Drug, Alcohol & Mental Health / Wellbeing - Recovery in Salford

1. Drug, Alcohol & Mental Health / Wellbeing - Recovery in Salford Moving On: Colin Wisely Andrew MacDonald Salford DAAT / NHS Salford: Presentation To Neighbourhoods Scrutiny Committee 18 04 2011

2. Strategy 2 overarching aims: Reduce illicit and other harmful drug use Increase the numbers recovering from their dependence Strategy 3 main themes: Reducing demand Restricting supply Building recovery in communities National Drug & Alcohol Strategy

3. Problem Drug / Alcohol use Healthy Living Recovery Tier ‘0’ Community Activity E.g. self-help Recovery Path Tier 1 Tier 1 Generic Community Drug & Alcohol Services e.g. GPs Recovery Path Tier 2 Tier 2 Semi Structured Community Drug and Alcohol Services Recovery Path Tier 3 Tier 3 Structured Case Management Community Drug and Alcohol Services Recovery Path Tier 4 Tier 4 Residential Drug & Alcohol Services – Detoxification/Rehabilitation

4. Some drug and alcohol users of all ages never enter formal treatment and ‘recover’ in the community (described as Tier ‘0’) - not all develop ‘problems’ – also where longer term ‘recovery’ takes place – very underdeveloped Increasingly younger users and newer types do not identify as having a ‘problem’ – so require new services and new thinking on structures and governance Case Management / Care Coordination all age groups Tier 3 - acts as the ‘gatekeeper’ for complex / coordinated care – an important feature – but relatively poor at managing exit because that is not it’s function The lack of structure below Tier 3 means when cases closed recovery journey (highlighted in green) less coordinated - encourages drop out / raises risk of relapse / overdose / exclusion / community safety et al Current Models of Care Drug and Alcohol ‘Tiered’ Treatment System Features

5. Keeping an ageing population of problematic drug users healthy Identifying problematic drug users ready for treatment and caring for those in recovery Prevention interventions for younger drug users at risk of developing chronic drug and alcohol problems Establishing family focused approaches Shift from acute care model Emphasise completion of treatment Emphasise re-engagement of drop out of treatment Identifying problematic drug use at an early stage National Issues – Challenge In Salford

6. Changing patterns in drugs markets Significant levels chronic alcoholism in drugs ‘treatment’ cohort Needs of those that are leaving treatment Children of problematic drug and alcohol users Need to re-engage treatment drop-outs Complex Alcohol, Drugs, Mental Health all levels and co-morbidity Gaps In Current System

7. Increasingly older (average 40+ nationally but only 34 in Salford) Higher levels mortality and co-morbidity in ageing population of heroin and crack users Declining incidence recorded younger heroin users Continued growth in the mass market for cannabis and new and old stimulant drugs Often combined with alcohol and tobacco ‘Legal highs’ and cocaine use challenge for mainstream population Cannabis and Stimulants present challenge mental health services Future challenge concerns distinguishing early onset of chronic drug and alcohol problems and responding to mass normative use This implies fine grain profiling of families and individuals Issues Arising From New Schema

8. Users present to adult services designed for opiate users Adult services shifting towards recovery orientation – city remains over invested in Tier 3 prescribing modalities Majority young people do not use drugs - those who do - many in a brief and normative fashion Challenge identifying young people early & distinguishing brief and normative phases of use from chronic patterns Challenge communicating good quality drugs and alcohol messages to those using in a brief and normative fashion Challenge to address the needs young people in families where adults are problematic drug and alcohol users Shift in Health Needs Using Population

9. Numbers successful problem drug user amd non problem drug user treatment completions risen considerably since 2006 - unplanned exits stable Future financial allocations calculated - retained in treatment moderated by days ‘in-treatment’ Considerable evidence base in terms of what works in recovery Re-engaging / Retaining drop-outs crucial – services need to reduce relapse amongst completers Key Commissioning Messages

10. Wholly-attributable alcohol-related hospital admissions and alcohol consumption in adults (litres per person per year) in England since 2002 (NHS IC 2010, IAS 2010)

