National Assembly for Wales / Cynulliad Cenedlaethol Cymru
Health and Social Care Committee/ Y Pwyllgor Iechyd a Gofal Cymdeithasol

Inquiry into alcohol and substance misuse / Ymchwiliad i gamddefnyddio alcohol a sylweddau

Evidence from Aneurin Bevan University Health Board – ASM 07 / Tystiolaeth gan Bwrdd Iechyd Prifysgol Aneurin Bevan – ASM 07

Aneurin Bevan University Health Board’s Submission to the National Assembly for Wales’ Health and Social Care Committee Inquiry into Alcohol and Substance Misuse

Introduction

1. The Aneurin Bevan University Health Board (ABUHB) covers the areas of Blaenau Gwent, Caerphilly, Monmouthshire, Newport, Torfaen and for specific services, South Powys. In the ABUHB area and across Wales substance misuse represent challenges to individuals, families, communities, health and social care services and criminal justice services.

Inquiry Term of Reference 1: The impacts of alcohol and substance misuse on people in Wales including young people and university students; older people; homeless people; and people in police custody and prisons.

2. As can be seen from the graph below, service user assessment by substance for all age groups indicates that alcohol is the greatest substance misuse issue for the ABUHB population.

Source: Welsh National Database for Substance Misuse (WNDSM) Services User Assessment Data for Substance Misuse Services in Gwent (2014)

3. There is specific evidence that an increasing proportion of people living in the ABUHB area are causing serious damage to their health through drinking too much alcohol.  Applying the most recent Welsh Health Survey results to the population estimate for Gwent, there are around 206,100 people (117,900 men and 88,200 women)  who are drinking more alcohol than is considered safe for their health on at least one day a week (PHW, 2014).

4. The Patient Episode Database for Wales (PEDW) data for 2012 clearly demonstrates that ABUHB has the highest rates for alcohol specific admissions as well as the highest rates of alcoholic liver disease admissions in Wales. 

5. The ABUHB hospital admission rates for diseases that are wholly associated with alcohol (alcohol specific) is significantly higher than the average for Wales and the ABUHB alcohol specific hospital admission rate for men is double the rate for women (PHW, 2014). 

6. Deaths from alcohol-specific diseases have increased over the last decade for both men and women living in the ABUHB area, although the death rate for men remains double the rate for women (PHW, 2014). 

7. Alcohol (specific and attributable) deaths are highest in the most deprived communities in the ABUHB area.   There is a paradox that a similar or slightly greater proportion of those people living in the least deprived parts of ABUHB drink above guidelines, but alcohol related deaths are highest in the most deprived communities (PHW, 2014).

8. The pattern of drug use continues to evolve throughout the UK: poly drug use and the use of New Psychoactive Substances (NPS) are growing.  Amongst young people, patterns of substance misuse are also becoming more complex – more presentations are now being seen in young people with evidence of physical dependence on alcohol as well as chaotic use of New Psychoactive Substances. Young people can also present with complex substance misuse. In addition to the drug/alcohol misuse there may be mental health issues such as ADHD, autistic spectrum disorder, depression, early psychosis etc.

9. Older adults can present with substance misuse. Evidence suggests that this is most commonly seen with alcohol misuse or misuse of prescribed/over the counter medication

10. Nearly all of the Homeless People in Gwent who are “sofa surfing” or “rough sleepers” are known to have enduring alcohol or drug problems: many have co-occurring physical and mental health problems and because of their chaotic lifestyle have exhausted or refused treatment options available to them.

11. Local data indicates that Gwent is experiencing a similar pattern of NPS to Wales. The number of people in Gwent presenting for assessment and/or treatment where the primary drug is classified as ‘other substances’ has risen gradually since 2009/2010 (WNDSM, 2014).  These might include substances not known at the assessment, or which are not in the drug list (i.e. classified under the Misuse of Drugs Act 1971), so could include NPS.

12. The age profile for NPS use in the Gwent area is similar to that of the rest of South Wales, the main users of NPS being teenagers and young people.  It is recognised that the effects of drug use are more pronounced amongst socially excluded groups and in the most deprived communities.

13. NPS use nationally has become increasingly associated with the risky behaviour of injecting the substances, which has been a factor in a number of drug related deaths and a related increase in Blood Borne Virus (BBV) prevalence. 

14. There is also a high prevalence rate locally of the use of Steroid and Image Enhancing Drugs, which is illustrated by the fact that approximately half the needles that are issued at local Needle Exchanges are for that purpose.

Inquiry Term of Reference 2: Effectiveness of current Welsh Government policies on tackling alcohol and substance misuse and any further action that may be required  

15. ‘Working Together to Reduce Harm’ (WG, 2008), the current Welsh Government Substance Misuse Strategy for Wales, provides an effective national tool for addressing all of the essential areas of focus to reduce harm from substance misuse in Wales:

16. — Preventing harm.

17. — Supporting substance misusers - aiding and maintaining recovery.   

18. — Supporting and protecting families.

19. —Tackling availability and protecting individuals via enforcement activity.   

20. Welsh Government promotion and investment in harm reduction initiatives within the substance misusing communities that are stipulated in the ‘Substance Misuse Treatment Framework Health and Wellbeing Compendium’ (WG, 2013) has been a very positive step, resulting in key priorities for service delivery such as the Drug Related Death Review process, which has encouraged the investigation of fatal poisonings and resulted in the ‘Take Home Naloxone’ initiative.

21. The Welsh Government’s Blood Borne Virus (BBV) Strategy, which is designed to increase testing, vaccination and treatment for BBVs, has been welcomed by all services providing care for substance misusers.

