Towards an effective social care model for arrest referral: Implications for criminal justice interventions for problem drug users

Aims: To assess an operational model for arrest-referral schemes that successfully facilitates the entry of highly entrenched and chaotic problem drug users into specialist drug-treatment services. Methods: (1) An examination of case records from a voluntary arrest-referral service (SMART CJS) based across the Thames Valley region of the UK during 2002-2003; (2) Probablistic database linkage of agency case records with the National Drug Treatment Monitoring System (NDTMS); (3) participant observation and semi-structured interviews with agency staff.

Findings: Over half of problem drug users (58%) maintained contact with the scheme following initial contact in police custody. Referrals were made to a wide range of social-care services in addition to specialist drug treatment to include prison-based services, housing support and primary care. This model was able to demonstrate very high levels of specialist drug treatment uptake (53%) following referral. There was a close relationship between the average length of time a problem drug user entered treatment following contact in police custody and the average length of an active case file. Such an approach was considered essential to maintain motivation with clients.

Discussion: This social care model has operational validity in ensuring treatment uptake of recidivist problem drug-using offenders. Continuity of care alongside referrals addressing wider community harms including social exclusion and public health should be encouraged.     

Exploring the intersections between novel psychoactive substances (NPS) and other substance use in a police custody suite setting in the north east of England

Abstract

Aims: Novel psychoactive substances (NPS), a range of plant-based/synthetic substances that mimic effects of other illicit substances (e.g. cannabis), are now illegal in the United Kingdom (May 2016) to produce/supply. Negative behavioural consequences of NPS use mean that users frequently transgress the law are arrested and detained in police custody suites. Evidence shows a link between traditional substance use and offending behaviour, with significant police time spent on alcohol-related incidents. We explore the intersections between NPS and other substances with police staff and users in custody; specifically the similarities and differences in treatment, management and policing of these substances.

Methods: A qualitative study using semistructured interviews and thematic analysis. We recruited 15 police staff (4 women/11 men) and 25 NPS users (9 women/16 men).

Results: Police staff perceived NPS users to be extremely volatile in custody and reported feeling less knowledgeable about how to manage and respond to their needs compared to other substance users (e.g. alcohol, heroin). Users rarely took NPS in isolation and often compared them to other illicit substances, balancing effects versus costs.

Conclusion: NPS use has a striking effect on custody work, primarily because of unpredictable user behaviour, adding further pressure to already overstretched police staff.     

Drug consumption facility as part of a primary health care centre for problem drug users—Which clients are attracted?

BackgroundTo investigate whether users of a drug consumption facility (DCF) established as part of a health care centre for problem drug users fulfilled entry criteria, especially public drug consumption, risky drug-application and housing problems. We also investigated whether the drug consumption facility attracted hard-to-reach opiate users who usually do not use the health care system.MethodsStructured interviews were carried out with 129 problem drug users beginning attendance at a drug consumption facility.ResultsMedian length of the current episode of regular heroin use was 3 weeks. Sixty-seven per cent of clients had been in addiction specific treatment or had left prison during the previous 3 months. Regarding behaviour in the last month, 53% reported drug use in public, 53% use of non-sterile equipment or water, 22% needle sharing, 8% reported an emergency admission to hospital, and 43% were living in unstable accommodation. Only 10% of clients had never received treatment for their drug use and 87% were currently in contact with psychosocial services.ConclusionsThe majority of clients were chronic opiate users with high rates of risk behaviour. However, they did have recent contact with the drug treatment system. DCFs may be particularly important for opiate users after prison or treatment and/or for those with unstable accommodation.     

