. To that extent it isdifficult to distinguish what the DHApropose from the current policy.

We do need a new and effective drugstrategy, and we already have all theresearch we need to implement it.Scientific research that is currently beingreported by Professor David Clark (page15), if implemented within the frameworkof the transtheoretical model of change,would in the long term drastically improvetreatment outcomes. What is lacking isthe will and courage to realise it.

A further obstacle to implementingtreatment based on scientific, tried andtested evidence, is the unrelenting

activities of those organisations who,regardless of their enlightened andhumane sounding agenda, are hell benton the legalising of addictive drugs,thereby wittingly or otherwise, spreadingthe scourge of addiction that is pollutingour country.Peter O’Loughlin,

The Eden Lodge Practice

Fear and bureaucracy

I would like to respond to two of theletters in your last issue (DDN, 7 May,page 10). Firstly, the one from Dr Bray:dead right, doctor, we are operating in aculture of fear. I have written to DDNtwice in the last few weeks on the subjectof the obsessive micro-management ofdrug services and I have criticised thearmy of bureaucrats who see themselvesas far more important than the lowlypeople who actually work with drug users.So, in light of my views, my job would beat risk if I didn’t ask for my name to bewithheld.

Secondly, the letter from Luke Kellyabout NDTMS. You’re dead right Luke, itsurely won’t be long before we are alsorequired to record a client’s shoe-size,eye-colour and whether they are left orright-handed.

We have reached the point where therules have become more important thanwhat they were originally put in place togovern.

For instance: a prison drug worker nowhas to complete nearly 50 pages ofpaperwork just to get a case up andrunning, then many other pieces of paperat various stages to ensure the databasecan ‘track’ what’s going on. At the sametime, that worker is told they can onlyengage a prisoner in a maximum of sixone-to-one interventions. They are forcedto spend endless time on paperwork butare only allowed to scratch the surfacewhen it comes to actually working with theclient. What does that tell drug workersabout what really matters? And, crucially,what does it tell the prisoner about thequality of the ‘treatment’ on offer?

I believe that prison and communitydrug workers’ roles are now so tightlyprescribed that the services they areallowed to provide to their clients are lessefficacious than they were at the start ofthe ten-year strategy, back in 1998, longbefore the bureaucrats hijackedtreatment. Any voices still out there?Prison & community drugs practitioner,

name and address withheld

Treatment | Client monitoring

www.drinkanddrugs.net10 | drinkanddrugsnews | 21 May 2007

Hoping to move on from the trials and tribulations of the National DrugTreatment Monitoring System (NDTMS), this week the NationalTreatment Agency launched TOP – the Treatment Outcomes Profile.Researched by respected addiction experts, it pares down the

information-gathering process to what’s needed, and at the same time goesbeyond the remit of NDTMS data, to show how well each client is doing intreatment, and the effectiveness of services and partnerships.

The new system will be used for each client that enters Tier 3 and Tier 4services in England and will be used as a structure for their care planning andreview process. The client is asked a short set of questions four weeks beforetreatment, then asked the same questions as part of the care planning and reviewprocess. By reviewing the changes over time, the key worker will be able to keeptrack of how their client is doing, and monitor their overall wellbeing.

Launching the system to invited stakeholders, Public Health Minister CarolineFlint said: ‘This is a world first and we need to bang the drum about this.

‘This system can help everyone – providers and commissioners. It measures andrecords real outcomes – drug and alcohol use, psychological health, social functioning.’The breakthrough was in measuring real instead of proxy measures, she said.

Clients would get a sense of whether they were receiving good treatment andthe evidence-based information would help to prevent drug-related deaths.Commissioners would be able to use the information to make sure adequate harmreduction services were in place, said the Minister.

Importantly she said, TOP would ‘keep us under scrutiny’, shouting aboutwhat’s not working – and also about what is.

The expertsTOP is a simple but effective way of collecting data, says Dr John Marsden of theNational Addiction Centre, one of the two outcomes experts who designed the system.