11. NDTMS 1: 14 harmful or dependent drinkers 18 + in treatment NATMS 572 young people who are primary alcohol users in Salford Further 155 young people alcohol misuse as an adjunctive problem to range primary substances Alcohol Use In Salford

12. Most young people do not use drugs, including alcohol, and for most of those who do their use is brief and normative First challenge is effective early intervention to distinguish brief and normative from chronic patterns of use More serious challenge communicating harm reduction messages to brief and normative users and engaging with young people in families where adults are problematic drug & alcohol users Young People Drug and Alcohol Use

13. Offenders – Hidden Alcohol Harm

16. Pending Nice Guidance 2011

17. New strategy emphasises outcomes drugs and alcohol abstinence ultimate goal – significantly shift Current model highly invested in specialist clinical interventions and lacks prevention focus or an aftercare recovery approach Tier 3 limited drug free outcomes - stasis - drop out and re-engaging - little progress wider treatment domains i.e. how well individuals function in community, family Integrated co-commissioning approach future investment in recovery highlights drugs and alcohol to downsize Tier 3 services and increase throughput towards recovery Implies an upscale of Tier 2 service to managing stable drug users post Tier 3 treatment – the same applies to alcohol users Need to commission services for niche needs of service users and existing drug and alcohol services offer a more ‘one size fits all’ approach Future Drug and Alcohol Service Provision – Salford’s View of the National Strategy

18. Process of building a recovery community well underway and task is integrating and enhancing existing local efforts Evidence base for this largely comes from the USA summarised by White and Kelly (2010) Need for better provision for young people particularly the under 25s, which cross cuts the drugs, alcohol and young people strategies Key shift involves early intervention in chronic drug and alcohol problems identifying future Problematic Drug Users and Problem Drinkers Clear signal to re-design criminal justice drugs interventions to improve efficiencies and outcomes in relation to HMP through care and the ‘gripping’ of high crime causing drug and alcohol users Overall, new design will emphasise integrated drug and alcohol provision which has the capacity to flex to individual need as appropriate Future Drug and Alcohol Service Provision – Salford’s View of the National Strategy

19. Pattern and culture of drinking, and the social circumstances of this group, are often different to those of older adults Children and young people less likely to have alcohol dependence than adults but hazardous drinking behaviours (binge-drinking) Full NICE clinical guideline managing alcohol dependence highlights multi-systems, multi-level approach - integrated alcohol services for children and young people NICE recommends Children’s and Adults’ commissioners jointly commission specialist services young people to age of 25 or 30

20. Level ‘0’ Recovery Community, Neighbourhood / Health Improvement Teams / Self Help / WWW based provision Level ‘1’ Lifestyle / Wellbeing Gateway and Generic Services Level ‘2’ Lifestyle / Wellbeing Gateway and Semi Structured Services, with External Care Coordination to manage those cases exiting structured treatment Level ‘3’ Structured Services with Specialist External Care Coordination for Structured and Highly Structured Treatment and Interventions Level ‘4’ Highly Structured Services including all Residential Detoxification and Rehabilitation across Recovery Provision ‘One Size Fits All’ does not fit Salford Children, Young People, Adults and Families – Integrated Service required for all ‘levels’ of complexity in Salford

21. 4 4 3 3 2 2 1 1 0 0 Tiered Treatment & Chronic Care TIME

22. 4 3 2 1 0 Prison Detoxified Re-enters treatment Enters Treatment Re-enters treatment Drop out IBA CJS Sustained Recovery Extended IBA / Group Crime Relapse Relapse Child of Problem Drinker Abstinent Recovery 18 20 AGE 30 YRS 40 50

23. 4 3 2 1 0 18 20 30 40 50

25. Recovery RECOVERY GRIP TEAM CLUB

26. RECOVERY CLUB HOUSING ETE WELFARE & BUDGET FAMILY & CARER INTERVENTIONS Fitness,groups, UNIVERSAL: Breakfast club etc RECOVERY specific art,cooking, budgets GRIP CLUB GRIP CLUB GRIP CLUB GRIP CLUB GRIP CLUB GRIP CLUB GRIP CLUB GRIP TEAM Move on

27. Ideal Recovery Treatment System

29. Timeline 2013 Integrated Services Tender Drugs and Alcohol Recovery System