Interventions to enhance testing,linkage to care and treatment uptake for hepatitis C virus infection among people who inject drugs: A systematic review

BackgroundThe burden of hepatitis C virus (HCV) infection is escalating among people who inject drugs (PWID), yet testing and treatment remains suboptimal. The aim of this systematic review was to evaluate the effectiveness of interventions to enhance HCV testing, linkage to care, and treatment uptake among PWID.MethodsA systematic literature search of Medline (Ovid 1946 – present), Embase, Global Health, Cochrane Central Register of Controlled Trials, PsycINFO, Clinical Trials Registry, and Web of Science was conducted covering interventional studies published before 20 July 2016. Studies evaluating interventions to enhance HCV testing, linkage to care or treatment among PWID were included. Data from included studies was extracted by one reviewer and checked by a second reviewer with disagreements discussed until consensus was reached. Relative risk ratios and corresponding confidence intervals were generated for studies included in analysis.ResultsAfter adjusting for duplicates, 10,116 records were identified. A total of 14 studies were included for analysis, of which 57% were randomised controlled trials. Interventions to enhance HCV testing included on-site testing with pre-test counselling and education; and dried blood spot testing. Interventions to enhance linkage to care included facilitated referral for HCV assessment and scheduling of specialist appointments for clients. Interventions to enhance HCV treatment uptake included integrated HCV care, drug use and psychiatric services delivered by a multidisciplinary team with case management services, with or without non-invasive liver disease assessment. All studies were conducted in the interferon treatment era and there were no studies conducted in low- and middle-income countries.ConclusionsIn the direct acting antiviral treatment era, well-designed studies evaluating interventions to enhance a simplified care cascade are crucial in facilitating treatment scale-up.     

A case-linkage study of comorbidity in mental health and substance misuse care populations

This study examines the total comorbid care ‘care population’ for one geographical area. It identifies the extent of (often unrecognized) shared care between coterminous ‘care populations’ in the context of the extent of assessed need and so identifies the gap between need and service provision. The study combined anonymized data for the total secondary mental health care population and all six substance misuse agency populations within one health authority population (N?=?646,239) over three years, to identify shared ‘dual agency’ comorbid client groups (all mental health agency clients receiving specialist substance misuse treatment and vice versa). Of the total population of drug agency clients (N?=?1206), 28% had received mental health services, and of alcohol agency clients (N?=?1476), 39% had received mental health services. For a total mental health population (N?=?19,029), 2% had received specialist drug services, and 3% alcohol services. These figures are compared to previous estimates of assessed need in treatment populations to identify gaps in service provision. Two thirds of ‘dual agency comorbid’ clients were male, 40% had attended Accident and Emergency (A&E) and half had been mental health in-patients. Mental health/drug agency populations were younger and mental health/alcohol agency populations received more mental health services.     

The role of the Chinese police in methadone maintenance therapy: A literature review

BackgroundThe behavior of police is an important factor in drug users’ access to preventive and therapeutic health services. In China, opiate users must be registered and approved by police before accessing methadone maintenance treatment (MMT).MethodsWe conducted a literature review to identify studies reporting original data about the influence of Chinese drug policing activities on MMT access and outcomes. Searches were conducted in PubMed, the Law Journal Library of HeinOnline, the Social Science Citation Index and China Academic Journals of CNKI for empirical studies conducted in China and published in academic journals between 2005 and April 2012.ResultsThe initial literature search retrieved 276 records, of which 85 were included in the review and 191 were excluded. The majority of the included papers were single-clinic observational studies. These studies reported that: (1) fear of incarceration deterred users from initiating and continuing MMT; (2) the rates of MMT referral by police were considerably lower than those by drug user peers and by community and the media; (3) police sending users to compulsory detoxification (DETOX) and reeducation through labor (RTL) centers contributed to higher rates of MMT patient dropout; (4) arrests in and around MMT clinics were not uncommon; (5) cooperation between local police and public health agencies was difficult to achieve; and (6) a limited number of trial programs were conducted to refer detainees in DETOX to MMT clinics after release, but the outcomes were not promising.ConclusionReviewed studies report drug policing practices that appear to be impeding MMT access and reducing successful treatment outcomes. Research focusing on the nature, prevalence and severity of these effects is urgently needed. Health and public security officials in China should review and reform policies and practices of registering, monitoring, and incarcerating drug users.     