While it was a work in progress, and results at this stage were ‘robust butprovisional’, the system had the ability to capture change. It showed drug use andchanges in behaviour, to give a ‘reasonably reliable picture of use’.

Beyond current data, which started with the period before the client wasadmitted to treatment, its four-weekly data updates would build up a picture ofthe client’s physical and psychological health, and quality of life.

‘I am confident we have a brief, valid and reliable instrument, readily

understandable to all key groups,’ he said.‘This had to be done in a way workers would use,’ said Dr Michael Farrell, co-

designer of TOP. ‘We wanted to build a little rowing boat, not the titanic.’One of the criteria in developing the form was to keep it to a page of A4, to

counter the current criticism that data collection is burdensome. ‘It’s as brief as itcomes, to make sure we get full implementation of it,’ he said.

Produced in a format that workers would use for their own purposes, it couldbe bolted onto other quality assessments, and should contribute to effective careplanning. It could also be used to manage case mix, ‘to make sure that workershave a reasonably balanced case load of complicated and less complicated people’.

‘The system doesn’t take over in any way from the extensive clinical trainingthat we expect people to have,’ said Farrell. ‘But instead of being bludgeonedaround retention times… [teams can] review care plans and assess the progressthey’re making [to look at] the broader impact of their performance.’

The testersJulia Cottier, a service manager at Chester and Ellesmere Port Drug Service, tookpart in testing TOP.

With four sites offering Tier 2 and 3 drug services across Cheshire and theWirral, Cottier was optimistic that her service could meet engagement targets forthe field test, which ran from November 2006 to April 2007, but the reality was alittle different.

‘We didn’t meet our targets on engagement and follow-up – maybe becauseinterviewers weren’t clients’ own keyworkers.’ She also questioned whether theyhad promoted the trial in the right way to encourage involvement.

Feedback from keyworkers had been ‘very enthusiastic’: TOP had been easy touse, after they had taken a bit of time to get used to it. The most important workin the roll-out was ‘to make all partners realise the difference this has ondemonstrating the impact of treatment,’ she commented.

Services would need to work out a timescale for incorporating TOP in their ownsystem, and the team’s workload would need to be adjusted to take account ofcompleting TOPs every three months. ‘Staff will need support to balance theirexisting workload, and there will need to be more supervision and training forstaff who see clients stay the same or deteriorate,’ commented Cottier.

Judith Costello tested TOP at Addaction in Blackpool, where 60 per cent of

Monitor to deliver

Will the new client monitoring system ‘TOP’ restore faith in data collectionby giving a picture of real outcomes? DDN was at this week’s launch.

The questions…The panel of speakers (quoted left) was joined by Paul Hayes,NTA chief executive; and Annette Dale-Perera, director ofquality, to answer questions from the stakeholder audience.

Will TOP be able to follow people

in and out of different services

over years? Will they need a new

one if they move services within a

couple of weeks?

Malcolm Roxborough: This will relyon a degree of local co-ordination.The intention is not to get thesame questions asked of the sameclients. We’re working closely withprisons in the hope of managingpeople’s information as they movethrough prison and communityservices – and yes, we’ll be able tomonitor them over years.Annette Dale Perera: We don’t wanta TOP done each time a client joinsa new service.

Can you give reassurance that data

collection is not a replacement for

service user involvement?

Paul Hayes: It would be criminal ifwe downgraded information fromservice users. Service user reps willhave better information they canuse – between services, serviceusers, commissioners, the NTA; allof us and communities. TOP shouldenhance all those dialogues.

Is TOP for drugs and alcohol? And

young people?

Annette Dale Perera: It has beenvalidated for alcohol as well asdrugs. But we’re testing it withdrugs because we’re the NTA. Ithas been validated for use withpeople of 16 plus.

Overdose is not included in TOP.

Why not?

