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 Royal College of Psychiatrists – ASM(AI) 31 / Tystiolaeth gan Coleg Brenhinol y Seiciatryddion – ASM(AI) 31

Alcohol and Substance Misuse Inquiry

RCPsych in Wales supporting paper to the National Assembly’s Health and Social Care Committee Inquiry into Alcohol and Substance Misuse

Dr Raman Sakhuja, Consultant in Addictions Psychiatry

Chair of the Faculty of Addictions, Royal College of Psychiatrists in Wales

4 February, 2015

The Royal College of Psychiatrists is the professional medical body responsible for supporting psychiatrists throughout their careers, from training through to retirement, and in setting and raising standards of psychiatry in the United Kingdom.

The College aims to improve the outcomes of people with mental illness, and the mental health of individuals, their families and communities. In order to achieve this, the College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers and their organisations. Nationally and internationally, the College has a vital role in representing the expertise of the psychiatric profession to governments and other agencies.

The Royal College of Psychiatrists in Wales represents over 500 Consultant and Trainee Psychiatrists in Wales. We have over 100 Members who either work in Addictions or who have an interest in this area. Our Members are medically trained and possess a thorough understanding of both the human physical and mental condition. We are dedicated to improving the wellbeing of our patients and have campaigned for the parity of esteem, ensuring the mental health and physical health are given equal prominence because they are inextricably linked. We work closely together with a variety of other healthcare professionals with this common aim.

Main Points:

There are a number of key areas for concern:

1. The Landscape of Substance Misuse and Addictions is changing:

· There is now a higher ratio of alcohol to drugs referrals where previously we were treating more people for substance misuse

· There is a higher number of older people presenting with alcohol problems and prescribed medication dependence

· Other than older people, there has been an increase in the number of people being treated for addictions to prescribed medication, in particular medication for pain relief.

· Over-the-Counter medication misuse is on the rise and specialist services are getting an increasing number for treatment

· There has been an increase in the number of men using the services who are suffering from the side effects of steroid use.

· There is also an increase in the number of people accessing services for NPS (Novel Psychoactive Substances)

· Behavioural Addictions eg. Gambling Addiction remains unfunded and poorly recognised

· Although the landscape has changed, old funding arrangements are still in place and do not take this into account

· The current Welsh Strategy excludes Behavioural addictions and we would advocate Behavioural addictions to fall within a National Addictions Strategy as opposed to simply being one for chemical addictions.

· There is clearly a need for more training to meet the changing needs in our population along with resources

2. We must improve liaison psychiatry services in General Hospitals by ensuring that drug and alcohol workers are linked to the Emergency Department and Medical Assessment Units:

· There is a growing number of repeat attendees at hospital whose needs are not being met.

· We must develop skills in frontline staff to treat withdrawals

· Each hospitals must have pathways for patient care that flow between wards

· Staff need to seek advice from specialists and not simply dismiss those suffering from the side effects of alcohol and substance misuse (see point 9 and Stigma).

3. We must invest in an Alcohol Related Brain Damage Services in Wales:

· ARBD is a broad clinical cluster which is preventable and treatable If caught early, specifically the reversible damage, it is completely preventable and can result in full recovery. recovery.

· We need to determine the need in the current population. In our experience, the need is high and growing

· We must identify who these patients are. We need to recognise who in the NHS has responsibility for them. These people have an interaction with the Health service at various points and raising awareness, early identification and treatment- both general and specialist are important to tackle this health problem

· The number of ARBD services is growing in England and Northern Ireland.

4. The services are failing those who suffer from mental health problems and alcohol and substance misuse

· Alcohol and substance addictions are not classed as mental health problems. Community Drug and Alcohol Teams therefore do not fall within the Mental Health (Wales) Measure.

· Those being treated by CDATs who require primary care mental health support experience even longer waits to receive psychological therapies compared with those who come under the Measure as they take a different and more difficult pathway to get treatment.

· Psychological therapises for co- morbid conditions such as PTSD have an evidence base now and this cohort does not have access to evidence based interventions at present. There is need for increasing access to these therapies.

5. There is sufficient evidence to show that the introduction of a Minimum Unit Pricing of alcohol will improve public health, including public mental health

· We endorsed the Welsh Government proposals set in the Public Health Bill Consultation (2014) for introducing an MUP at 40p, to be reviewed over time.

· Minimum alcohol price is the most effective and selective mechanism to reduce heavy drinking and alcohol-related harm. The modelling suggests greater benefits are at a higher minimum price. The most recent report by the University of Sheffield for the UK and Scottish Governments estimates that a 40p per unit price will reduce deaths cumulatively by 5.4% per annum. A 50p price produces a 17.2% annual reduction and 60p price a 33.2% reduction.

· The estimated crime reduction at 60p (3.7%) is more than five times that at 40p (0.6%) (University of Sheffield 2012).

6. Area Planning Boards have interpreted Welsh Government Guidance differently, resulting in a lack of consistency of service delivery throughout Wales in effect creating a postcode lottery- further resulting in a lack of standardised approach to clinical governance

7. There are currently very few dedicated alcohol and substance misuse services for children in Wales

8. Invest in research into new interventions for people with addictions, including behavioural addictions such as gambling addictions.

· The only research that we are aware of is a joint project between RCPsych in Wales and Roehampton University on the increase in number of young people and gambling.

9. Reduce Stigma for those suffering with alcohol and substance misuse addiction.

· Although drinking is an intrinsic part of our society and widely acceptable, we must understand the dangers of alcohol and accept that those who suffer from alcohol addiction deserve treatment.

· Currently there is a stigma attached to having a substance misuse problem so many people’s conditions go untreated

· Clinician’s attitudes are often dismissive of those with addictions who do seek treatment for their physical health needs

· An addicted brain is a Chronic Brain Disorder and we would advocate an approach to dealing with Addictions (substance &alcohol misuse along with Behavioural Addictions) as a health issue and not a criminal issue.

Summary- Possible Solutions

1. Understanding the changing concepts and reviewing the strategy- encapsulating Behavioural Addictions and age spectrum.

2. Introduce Minimum Price for Alcohol.

3. National Destigmatising Campaign for general public and professionals- Repeat and using social media + face- to- face

4. Increasing resources-

- Training- All tiers of Healthcare, Social care and Criminal justice system- Raising Awareness, Understanding the Addicted Brain, Treatments available

- Training specialist services for tackling with changing landscape of Addictions

- Research- Increasing knowledge of Addictions, Early recognition systems, newer treatments

- Inpatient facilities within each HB.

- Liaison Services

- Access to Evidence Based Psychological therapies

- Specialist services for ARBD

- Funding specialist services within Health to cater to increased and changing demand

5. Integration of Services- Health and Services

6. Using specialism of Psychiatrists trained in Addictions to influence local and national service provisions

7. Training more Psychiatrists in Addictions and Mental Health

8. Standardising governance structures within APB and commissioning