Hallucinogenic Mushrooms in Guatemala

Abstract

This study allocated 201 (nearly) daily users of heroin and/or crack into four groups, depending on their addiction care participation. Earlier studies have compared treatment groups and nontreatment groups. In this study the treatment group is divided into three categories: (1) drug users in contact with only treatment agencies—i.e., methadone maintenance, clinical and ambulant drug treatment; (2) drugs users in contact with only care agencies—i.e., day and night shelters and drug consumption rooms, which have no explicit aims to change patterns of drug use; and (3) drug users in contact with both treatment and care agencies. This allocation intro three different groups fits the notion of harm reduction, one of the policy aims in the Netherlands. The fourth group consists of drug users in contact with neither treatment nor care agencies. The results show that it is useful to distinguish these four categories, instead of two. The four groups are different from each other with respect to some of their characteristics (e.g. debt situation, prostitution. homelessness) and their drug use (e.g. drug use in public, use of crack, and use of other drugs). A much clearer distinction can be made between the “care” group and the “treatment and care” group. Treatment and care agencies can thus better match their services to their clients or patients.     

Abstinence and drug abuse treatment: Results from the Drug Outcome Research in Scotland study

Aims: To identify the proportion of drug users contacting drug treatment services in Scotland who were able to become abstinent 33 months after having started a new episode of treatment and to identify which services were most closely associated with such abstinence. Design: Follow-up survey of 695 of the Drug Outcome Research in Scotland respondents 33 months following recruitment into the study. Setting: Scotland. Participants: Injecting drug users who were initially contacted at drug treatment services and then followed up for 33 months post-recruitment. Measurements: Self-reported drug use and service usage. Findings: Although becoming drug free was the expressed goal of the majority of drug users recruited into the Drug Outcome Research in Scotland study, at 33 months following recruitment only 5.9% of females and 9.0% of males had been totally drug free (excluding possible alcohol and tobacco use) for a 90-day period in advance of being interviewed. There was considerable variation within this study in the proportion of drug users becoming drug free dependent upon the services they had been in contact with. The level of achieved abstinence in this Scottish study was substantially lower than that identified in the National Treatment Outcomes Research Study in England. Conclusions: There is a need to establish why so few drug users in contact with the methadone programme in Scotland appear able to become drug free 33 months after having contacted this service. On the basis of the results presented in this paper there is a need to ensure that drug users seeking help in becoming drug free are able to access residential rehabilitation services although at the present time such services are relatively rare within Scotland.     

Driving among drug users: Are we doing enough? A chart review of assessment of driving and related issues in drug misusers

Aim: Driving among drug users is a major health concern. Professionals working in substance misuse service have a duty of care to manage the risks involved. We analysed the practice of multidisciplinary team in drug treatment service discussing driving with the patient and providing them with relevant information regarding the regulations. We compared this practice with the existing policies and guidelines.

Method: A chart review of healthcare professionals in the drug treatment services discussing driving and related issues with the patient was carried out. One hundred case records were analysed for evidence of documentation of the above information.

Results: A clear record of discussion of all driving-related issues was documented in only 28% of records reviewed. In more that half of the cases there was no record as to whether the patient was driving or not.

Conclusions: The results raised some ethical questions that would influence the policy makers and practitioners. These finding suggest that major changes are needed in our practice both for our legal protection and for the best interests of patients and public.     

Do psychiatrists make a difference? Impact of levels of medical input to the range of treatment provided in in-patient drug detoxification services

Aims: There is limited research evidence about the role of in-patient detoxification for drug users and in determining where this form of treatment should occur and with what level of medical support and supervision.

Methods: The current study is based on a national survey of National Health Service (NHS) providers of drug detoxification in residential settings in England. Of the 76 services identified, 56 (74%) completed and returned the survey, including 19 specialist providers and 37 general medical or psychiatric wards that had beds available for residential drug detoxification.

Findings: There was marked variability across providers in the level of medical and non-medical staffing, and in the characteristics of the treatment programmes available. These factors differed systematically by whether the unit was a specialist provider, particularly with regard to levels of medical input. There was greater medical input in the specialist units (statistically significant for staff grade and SHO psychiatrists) while there was greater input from occupational therapy on the general medical or psychiatric wards. There was also a higher ratio of nursing staff for each drug bed in the specialist units.