Annette Dale Perera: It should beincluded as part of your normalreview. Just because it’s not on[this form] doesn’t mean youshouldn’t address it.

Which groups of clients are we

expected to report back on?

Malcolm Roxborough: We’reexpecting data on Tier 3 and 4clients. But we could also takedata from Tier 2.

When there’s been no obvious

improvement by the client,

how is this fed back to them? How

might this be dealt with,

without being negative?

John Marsden: Each person’s data istheir unique fingerprint. Positive datacan be a positive reinforcement. Butthe form is designed over four weeksso you can capture little lapses, littlesnapshots [of behaviour]. So failureis less relevant.Judith Costello: It gives you thechance to keep focusing on thecareplan.

Will there be any financial support

for voluntary organisations rolling

this out?

Annette Dale Perera: There’s noextra money to implement TOP –it’s part of the normal NDTMS. Butwe will be working withcommissioners to make surethere’s provision to do it.

Most service users will see this as

just another form. What’s the

point of participating?

Julia Cottier: It’s about how weimplement it. TOP has to be seenas the most effective way of doingwhat we do.

Will TOP help to manage staff?

Julia Cottier: I’d like to think it willbe used in a most supportive way,to redress demotivation, [anopening to say] we’re not offeringthe right group of things.Paul Hayes: Obviously this has tobe managed sensitively, but we allhave to be helped to improve whatwe do. We need to understand it todo something about it. Some of usmight turn out not to be in the rightprofession… some service usersmight turn out not to be in the rightservice. As long as we do this sen-sitively and cautiously and takeeveryone with us, we have achance to break down stigma,improve services – and do what itsays of the tin.’

www.drinkanddrugs.net 21 May 2007 | drinkanddrugsnews | 11

Treatment | Client monitoring

clients are on Drug Rehabilitation Requirements (DRRs) and come via the courts. At the beginning of the trial Costello was ‘very concerned how we were going

to do our own assessment as well as the questionnaire’. She had also had concernsabout having to ask DRR clients for yet another drug test, when they were alreadybeing tested twice a week.

The reality was very different. ‘The clients didn’t mind testing, didn’t mindpersonal questions… in reality it was better than our own assessment,’ she said. ‘Itwas fantastic to hear about the client in such a short time – it made my job mucheasier.’

As ‘someone who doesn’t find data management easy’ she had no difficulty inusing the new system, and easily exceeded a testing target that she had beenworried she wouldn’t be able to meet.

Costello believes that monitoring clients for every three-month period couldhelp with motivational interviewing and better client engagement.

The NTA manager‘NDTMS is usually prefixed with a word that means ‘damned’,’ admitted MalcolmRoxborough, the NTA’s information manager.

Receiving 440,000 treatment records a week that are used to monitor centralgovernment targets, local government performance and to inform commissioningand treatment planning, there were many demands on the system.

Information had, until now, been taken on first contact with the client – theirdemographic, drug use, treatment need, housing circumstances. ‘But we don’thave a picture of how this changes throughout their journey – and this is whatwe’re hoping to change through TOP,’ said Roxborough.

‘Care monitoring could be much more effective with the new system,’ he said.‘It will be a more consistent way of helping clients review their progress.’

It could also steer the development of services in different areas, throughbetter evidence-based commissioning. ‘If you’re involved in commissioning, it’s asimportant to know where you’re not achieving and what’s not working,’ saidRoxborough.

During the bedding-in period for TOPs, he invited feedback from services andclients, and was certain that the all-round effort would be worth it: ‘Drugtreatment will be measurable in a way it’s never been before – and that will be thekey to ensuring investment continues in drug treatment.’ DDN

‘This is a world first and we need to bang the drum... This system can help everyone – providers andcommissioners. It measures andrecords real outcomes – drug andalcohol use, psychological health,social functioning.’

Provocatively clothed female singersperforming their single ‘promiscuousfantasy’, is not an opening you would expectat your average conference. Yet the Young

Women and Health Event 2007 was definitelysomething different.

