Wednesday, 28 March 2018

What are drug consumption rooms for?

I’ve been thinking a lot about drug consumption rooms lately – often referred to in the field as DCRs.  They’ve been an issue nationally, with the debates around the Glasgow proposal as well as noises from Durham and other places.  And it’s no secret that drug-related litter has been an issue in Bournemouth and Weymouth, which my job covers, so it’s a day-to-day thing too.

The arguments are pretty familiar.  There’s not any real doubt that these facilities can have a positive impact for people who use drugs and the wider community.  However, there’s a debate about the scale of that impact and whether scarce resources are best spent on these kinds of facilities rather than other, more established, initiatives.  We’re never going to live in a utopia where everything that everyone needs or wants is funded and so these questions are real: what would we be trying to achieve with DCRs, and would it be worth it?

(For those of you who don’t follow these debates in as much detail as me, the term DCR can cover a range of things, but generally means somewhere to inject drugs under supervision.  The arguments in favour are that they reduce risks to people who use drugs as they have somewhere cleaner and safer, where someone is checking that they’re OK – but it’s not just about the users themselves, as they can potentially reduce public use and drug-related litter as well as drug-related crime.  If you want a good summary, Glasgow and Southampton councils have done great work on this.)

The view of the ACMD is that DCRs might be useful, but as part of a wider package of interventions; they shouldn’t be seen as a panacea on their own.  That is, of course, fair, but it’s not the most practical advice for commissioners who are struggling with increasing numbers of drug-related deaths, an ageing cohort of people who aren’t making great progress in treatment, and rising rates of homelessness and public injecting.  A comprehensive package of interventions would be great, but we didn’t have that in 2010, and now we’ve got cuts of 20% already, with no funding at all guaranteed beyond 2020.

So can – or rather should – DCRs be part of the picture in terms of commissioning under austerity?

When this debate comes up, it’s often framed in terms of the ‘methadone wars’ – that harm reduction has been sacrificed on the altar of ‘recovery’.  But (and I’m not alone on this, it’s not an original thought) I can’t get my head around this invented binary.  How does anyone achieve recovery without reducing the harm from their substance use?  How can giving someone advice and information about substance use be counterproductive to them achieving recovery?  Or, putting it bluntly: you can’t recover if you’re dead.

And a lot of people who use drugs are dying.  I don’t think this can be overstated – though it’s not necessarily the most powerful political argument in favour of drug treatment.

But setting aside this idea that treatment has been damaged by a focus on recovery or ‘successful completions’ (which I appreciate is some people’s experience, but it’s not mine), if we’re coming at this issue fresh, without the baggage of previous political debates, what should we do about DCRs?

Well the first point I often hear is that we should (to reference John Major) get ‘back to basics’.  If only we did needle exchange (and possibly opiate substitution treatment [OST]) properly, then there wouldn’t be these issues.  I’m informed that we’ve lost specialist needle exchanges and pharmacies offer a poor replacement.

But I don’t recognise this picture.  Commissioners find contracting with pharmacies frustrating: there’s lots of them and their local authority ‘business’ (whether needle exchange, supervised consumption of methadone or sexual health services) is a fraction of the overall turnover from NHS England or the commercial side of their work.  You can’t effectively manage a hundred contracts of this type.  The provider doesn’t care about your element of the service that much, and as a commissioner you can’t spare the time or energy to manage each one of them with the same intensity you’d apply to a specialist provider.  So inevitably the service isn’t great.

But that’s no criticism.  In fact, it’s in line with NICE guidelines, which suggest a tiered approach to needle exchange where specialist services offer the gold standard, including harm reduction advice, but we can’t provide that in every neighbourhood and indeed this level of involvement might put some people off, so we need to offer accessible facilities in a wide range of locations too.  It wouldn’t be possible to have a specialist needle exchange in every town or village in Dorset, but it’s possible to deliver this through pharmacies – though inevitably at a lower level of intensity.

I just don’t recognise the picture I’ve seen (or rather heard) painted that commissioners have lost all the structure and experience of 30 years ago, seen as the heyday of harm reduction.  Maybe it’s true elsewhere, but although we’re always able to improve our needle exchange offer, and the past few years haven’t been ideal, I can’t see that we’re moving away from specialist services to pharmacies.