Conclusions: Although better medical support is available in specialist units, the marked variability across participating units suggests an inconsistency in residential drug treatment that is worrying and requires further investigation.     

A cost-effectiveness analysis of primary versus hospital-based specialist care for direct acting antiviral hepatitis C treatment

BackgroundHepatitis C virus elimination may be possible by scaling up direct-acting antiviral (DAA) treatment. Due to the safety and simplicity of DAA treatment, primary care-based treatment delivery is now feasible, efficacious and may be cheaper than hospital-based specialist care. In this paper, we use Prime Study data – a randomised controlled trial comparing the uptake of DAA treatment between primary and hospital-based care settings amongst people who inject drugs (PWID) – to estimate the cost of initiating treatment for PWID diagnosed with hepatitis C in primary care compared to hospital-based care.MethodsThe total economic costs associated with delivering DAA treatment (post hepatitis C diagnosis) within the Prime study – including health provider time/training, medical tests, equipment, logistics and pharmacy costs – were collected. Appointment data were used to estimate the number/type of appointments required to initiate treatment in each case, or the stage at which loss to follow up occurred.ResultsAmong the hepatitis C patients randomised to be treated within primary care, 43/57 (75%) commenced treatment at a mean cost of A$885 (95% CI: A$850–938) per patient initiating treatment. In hospital-based care, 18/53 hepatitis C patients (34%) commenced treatment at a mean cost of A$2078 (range: A$2052–2394) per patient initiating treatment – more than twice as high as primary care. The lower cost in the primary care arm was predominantly the result of increased retention in care compared to the hospital-based arm.ConclusionsCompared to hospital-based care, providing hepatitis C services for PWID in primary care can improve treatment uptake and approximately halve the average cost of treatment initiation. To improve treatment uptake and cure, countries should consider primary care as the main model for hepatitis C treatment scale-up.     

Integrating multiple programme and policy approaches to hepatitis C prevention and care for injection drug users: a comprehensive approach

BackgroundNew York State is home to an estimated 230,000 individuals chronically infected with hepatitis C virus (HCV) and roughly 171,500 active injection drug users (IDUs). HCV/HIV co-infection is common and models of service delivery that effectively meet IDUs’ needs are required. A HCV strategic plan has stressed integration.MethodsHCV prevention and care are integrated within health and human service settings, including HIV/AIDS organisations and drug treatment programmes. Other measures that support comprehensive HCV services for IDUs include reimbursement, clinical guidelines, training and HCV prevention education. Community and provider collaborations inform programme and policy development.ResultsIDUs access 5 million syringes annually through harm reduction/syringe exchange programmes (SEPs) and a statewide syringe access programme. Declines in HCV prevalence amongst IDUs in New York City coincided with improved syringe availability. New models of care successfully link IDUs at SEPs and in drug treatment to health care. Over 7000 Medicaid recipients with HCV/HIV co-infection had health care encounters related to their HCV in a 12-month period and 10,547 claims for HCV-related medications were paid. The success rate of transitional case management referrals to drug treatment is over 90%. Training and clinical guidelines promote provider knowledge about HCV and contribute to quality HCV care for IDUs. Chart reviews of 2570 patients with HIV in 2004 documented HCV status 97.4% of the time, overall, in various settings. New HCV surveillance systems are operational. Despite this progress, significant challenges remain.DiscussionA comprehensive, public health approach, using multiple strategies across systems and mobilizing multiple sectors, can enhance IDUs access to HCV prevention and care. A holisitic approach with integrated services, including for HCV–HIV co-infected IDUs is needed. Leadership, collaboration and resources are essential.     