Marking the launch of the Young Women Nowmovement (YWN), the event aimed to inspire positivechange among young women by giving them theconfidence and motivation to lead a non-destructivelifestyle. It showcased an impressive array of strong,creative and successful female speakers who promotedwellbeing and self-respect to the young delegates.

Organiser Harninder Athwal, communications officerfor The Federation, started up YWN with Tammi Gillett,a consultant for In-volve, after coming into contact withan increasing number of cases of young girls self-abusing and seeing that there was little help on offer.Her previous roles in a youth offending team and as aprobation officer involved her with young women withmultiple problems and made her realise her frustrationat the lack of sufficient services available to work withthem – and made her determined to do somethingabout the situation. At the outset she wondered whereon earth she was going to start, but now she says shecan ‘imagine that it is still like that for manypractitioners’.

Athwal is passionate about her cause andbelieves it’s important to provide services with theskills and knowledge to work with women effectively,responding to their needs. ‘At YOTs the main focus ison the offending. But, often this is the last thing thatneeds to be addressed. They might have beensexually abused, which is why they used drugs, whichleads them to commit an offence – and the reasonwhy they end up here,’ she says.

During the conference, Athwal spoke about‘overcoming the war on women’ and raised issuesaround rape, domestic violence and boys being

favoured over their female siblings in some families – allof which could lead to low confidence and subsequentlysubstance abuse. Young women who turned tomisusing drugs were denying themselves their own self-discovery and potential, she said – potential thatneeded to be recognised and used to help them.

She hoped that the conference would encourageyoung women to have a voice. ‘A common issue foryoung women is identity. Who am I? Where am Icoming from and going to? The journey for womensometimes gets lost,’ she says. Early interventioncould teach them about self-worth before they comeinto contact with the criminal justice system or drugrehab. ‘Intervention needs to start at home – givingparents the skills and knowledge to parenteffectively,’ she says. ‘Then it’s the education systemand equipping teachers, and then society. They allhave an impact on how a young woman will turn out.’

Dinah Senior, senior consultant for In-Volve, whodescribed today’s young people as ‘Lord of the Flies butwith guns, money, crime and drugs’, gave theconference an intense portrayal of her life from child towomanhood. She spoke about having negative feelingsabout her body image as a child, and was in an abusiverelationship in her twenties, but now successfullymanages strategic projects for In-Volve and works tohelp those within socially excluded communities.

Treatment agency Addaction explored thepressures of society on young women with a filmedcase study about a 15-year-old girl addicted toecstasy. She would consume two tablets a day for aperiod of two months to overcome feelings of low self-esteem and a negative body image.

‘The adolescent period is a time when girls areexploring themselves, finding out who they are,’comments Athwal. ’But the pressures from societyare stopping them from finding themselves. Thesegirls are so busy trying to please men that theyactually forget who they are, which can mean them

turning to substance misuse to create a numbnessaround them.’ ‘This delays the whole self-discoveryprocess,’ she says.

Floetic Lara, one of the poets to perform at theevent, used her lyrics to explore self-respect, self-loveand self-pride. Kat Francois’ poem, Essence of awoman (right), looked at using inner-strength andfemale empowerment to rise above any negativeissues faced within society.

Athwal was pleased with the reaction to differentelements in the conference programme: ‘Many youngwomen took to the poetry and could relate to it, whileothers related more to the whole presentation,’ shesays. ‘It’s about getting a mixture of things to capturea lot of them in one form or another.’

Athwal intends the YWN conference to be anannual event, with next year set to raise issuesaround self-harm, eating disorders, crime anddomestic violence. Information gathered from thisyear’s event will feed into the Greater LondonAuthority’s Health and Inequalities Strategy.

Since the conference YWN have been using thenetworking website MySpace, to keep the issuesalive, and find out more about what young womenwant. Feedback is already coming across loud andclear: ‘A lot of young women are telling us that theywant services that are more flexible at their approach– so they can walk in at seven on a Saturday morningand have access to help,’ says Athwal.

