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We welcome
the opportunity to give evidence to the Assembly Committee Inquiry
into Alcohol and Substance Misuse.
In Wales,
and across the UK, alcohol and drugs represent significant
challenges to both individual and public health. Users
of alcohol and other drugs are at risk of a number of serious
adverse effects; acute and chronic, direct and indirect, on
physical and mental health. Problematic use also results in
substantial social consequences for the individuals, their families
and the wider community and a significant burden on the NHS and
other social care and criminal justice services. The Welsh Strategy
for Substance Misuse ‘Working together to reduce harm’
incorporates both drugs and alcohol and as such this term will be
used to include both drugs where relevant in this submission.
The harm
reduction approach being taken in Wales in relation to substance
misuse is the right one. It is multi disciplinary and focused on
health. We wish to see it further developed in the following
ways:
- Primary prevention of substance misuse by the increased use
of powers and population-level interventions to reduce consumption
and prevent escalation to problematic use
–through
legislation including the introduction of minimum unit pricing for
alcohol, restriction of sales, taxing alcohol products at a
level proportionate to the volume of alcohol
- Early
engagement and the provision of credible, timely and tailored
information and advice for individuals who are consuming alcohol and/or other
drugs and experiencing harms to themselves or impacting on their
families, carers and the wider community
- Development of clear pathways for care
– from early or initial
contact with health and social services (for example ambulance,
police, primary care, youth services and clinical practitioners) to
specialist substance misuse services (from low threshold and
outreach community work through to clinical treatment)
- Adaptation of specialist substance misuse
services - to meet the needs of current and future alcohol,
drug and poly-drug users in a timely and accessible way.
Services are currently focused on treatment of one primary
substance be that alcohol or drugs. Services should further
adapt to address all substance misuse needs and poly-drug use and
wider social care needs.
2
The impacts of alcohol and substance misuse on people in Wales
Information from a number of sources in the
UK, including Wales, suggests that patterns of alcohol and
substance misuse have evolved considerably both across the
population as a whole and within specific vulnerable groups. These
include:
·
Access to, and experimentation with, a wider range of emerging and
illicit drugs, as well as prescription only medicines, particularly
amongst younger people and students, along with long term drug
users, including those who are homeless or in prison
·
Changes in patterns of alcohol consumption, with a move away from
drinking in community settings, e.g. public houses, to drinking at
home, which is less visible and less expensive. Pre-loading,
the consumption of alcohol and/or drugs at home before going out,
is not uncommon particularly amongst younger people and university
students
·
Increased identification of alcohol related brain damage in later,
or even earlier, middle age amongst problematic alcohol users
·
Increased poly-drug use in terms of alcohol and drugs, including
prescription only medication
There are also some research indicating that:
·
Young people are more inclined than ever before to drive under the
influence of drink or drugs and have higher drink and drug driving
rates than any other age group,
·
Older people are drinking more at home, in part to deal with
loneliness and social exclusion,
·
Pregnant women are drinking to excess risking harm to themselves
and their unborn child
·
‘Drunk walking’ on the way home from a night out is
placing people at risk of accidental harm or intentional harm by
others.
The impacts of these
changes, are reflected in terms of physical and mental ill-health.
This is evidenced by the rates of disease, hospital admissions,
self-reported substance use and mental well-being and drug and
alcohol related deaths:
- In 2013-14, 308
young Welsh residents (aged up to 24 years) were admitted to
hospital specifically due to alcohol and 503 due to drug use
although hospital admissions for substance misuse amongst younger
people are declining year on year.
- In terms of wider
social harms there were 4,935 of cases of children in need where
parental substance misuse (including alcohol misuse) was recorded
as the relevant parental factor, representing 25 per cent of
all cases of children in need in Wales. Children in care,
particularly those in local authority care, are more likely to
progress to later substance misuse than the general
population.1
-
In 2012, one in four motor vehicle drivers killed in traffic
collisions were over the drink-drive limit.
In 2013, there were 119 accidents where the reporting police
officer considered that a pedestrian(s) being ‘impaired by
alcohol’ was a contributory factor to that
accident.2 In relation to drug driving, it is reported
that, for every 5 accidents where the driver was impaired by
alcohol, there was around 1 accident where he/she was
‘impaired by drugs’, both illegal and
medicinal2. In addition, young drivers are more
susceptible to the effects of drink than older drivers and are more
likely to crash if they have consumed alcohol but are below the
drink drive limit.
-
Amongst older people hospital admissions due to alcohol remain
relatively stable year on year. However, hospital admissions for
drugs and referrals to specialist substance misuse treatment
services, for both drugs and alcohol are increasing within this age
group; a 15.8 per cent increase between 2009-10 and
2013-14.1 This represents a challenge to services
to best meet the needs of this ageing population.
Those who are homeless are particularly vulnerable both due to
existing substance misuse issues and to the risk of developing
problematic patterns of drug and alcohol use due to their
homelessness. Homelessness can and does affect individuals of
all ages including very young and older people. In terms of
prison and custodial settings, the crimes most prominently
associated with alcohol are those involving violence,[9]
including domestic violence.