22. The Liver Disease Delivery Plan provides many commendable recommendations which will be of great public health value, including recommendations designed to reduce BBVs and alcohol misuse.

23. The advocacy in the Liver Disease Delivery Plan of Alcohol Liaison Nurses has been particularly welcomed as a help in dealing with all of the patients suffering from alcohol specific diseases in the secondary care setting.  

24. The roll out of the Public Health Wales ‘Have a Word’ (ABI) training has proved effective in ensuring health and social care practitioners are suitably skilled at engaging with individuals to identify hazardous and harmful drinkers and encourage positive behavioural change.

25. There is extensive international evidence on interventions which have the greatest impact on tackling alcohol: making alcohol less affordable (as consumption is price sensitive), less available and accessible (as these are linked to consumption) and less attractive (through strengthening current marketing regulations).  We support the introduction of the  Welsh Government Public Health Bill in 2015 which is advocating the implementation of a 50p Minimum Unit Price (MUP) for alcohol, as there is evidence to prove that  consumption of alcohol is price sensitive (WG, 2014).

26. The appointment of the Local Health Boards as a responsible authority has the potential to exert a positive effect on local licensing decisions.

27. The establishment of Area Planning Boards (2010) has been a positive thing as this provides the structure for the collective responsibility and engagement of the key agencies of police, probation, social care, health and the third sector to ensure all aspects of the agenda are taken forward in a joined up and effective approach.

Further action that we would recommend at a governmental level:   

28. — Advocate for protection of Public Health as the fifth objective in the Licensing Act in England and Wales.

29. — Support actions to implement policies that make alcohol less accessible, less available and less attractive to the public. 

30. — Reduce the legal limit for blood alcohol concentration for drivers to 50mg/100ml.

31. — Provide leadership on the prevention/education agenda in Wales to ensure that evidence based and standardised best practice is used nationally for all information communicated in campaigns and educational programmes for all target audiences both public and professional (a national communications strategy).

Inquiry Term of Reference 3: The capacity and availability of local services across Wales to raise awareness and deal with the impact of the harms associated with alcohol and substance misuse 

32. Substance misuse is a wide ranging problem affecting all ages and all areas of society. Although there is evidence that certain groups have higher prevalence (e.g. younger males in deprived areas) it is by no means exclusive to those groups. Over many years government policy, with regard to treatment provision, has been directed at this ‘typical’ user. This has, however, left many others either without access to services or with the option of attending services they find unacceptable e.g. older people.

33. Local services are well placed to raise awareness of substance misuse as they have local knowledge but would benefit from a national lead on substance misuse prevention and education rather than seven Welsh Health Board areas providing ad hoc responses.

34. The commissioned services and statutory services have a good history of working together to provide good substance misuse services for the population of Gwent. However, it is now apparent locally that greater provision needs to be made in the health sector for an increasing range of substance misusers who have complex clinical issues as they will require experienced clinical care.

35. More presentations are being seen in young people with evidence of physical dependence on alcohol as well as chaotic use of NPS.

36. In Europe and the UK it is predicted that the number of people over 65 with a substance misuse problem will more than double from 2001-2020 (European Monitoring Centre for Drugs and Drug Addiction, 2008). However, in most instances the use of substances in this age group remains undetected. Individuals do not present with it, professionals do not ask about it and addiction services are not geared to deal with it. Treatment regimes for older adults (e.g. alcohol detoxification) require alteration to deal with declining liver function with age and the presence of multiple co-morbidities but only specialist prescribers have the expertise to manage this. With the reduction in NHS addiction service provision (and with fewer consultants in addiction), this expertise is not always available.

37.  Individuals with serious mental health problems are increasingly presenting with additional substance misuse issues. It has been estimated that up to 75% of drug using patients have a mental health problem (Scottish Advisory Committee on Drug Misuse, 2003) and Community Mental Health Teams report that 8-15% of patients have co-occurring substance misuse problems   (Department of Health, 2002). Their use often exacerbates their mental illness and vice versa. In addition, the risk of suicide in drug users is twenty times higher than for the general population (Appleby et al 1999). Engaging these individuals can be quite difficult and very often assertive approaches are required. Standard treatment services are often not commissioned to take such an approach and may not have the expertise of staff to deal with the complex interplay of morbidities.

38. Physical ill health can also present alongside addiction issues. In some cases this is a direct result of the addiction (e.g. cirrhosis in alcohol dependent patients) and in others, incidental. Prescribing in these patients requires specific knowledge and expertise around the potential for drug interactions and the potential for exacerbating the physical illness.

39. In some cases patients may become addicted to medication prescribed to treat a physical illness. For instance there is a growing recognition in Wales of the problem of addiction to prescribed opiates in chronic pain. Treatment requires knowledge of a range of potential management strategies outside of the standard addiction service tool bag. Treatment also requires close working between addiction services, pain teams (where they exist), primary care and the patient themselves. These patients are often not the ‘typical’ service user and may find the traditional set up of drug treatment services difficult to engage with. As a result they may drop out of treatment.

40. Alcohol Related Brain Damage is a growing issue and more patients are being referred to alcohol treatment services because these patients fall between the gaps in other services (e.g. memory services, neurology). Performing detoxification processes in these patients, as with alcohol dependent patients with other physical health issues, requires considerable clinical support and again, these services have often not been considered in Wales.

41. The ABUHB welcomes the Welsh Government recommendation for the provision of Alcohol Liaison Nurses to help with their overstretched workloads caused by alcohol misuse locally. The Health Board will seek to develop this resource as soon as resources can be identified.