‘They also want passionate workers, people thatactually believe in what they’re doing, she says. ‘It’snot necessarily the service that’s going to change aperson, but that individual can motivate a person andhelp them through the process to a better life.’ DDN

To find out more about Young Women Now, emailHarninder Athwal: harninder@thefederation.org.uk. TheMySpace address iswww.myspace.com/youngwomenandhealth

12 | drinkanddrugsnews | 21 May 2007

Lifestyle | Women

www.drinkanddrugs.net

Now tell us what you want..!Harninder Athwal(pictured), founder of anew movement calledYoung Women Now, tellsDDN how listening towhat young women wantcan divert them fromdrugs and destructivebehaviour and towards ahealthier lifestyle.

IN CORNWALL, as in many parts of the country, the specialist drugsservice (CDAT) relies on referrals from general practitioners for clientswith drug problems. These referrals relate almost exclusively to heroininjectors.

In an ideal world, the letters that accompany them would contain vitalinformation on, for example, route of use, mental health and physicalhealth needs, that can be used to prioritise the user into treatment, orsignpost to non-stat agencies where appropriate.

Unfortunately this was not often the case, and so a few years ago wedeveloped a standardised form that was distributed through the GPsurgeries, to help with this process.

In 2006 we conducted an audit to find out to what extent GPs wereproviding the information that, ideally, we required. It was also carried outto establish whether more information was passed on through typedletters or referral forms, and to find out which system appeared to workbest.

Fifty people were selected randomly, whose main cause of concernwas illicit substances. We found that GPs preferred to refer 46 patientsout of 50 through typed letters, and only four referrals out of 50 weremade by using referral forms.

Although there was no difference in demographic informationdisclosed by the GP (age and sex etc) significantly more information wasprovided regarding method, frequency, complications and risks of druguse in referral forms, as compared to typed letters.

The insufficient information in the typed letters added to increasedworkload for the substance misuse team, as 10 per cent of people werebeing followed up for more information.

After the audit a gentle reminder, in the form of a letter to the practicemanagers, was sent to improve the quality of information in the letters –and to ask them if possible, to use the referral forms in place of, or inaddition to, the letters.

In the re-audit it became evident that the number of referral formsused for referrals increased to 17 out of 50. Although the quality ofinformation had improved generally in letters and forms, the referralsforms still held a significant edge in provision of crucial information.

The purpose of this audit was to improve the GPs’ awareness aboutcommunication of important parts of information, to provide the bestcare to the service user and the method of transferring this informationin an organised way.

It is reassuring to know that standardised forms can help in thisrespect, and we would urge teams with similar problems to follow suit.Of course over the next few years, information management withinsubstance misuse will change a great deal and increasingly referrals aremade electronically. This will change the media used to make referrals,but it will not change the basic principle that it is important that the linksbetweens primary and secondary care are nurtured and, wherenecessary, improved.

Dr Adrian Flynn is consultant liaison psychiatrist at Cornwall

Partnership Trust; Dr Rupert White is consultant at Cornwall Drug and

Alcohol Team; Dr Omair Khan is senior house officer (psychiatry) at

Cornwall Partnership Trust.

ESSENCE OF A WOMAN

The time has come for me to free myself from this emotional slavery.From this invisible but debilitating holdthat life seems to have over me.To banish all negative thoughtsthat only succeeds in creating inner confusion and distractibility.I am the essence of womanand I have been blessed with the most wondrous giftsthat life has to offerNo one can take these away from me,regardless of what spiritual violence they may place upon me.

Cut me and I will bleedbeat me down and I will bruise,I am made with mere flesh and blood too.Sticks and stones will hurt my bones and names will truly harm me.I have the foresight to see into the future,to a time when certain trivialitieswill no longer matter to me.I refuse to give into negative forces,that falsely believe they are stronger than me.