Street-level policing in the Downtown Eastside of Vancouver, Canada, during the 2010 Winter Olympics

BackgroundPolice presence within street-based drug scenes has the potential to disrupt injection drug users’ (IDUs) access to health services and prompt increased injection-related risk behaviour. We examined street-level policing in the Downtown Eastside (DTES) of Vancouver during the Olympic Winter games, to assess the potential impact on access to harm reduction services and injection-related risk behaviour.MethodsWe analysed data from observational activities documenting police and drug user behaviour, unstructured interviews with drug users in street settings (n = 15), expert interviews with legal and health professionals (n = 6), as well as utilisation statistics from a local supervised injection facility (SIF).ResultsAlthough police presence was elevated within the DTES during the Olympics, there was little evidence to suggest that police activities influenced IDUs’ access to health services or injection-related risk behaviour. SIF attendance during the Olympics was consistent with regular monthly patterns.ConclusionPolice presence during the Olympics did not reduce access to health services amongst local IDUs or prompt increased injection-related risk behaviour. Increased cooperation between local law enforcement and public health bodies likely offset the potential for negative health consequences resulting from police activity.     

Consumer and treatment provider perspectives on reducing barriers to opioid substitution treatment and improving treatment attractiveness

In New Zealand approximately 4600 people receive opioid substitution treatment (OST) for opioid dependence, primarily methadone maintenance treatment. This study explored ways in which OST could be improved, given the significant waiting times for treatment. Two parallel surveys were conducted: 1) peer interviews with 85 regular daily or almost daily opioid drug users (51.8% receiving OST, 18.8% not currently receiving OST, and 29.4% never received OST) and; 2) a census of all 18 specialist OST service providers. When asked how OST might be improved, the four categories most commonly cited by the opioid users were 'better treatment by staff', 'more flexibility', 'better takeaway arrangements', and 'decreased waiting time'. Both opioid users and specialist services rated 'restricted takeaways' and 'having to go on a waiting list' in the top three perceived barriers to OST. Almost all services reported significant resource issues and barriers to the transfer of stable clients from specialist services to continuing treatment in primary care. The findings from this study indicate how OST can be made more accessible and attractive and thus achieve better uptake and retention.     

Scotland's National Plan on Alcohol Problems

Aim: The Research Outcome Study in Ireland (ROSIE) is the first large-scale, prospective, multi-site, drug treatment outcome study in Ireland.

Method: Using a structured questionnaire, the substance use, health, crime and social problems of 404 opiate users were assessed at treatment intake (6 months, 1 year and 3 years later).

Findings: While the majority of study participants were opiate users, poly-drug use was the norm (76%, n?=?308). Most participants had a history of injecting drug use (77%, n?=?308), however only 42% (n?=?170) reported injecting in the preceding 90 days. Participants reported a range of mental and physical health complaints and extensive contact with social care services. High crime rates were observed. Analysis revealed differences in the characteristics and substance use of participants across treatment modality.

Conclusions: The range and severity of problems affecting individuals commencing treatment for their problem drug use highlights the complex needs of the cohort. These problems create substantial costs for providers of social care services in Ireland and can affect treatment outcomes.     

临床药师参与心血管内科临床治疗实践的回顾性研究及思路探讨

目的 研究和探讨临床药师在心血管内科开展药学服务的类别和内容,为药师参与临床治疗提供思路。方法 通过统计临床用药干预建议的类别及接受率,结合病例分析临床药师参与临床工作的内容与方法。结果 临床干预建议中,非专科用药干预建议略多于专科用药,分别占53.5%和46.5%;其中非专科用药接受率比专科用药略高,为90.8%。结论 临床药师应掌握专科主要病种的治疗药物,熟悉常见合并症非专科治疗用药的使用方法,具备良好的沟通技能,以便为临床提供多种形式的药学服务,促进药物应用更加安全、有效。     

A case-linkage study of comorbidity in mental health and substance misuse care populations

This study examines the total comorbid care 'care population' for one geographical area. It identifies the extent of (often unrecognized) shared care between coterminous 'care populations' in the context of the extent of assessed need and so identifies the gap between need and service provision. The study combined anonymized data for the total secondary mental health care population and all six substance misuse agency populations within one health authority population (N = 646,239) over three years, to identify shared 'dual agency' comorbid client groups (all mental health agency clients receiving specialist substance misuse treatment and vice versa). Of the total population of drug agency clients (N = 1206), 28% had received mental health services, and of alcohol agency clients (N = 1476), 39% had received mental health services. For a total mental health population (N = 19,029), 2% had received specialist drug services, and 3% alcohol services. These figures are compared to previous estimates of assessed need in treatment populations to identify gaps in service provision. Two thirds of 'dual agency comorbid' clients were male, 40% had attended Accident and Emergency (A&E) and half had been mental health in-patients. Mental health/drug agency populations were younger and mental health/alcohol agency populations received more mental health services.     