If anything, as I say, I would have thought that the public health experience of having to directly commission pharmacies to do all sorts of bits and bobs that you wouldn’t have thought were the local authority’s responsibility (the morning after pill, for example) would have made commissioners more reluctant to use this as some kind of efficient escape route from the problems they’re facing.  There’s more uncertainty and less control – how’s that a recipe to sleep easier at night?

The issue is more likely to be integration – not only between pharmacies and the wider treatment system, but simply between needle exchange and more structured treatment.  I’ve been told that many service users actually prefer using pharmacy needle exchanges to the specialist services -precisely because they don’t get those hassling harm reduction initiatives or people trying to engage them into ‘structured’ treatment.

And that’s where we get to a really difficult point.

DCRs are often sold, following the ACMD argument, as an opportunity to engage people into treatment.  A DCR can be a hub for the full range of harm reduction activities and wider social interventions like housing, benefits, employment, probation and so on.  The argument is that some of the people most in need of support are going to come into this facility, so it’s an opportunity to get a whole range of ‘wrap around’ services put in place as part of a broader treatment ‘plan’.

But most DCRs aren’t just harm reduction hubs; they also offer – for example in the Glasgow proposal – structured treatment, often heroin assisted treatment.  Certainly there’s all sorts of services operating from most, from methadone dispensing to housing benefit advice.  That can sound like a great idea; an opportunity to engage people straight from injecting illicit substances to being on a legal prescription.

But equally it can sound like the opposite of what some harm reduction advocates would hope.

In Weymouth, we have brought all our services under one roof.  There used to be a site for prescribing, a site for harm reduction and group work, and a site for the criminal justice team.  And then the abstinence-based ‘aftercare’ operated from a range of sites (like church halls) that weren’t permanent fixtures.

(It’s not just austerity that brought services together; it’s also service user feedback.  One (unnamed) individual used what’s become known locally as ‘the dentist analogy’: imagine if you had to go one place to have your anaesthetic, then walk down the road to get your tooth drilled, then hop on a bus to then get the filling actually put in.  That’s what dealing with substance misuse treatment (and all the other related services) felt like to them.  Saving on rental costs by sharing premises won’t dig us out of our financial hole; one member of staff can cost more than the rent on a workable building – just check rightmove.  It’s the people that make the difference in services, and quite rightly that’s what commissioners are mostly paying for.)

So what’s the problem with bringing services under one roof, as they would be to some extent with a DCR?  Well, it means that by definition you don’t have dedicated harm reduction services; they’re operating from the same premises as the prescribing provider who will be (more often than not) part of the NHS.  So our needle exchange now operates from the Weymouth Community Hospital site.  Since it moved from a dedicated third-sector ‘drug agency’ base, the numbers accessing needle exchange there have fallen.  People, we’re told, find it intimidating to access needle exchange at the same site where they pick up their prescription.  (And equally, people who are now abstinent find it a challenge to step through the door of a facility where people are still in ‘active addiction’.)

I appreciate this is rambling.  I haven’t got (as I often ask for in the day job) a clear definition of ‘the problem’ or a proposed ‘solution’.  But that’s the point.  A lot of people (including me) are excited by DCRs, but if I’m honest that’s partly because they’re shiny and new to a UK audience – and therefore untainted and full of promise.

On this blog I’ve often moaned about how minimum unit pricing for alcohol is an empty vessel into which people pour all their (alcohol policy) desires: it’ll stop underage drinking, binge drinking, dependent drinking, excessive everyday drinking, and so on.  It’ll even revive the pub trade.

I worry that DCRs will become the same thing for drug policy: they’ll reduce drug-related litter, public injecting, blood borne viruses, crime, antisocial behaviour, and they’ll foster recovery and abstinence while they’re at it.

Will DCRs really be a harm reduction hub?  And if they are, should they also be a site for delivering treatment?  Or will that scare people off?  (Both people who aren’t ready for treatment and those who want to see a bit more stability in their lives.)  To return to my regular themes on this blog, I think we need to work out what we’re trying to achieve before we start leaping to solutions.

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