I was raised better to lay down and cry,Instead I will rise with the sun and I will shinelike a phoenix coming out of the ashesI will dust myself free,and try over and over again if must be.I am a daughter of Jah,nothing has ever come easy for me, from the moment that Adam took the apple from Eve I was damned for all of eternity.

I am the essence of woman,all women that have ever been used, abused, physically, emotionally,humiliated, rejected, betrayed.I am all of these,but I refuse to bend my head downand not look my enemy in the eye,nor will I become submissive,for such actions do not come natural to me.I do not have to shout or be aggressive,to put up a worthwhile fight,at times silence is the only answer.

As a women born to nurture and create,there is nothing that can be doneto make me eternally bitter or angry.For I possess strengths that no-one else can see,that have held together nations and built holds societies,so do not underestimate me,after days, months, years, decades, of ill-treatment and disrespect,I will no longer be held responsible for my actions,or easily satisfied.There comes a time when the essence of woman,has to say enough is enough.

Kat Francois

21 May 2007 | drinkanddrugsnews | 13

Lifestyle | GP referrals

www.drinkanddrugs.net

Curing bad paperworkStreamlining the referral process from GPs can significantly

improve the patient’s journey into drug services, as

Dr Adrian Flynn, Dr Rupert White and Dr Omair Khan found

out from their recent audit in Cornwall.

Prison health | innovation

www.drinkanddrugs.net14 | drinkanddrugsnews | 21 May 2007

W hy shouldn’t innovation bepart of prison life?, asksPeter Mason, chief executive

of the Centre for Public Innovation.‘Innovation can work better thananything else I know. It can liberateenergy and productivity,’

Furthermore, he believes that‘innovation works better under scarceresources. Necessity is the mother ofinvention.’

As chief executive of the Centre forPublic Innovation, Mason has been anenthusiastic driver for improvementsin prison health over the past fiveyears. ‘We’ve been delighted tosupport over 500 innovations in theprison system,’ he told winners at therecent Prison Health InnovationAwards. This year the award focused onbright ideas to tackle substance misuseissues for prisoners and offenders.

The initiative had brought ‘thous-

ands of prisoners into contact withinnovations’ and encouraged improvedrelationships within prisons. Masonencouraged prison staff at theceremony to be brave in capitalising onopportunity and tenacious in puttingideas in place.

‘Innovation can be breathtakinglysimple,’ he said. ‘But pound for poundit can work better than anything elseI know.’

Presenting the awards, RichardBradshaw, director of prison health forEngland and Wales said: ‘The challengefor us is to take some of these ideas andmake them applicable elsewhere. Wecan make the learning curve for othersa lot shorter.’

Gemma Sayers and Debbie Sayerswork at Lewes Prison, a category B maleprison in East Sussex. Noticing thevulnerability of remand prisoners todrug deaths as soon as they were

released spurred them on to developOverdose Aid – a scheme to give in-mates practical skills and knowledge.

Important information on how torecognise signs of overdose, when tocall an ambulance, and resuscitationwere taught through quizzes, demon-strations and a video, with supportfrom their primary care trust.

‘The information held quite a fewsurprises for prisoners,’ said themother and daughter team. ‘Webroadened it to include anaphylacticshock and other situations, so theycould use their skills in everyday life.’

Katie Roberts and Louise Athertonwanted to tackle the issue of steroidabuse among many of the young menat Thorn Cross Young OffendersInstitution. Initial thoughts of gettingin a guest speaker transformed into adynamic publicity campaign targetingthe whole prison, from training as partof the induction programme to exam-ining the dangers of steroids throughperforming a play.

‘All of the trainees said it had madethem think about lifestyle choices,’said Roberts. ‘We set about buildingconfidence and self-esteem. Thedifference in some of the prisoners wasremarkable.’ They now plan to take theinformation to local schools and colleges.