As shown above, the harms associated with substance misuse are wide
ranging, complex and dynamic. As such, it is recommended that
efforts to improve primary prevention through increased powers to
reduce availability and secondary prevention to prevent escalation
to problematic use be explored. This should be undertaken
alongside adaptation of the range of organisations and
services designed to engage, identify and treat problematic drug
and alcohol use in Wales
3
Effectiveness of current Welsh Government policies and any further
action required
The current Welsh Government substance misuse
strategy for ‘Working together to reduce harm’, along
with specific policies to tackle the availability and harms
associated with substance misuse, both drugs and alcohol, have been
shown to be effective. This is evidenced by the decrease in
hospital admissions and deaths related to alcohol and drugs.
However, there is always more that can be done to:
·
Limit access and work to make alcohol and drug use less socially
acceptable
-
Prevent initiation to problematic use of drugs and alcohol
-
Identify and diagnose early signs of problematic substance
misuse
-
Provide timely and effective treatment for those with substance
misuse problems including pharmacological, psychosocial and
clinical care
The implementation of
the alcohol brief intervention (ABI) training by Public Health
Wales has ensured that both NHS and non-NHS staff are suitably
skilled to engage with individuals to identify potentially harmful
drinking patterns and encourage behavioural change. Over 7,000 such
staff have now been trained to deliver ABI across Wales, ranging
from military personnel to midwives. The Welsh Government has been
a key driver in the development of this programme.
The proposed
introduction of minimum unit pricing as policy in Wales is welcomed
as are the policies of reviewing fatal and non-fatal drug
poisonings and alcohol related deaths, to ensure that lessons
learned and recommendations may be implemented to reduce future
deaths.
The proposed Liver
Disease Delivery Plan should ensure that health boards are well
placed to prevent, diagnose and treat alcohol related liver disease
and hepatitis infection as a consequence of problematic substance
misuse, specifically injecting drug use.
In addition to these
existing policies, the following recommendations are made to
further tackle substance misuse:
- All alcohol products should carry a health
warning from an independent health regulatory body
- The sale of alcohol should be restricted to
specific times of the day
- The availability of uncontrolled new
psychoactive substances should be regulated
- Tax on alcohol products should be
proportionate to the volume of alcohol
- Licensing authorities should be further
supported to utilise existing powers to tackle alcohol-related harm
by controlling total availability in their area
- Alcohol advertising should be limited to
newspapers and other adult press while its content should be
limited to factual information. All advertising should
also contain a evidence-based
health warning specified by an independent
regulatory body and displayed at an independently regulated
size.
- The legal limit for blood alcohol
concentration for drivers should be reduced to 50mg/100ml. Scotland
has already taken a lead in this area, bringing them in to line
with mainland Europe.
- All health and social care professionals
should be trained to provide early identification and brief alcohol
and wider substance misuse advice
- People who need support for substance misuse
(drugs and/or alcohol) problems should be routinely referred to
specialist alcohol services for assessment and
treatment4
- Existing laws to prohibit the sale of alcohol
to individuals who are already heavily intoxicated should be
enforced in order to reduce acute and long term harms to their
health and that of the individuals around them
- Sanctions should be fully applied to
businesses that break the laws on under-age sales4
- Efforts should be made to implement Graduated
Driver Licensing (GDL) in Wales. The GDL programme has three main
components: a night time driving restriction, a passenger
restriction and a ‘zero tolerance’ on alcohol
consumption. This reflects the fact that young drivers are more
susceptible to the effects of alcohol than older, more experienced
drivers
We believe that a harm reduction and
health-centered approach is likely to be more effective than one
based on criminal justice. If Wales were to adopt legislation
prescribing health in all policies, this would be strengthened. We
believe this should be achieved through the Wellbeing of Future
Generations Bill with health included in its common aim.
4
Capacity and availability of local services to raise awareness and
deal with the impact of the harms
There are a wide range of services across
Wales with a remit to raise awareness and address the harms
associated with substance misuse including statutory health, social
and criminal justice organisations, third sector and private
organisations. The primary issue relates to the capacity of
services offered locally, rather than their range.
Local services across Wales are well placed to
raise awareness of the harms associated with both drug and alcohol
using knowledge of local trends.
However, existing substance misuse services
tend to be accessed once problematic alcohol or drug use is firmly
embedded rather than seeking support at earlier stages when
psychosocial and other treatments may be very effective in reducing
progression to severe harms. It must be recognised that there
remains a great deal of social stigma in relation to problematic
use of alcohol and/or drugs. As such individuals may be fearful of
association with specialist services, or even of discussing issues
with primary care practitioners, and therefore fail to engage with
these services. It is these types of issues that the ABI programme
aims to address, but there is much work still to be done.
Adapting services, based upon evidence of the
needs of the substance using population, in particular the needs of
vulnerable groups e.g. older people, would address this along with
increasing levels of expertise amongst the staff. In
addition, the development of a clear pathway to services would
support engagement and reduce harms.
Local services, including local authorities,
need to be supported by increased powers to reduce the
availability, promotion and problematic use of alcohol and
drugs. The introduction of policies to achieve this,
including minimum unit pricing, could support the individual and
societal change required if the harmful impact of alcohol and other
substances is to be addressed.
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