A comprehensive package of support to facilitate the treatment of problem drug users in primary care: an evaluation of the training component

Since the early 1980s, government policy documents and specialist reports have encouraged the involvement of general practitioners (GPs) in the treatment of problem drug users. In spite of such policy initiatives, their involvement has been patchy and slow. In response to this apparent reluctance, the London Boroughs of Brent and Harrow established the substance misuse management project (SMP) to support and train GPs in the management of substance misuse. The SMP is a GP-led project that provides ongoing support, shared-care protocol, primary care team training, treatment audits and financial reimbursements. In 1996, the SMP worked with GPs who were not currently involved in treating problem drug users, and those who were providing only minimal interventions. This paper evaluates the training and support given to these GPs and examines changes in their practice. A pre- and post-test survey was undertaken of GP knowledge, attitudes and levels of activity. A structured questionnaire was administered to all GPs before training (n=40) and re-administered between 6 and 9 months following training. SMP audit data were also reviewed to validate any reported changes in practice. All GPs initially reported insufficient knowledge to manage problem drug users. One-fifth were unaware they could prescribe methadone, and nearly half believed drug problems should be treated by specialist services. Post-training, the GPs had increased their levels of treatment activity and reported greater confidence and willingness to treat. This study demonstrates the potential to involve GPs in the treatment of problem drug users. The training was part of a package that included ongoing support sessions, team training, audits of treatment and financial reimbursements. It is proposed that, whilst training is a necessary condition, a more comprehensive package of support is needed to facilitate the treatment of problem drug users in primary care.     

Cost of Outreach for HIV Prevention Among Drug Users and Youth at Risk

SUMMARY

Economic evaluation has become an increasingly important component in determining the effectiveness of HIV prevention programs. One type of intervention that governmental and nongovernmental organizations have supported to prevent the spread of HIV is outreach. We conducted a cost analysis at eight sites that provide outreach services to two populations at high risk for HIV infection: injection drug users and street youth. We assessed the potential benefit of HIV prevention through outreach services by comparing outreach costs with the medical costs of treating an HIV infected individual.

The average cost of outreach services was $13.30 per contact. The cost per contact for services to street youth was 78% higher than for drug users. Comparing the cost per contact with HIV treatment costs, if only two in 10,000 contacts reduce their high-risk behavior so as to avoid transmission of HIV, outreach would yield a net benefit. These results provide evidence that outreach programs compare favorably to other HIV prevention strategies in terms of cost.     

Friends matter but so does their substance use: The impact of social networks on substance use,offending and wellbeing among young people attending specialist alcohol and drug treatment services

Abstract

Aims: The current study assesses the impact of youth drug treatment on substance use, offending and wellbeing in a sample of young people recruited from specialist youth alcohol and drug treatment. The paper examines the impact of treatment engagement on the size and substance use profile of the young person's social network and hypothesises that the best treatment outcomes are associated with maintaining the size of the young person's social network but changing its composition to reduce the representation of substance use in social networks. Methods: A cohort study of 112 young people (aged 16–21) engaged in specialist youth alcohol and drug treatment services in Victoria, Australia, were recruited at the beginning of treatment and re-interviewed six months later using a structured questionnaire. Findings: There were improvements in substance use, social functioning, mental health and life satisfaction from baseline to follow-up. While network size was associated with mental health and quality of life markers, only having a lower proportion of substance users in the social network was associated with lower substance use and offending at follow-up. Conclusions: Social networks are a key component of wellbeing in adolescence. This study suggests that through independent analysis of network size and network composition, both the size and the composition of social networks have an important role to play in developing interventions for adolescent substance users that will sustain behaviour changes achieved in specialist treatment.