Michael Cowan wanted to help turnthe attitudes of young men at FelthamYoung Offenders Institution fromnegative to positive. With the help ofpsychiatrist Johan Reshiglues, hedeveloped a boardgame called SpiralChoices, where players make lifestyledecisions about drug and alcoholmisuse, with the help of a facilitator.

‘Participants were amazed theycould have choices,’ said Cowan.

Moving forward with every throw ofthe dice to reach ‘life’ at the end, theylearned a lot about teamwork, heexplained. ‘Scenario’ cards along theway generated discussion on what theyshould do in different situations, andthey received a certificate at the end.

‘The certificate was good for them,’said Cowan. ‘Some young people inprison felt they hadn’t achievedanything in their life.’

Mike Underwood set himself thechallenge of improving prisoners’knowledge of drug misuse and sexualhealth for their return from EverthorpePrison to the outside world. Withfreebies from Durex, who were keen tosupport the initiative, he engaged

prisoners in designing a harm reductionpack. Alongside condoms, the pack hadinformation on where to go to accessservices in the community, and a surveyasked them if they had found the packuseful and used the contents – whichwas free to post back, with the chanceof winning an iPod.

Admitting that producing the packwas not easy – ‘prisoners’attention spanis so short’– Underwood said the projectwas worth the effort: ‘If they use it once,it’ll have done its job.’

A CARAT worker at Ashwell Prison,Scott Davidson wanted to encouragemore prisoners to relocate to thevoluntary drug testing unit. His taskwas not easy: plenty of drugs werefinding their way into the open prison,so he thought about ways to challengethe boredom that led to drug use.

Believing that a programme of leisureactivities would incentivise them to try amore positive approach, Davidsonintroduced bingo games and quiz nights,where participants played in teams.Those with negative drug tests had theirnames entered into a draw to use aPlaystation for a weekend.

With the experiment achievingpositive results, he now runs activitynights every Wednesday and Thursday,and has brought in an Xbox Console forfootball tournaments.

Charlotte Tompkins and Nat Wright,of Leeds Prison, chose producing ahealth promotion DVD to bring homethe dangers of drug taking in prison. Thefilm showed ex-injecting drug userstalking about aspects of using drugsinside, and looked at using motivationalenhancement therapy to changebehaviour.

Working for North Lancashire PCT,Hilary Abernethy knew all about thehigh levels of blood borne viruses in theregion. Conducting Kirkham Prison’shealth needs assessment made herrealise the need for more sexual healtheducation for prisoners, and she set up atraining course that would go beyondteaching prisoners, to helping thembecome peer educators to otherinmates. She trained up to ten prisonersat a time about blood borne viruses andsexually transmitted infections.

Working between the PCT and theprison had presented some difficultchallenges – but, says Abernethy,‘giving prisoners responsibility for theirown health renewed my somewhatflagging motivation’. DDN

Inside innovatorsSupporting prison staff to find imaginative

ways of tackling prison drug problems can

have encouraging results, as DDN reports.

What the science shows, and what we should do about it (Part 3)

www.drinkanddrugs.net 21 May 2007 | drinkanddrugsnews | 15

Background briefing | Professor David Clark

family skills for positive communication andmonitoring. Secondly, building family reciprocity inexchanging and sharing positive reinforcement.

9. Substance use problems are affected by a largersocial contextAn individual’s larger social context influences therisk, severity and length of time of substance useproblems.

Environments in which drugs are more readilyavailable promote use. On the other hand, theavailability of other reinforcers and activities isprotective against substance use problems.

Social modelling can promote or deter use.Cultures in which abstinence is the norm, and inwhich drug use is stigmatised, have lower rates ofdrug use and drug-related problems.

On the other hand, criminal sanctions for use arerelatively ineffective in suppressing drug use,particularly once it is an established pattern.

Norms about substance use play an importantrole. Clear norms and modelling of moderationinfluence drinking rates.

However, some people misperceive behaviouralnorms. Young people who overestimate thepercentage of peers who smoke or drink are morelikely to do so themselves, and start to engage inthese activities at a younger age. Communicatingthe actual behavioural norms for a group (normcorrection) can have a deterrent effect on use.

The normative social meaning of substance use,which often has symbolic value, is also important.When psychoactive drugs become marketablecommodities, advertising tends to normalise use andto associate it with attractive and symbolic outcomes.

10. Relationship mattersThere is something therapeutic about certainrelationships. For example, it matters who isdelivering a treatment for substance use problems.

Research has shown that the clients of randomlyassigned counsellors often differ widely inoutcomes, even if they are receiving the samemanual-guided treatment.

The clients of counsellors who are higher inwarmth and accurate empathy show greaterimprovements in substance use problems. As earlyas the second session, clients’ ratings of theirworking relationship with the counsellor arepredictive of treatment outcome.

Motivation for change seems to emerge in therelationship between client and counsellor, even inrelatively brief periods of counselling.

Some counsellors have consistently worseoutcomes than their colleagues. A confrontationalstyle that puts clients on the defensive is counter-therapeutic.

The American addiction experts indicated thatthese ten principles suggest ‘particular directions indesigning programs, systems, and social policy toreduce drug use and associated suffering, societalharms and costs’.

I will consider their ten broad recommendationsfor addressing substance use problems in society inmy next Briefings.

Rethinking Substance Abuse: What the science shows,and what we should do about It, edited by William R.Miller and Kathleen M. Carroll, Guilford Press, 2006

Leading US addiction scientists met in 2004 at a‘think-tank’ conference to share research findings intheir respective areas and discuss possible implica-tions for treatment and prevention interventions.

The conference resulted in a seminal book, inwhich the authors draw together the wealth ofscientific understanding from the range of topicareas considered to produce a set of ten cross-cutting principles, and then reflect on their implica-tions with ten recommendations for interventions.

In this Briefing, I continue with the last threeprinciples.

8. Drug problems occur within a family contextProblematic use of drugs and alcohol is a risk factor foryoung people’s drug use, and is also linked to a varietyof family problems and more general risk factors.

Parents with drug and alcohol problems are lesslikely to provide the kind of parenting that reducestheir child’s risk. For example, children of parentswith substance use problems are less likely todevelop self-regulation skills, particularly ifparenting is disrupted before the age of six – acritical age for learning self-control.

This is particularly true for children who have otherdevelopmental risk factors, such as a difficult tempera-ment or attention-deficit hyperactivity syndrome.

The likelihood of domestic violence and childabuse is greatly increased when parents have drugand/or alcohol problems.

Conversely, family environments can beprotective against future substance misuse. Factorsthat decrease first use of substances, decrease riskof future problematic use.

Parental disapproval of drug use is protective. Anoptimal parent style is one that is, ‘consistent,supportive, and authoritative (moderately structuredand midway between the extremes of permissive-negative and neglectful and authoritarian-punitive)’.

Parental monitoring of children’s whereabouts,activities and friends is a particularly importantfactor. A family involvement in religion or otherconventional activities is also a strong protectivefactor. In adolescence, these family factorscounterbalance the influence of peers.

Children who are particularly susceptible toadverse peer influence include those who are‘extroverted, present- (not future-) focused, havelow self- esteem and low grades, use avoidantcoping styles, spend more time away from home (egpart-time work), and tend to be followers’.

Effective interventions with families have tendedto concentrate on two factors. Firstly, strengthening

‘The clients of counsellorswho are higher in warmth andaccurate empathy showgreater improvements insubstance use problems. Asearly as the second session,clients’ ratings of theirworking relationship with thecounsellor are predictive oftreatment outcome.’

Professor David Clark continues to describe the main findings and recommendations from

a major new book based on the views of America’s leading clinicians and researchers of

how treatment would look if it were based on the best science possible.

16 | drinkanddrugsnews | 21 May 2007

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