The lockdown may be having a disproportionate effect on female service users, warns Gordon Hay.

The coronavirus pandemic and the subsequent lockdown impacts on all society, and is likely to be impacting more on groups such as those in contact with drug or alcohol services. Research studies are being launched to explore how COVID-19 and lockdown impact on people who use drugs, and there is a wider discussion about how levels of alcohol use within the general population have changed over the last few months (DDN, May, page 5) and issues such as the relationship between domestic abuse and alcohol use during the current crisis. While new research studies are being set up, existing monitoring and surveillance systems can quickly be augmented to highlight emerging issues facing those in contact with drug or alcohol services.

The Public Health Institute at Liverpool John Moores University has, since 2013, hosted the Integrated Monitoring System (IMS) which records activity at a range of primarily low-threshold drug and alcohol services across Merseyside and Cheshire. Just as the UK entered lockdown, six additional questions were added to the monitoring system to enable services and commissioners to identify additional issues facing their clients.

As services were not mandated to ask the additional questions, the numbers are relatively small but large enough to highlight the impact of gender. Two months from lockdown, emerging findings from 1,435 contacts with services involving 468 clients suggest that female clients are impacted more than males. Overall, very few clients (about 1 per cent) report concerns about having symptoms of coronavirus. Interestingly, only a similarly small amount reported problems accessing medicines, healthcare or harm-reduction supplies – however this finding is unlikely to be representative of all people who use drugs or have problems with alcohol, as the monitoring is being undertaken in healthcare, particularly harmreduction, settings.

More clients report difficulties in social distancing and accessing basic needs such as food. While social distancing was reported as an issue for 22 per cent of female clients, only about 10 per cent of male clients reported difficulties. For accessing basic needs, 6 per cent of female clients as opposed to 2 per cent of male clients reported issues.

Changes in the clients’ alcohol, drug or tobacco use were explored. Although it cannot be assumed that any changes are increases or decreases, 15 per cent of female clients reported a change compared to 6 per cent of male clients. While all of these differences are seen to be statistically significant, the starkest gender difference occurred when considering mental health, with 23 per cent of female clients reporting that their mental health had been affected by the current environment, compared to 10 per cent of male clients.

Research typically shows that women who use drugs face additional challenges, for example the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) suggests that women are particularly likely to experience stigma and social disadvantage and to have less social support. They may be likely to come from families with substance use problems and have a substance-using partner, have faced Adverse Childhood Experiences (ACEs) and may have co-occurring mental disorders.

The emerging information from this monitoring system is not a replacement for more detailed research, as we can only highlight that there are differences and would only be able to speculate on why these differences are occurring, and research is needed to examine why females are experiencing lockdown differently to males. Those working in drug and alcohol services, and commissioners of these and similar services, should be alert to any additional difficulties faced by female clients and seek to explore them in more detail during contacts with female clients.

Gordon Hay is a reader at the Public Health Institute, Liverpool John Moores University

This article was first published as an emerging research article in Drink and Drugs News (DDN).

In this blog researcher Lisa Jones describes the findings of a new rapid review that examines alcohol’s contribution to intimate partner violence.

Heavy alcohol use contributes to a range of significant harms to people other than the drinker themselves. In intimate relationships, harms associated with a partner’s alcohol use may range from minor incidents to those with more severe impacts, including violence. Violence occurring in the context of intimate relationships is commonly referred to as intimate partner violence, although other terms in use include domestic abuse and domestic violence.ly.

If I remember back to my own secondary school years in the late 1980s and early 1990s, we didn’t receive anything that could be considered evidence-based prevention. On one occasion, a local church group came into our class and informed us that all drug use leads to disaster and that it was only a matter of time after taking our first LSD tab that we would be jumping out of windows or putting our head in a jet engine (!). Even today I hear of drug education and prevention approaches that still rely on these fear arousal tactics, that make the assumption that all drug use leads to harm, or that we just need to give recipients ‘the facts’ in order to help them make healthy choices.

In this blog, we describe the findings of our rapid review that examined alcohol’s contribution to intimate partner violence.

Globally, intimate partner violence is the most common form of violence perpetrated against women. Although women may also perpetrate violence against their male partners, women are more likely to experience sexual violence, severe physical violence and to be murdered by their male partner. Intimate partner violence can also occur in the context of lesbian, gay, bisexual and/or transgender relationships, but it is currently difficult to be certain about prevalence.

Studies consistently show an association between alcohol use and intimate partner violence and that women are at a higher risk of having physical violence perpetrated against them by a partner who has been drinking than men are. Although the vast majority of drinkers will not experience violence in their relationships, high rates of heavy drinking are found among perpetrators of intimate partner violence, and compared to men in the general population, higher rates of men in substance use treatment have perpetrated violence against an intimate partner.

We found that there are different ideas and explanations about how and why alcohol use is linked to intimate partner violence. Alcohol does not work alone as a cause of violence in intimate relationships, and is linked via its interaction with a range of factors. Some are related to the individual, such as their personality traits or experiences of adversity in childhood; others are to do with how alcohol affects the dynamics of the intimate relationship; and others are environmental, such as how society views drunken behaviour and how our drinking culture may reinforce (and even ‘excuse’) the links between men’s drinking and violent behaviour in general. The physical and cognitive effects of alcohol also play a role.

Our rapid review also looked at the evidence for what might effectively address the links between alcohol and intimate partner violence. A public health (or whole population) approach views alcohol-related intimate partner violence as a preventable consequence of alcohol and its interaction across the individual, relationship and environmental factors identified. Within a public health approach, policy and interventions that target the whole population, such as measures that reduce the availability or increase the price of alcohol, are thought to be the most effective and efficient way of tackling the problem. Minimum unit pricing, for example, has been predicted to impact on intimate partner violence as an extension of its effect of reducing alcohol use among would-be perpetrators.

However, the high prevalence of intimate partner violence perpetration amongst men receiving substance use treatment also highlights the need to address the problem among groups of individuals at risk of intimate partner violence and amongst those who are already involved. Integrated interventions, which alongside treating heavy alcohol use concurrently address perpetration of intimate partner violence, have been proposed as the best solution. We found, however, that few studies have been undertaken and that we need more research to develop the evidence base.

Bringing the evidence together through this rapid review has revealed the complexity of the relationship between alcohol and intimate partner violence. Overall, we concluded that we urgently need more research to help develop our understanding of the various factors that link alcohol use to intimate partner violence. We also need more in-depth research with men and women who have experienced violence in their relationships to better understand the impact across different types of drinking behaviours and the different forms of intimate partner violence.

Our rapid review also identified that we are some way off being able to develop clear recommendations for policy and practice on tackling this issue. However, we suggest that future policy actions on this topic acknowledge the complexity of the relationship.

We also called for the further development and evaluation of integrated interventions to address the high rates of intimate partner violence perpetration among men accessing treatment for problems with their alcohol use. This is currently the focus of a National Institute for Health Research funded research programme, ADVANCE, led by one of our rapid review co-authors.

Read the rapid evidence review

This article was first published as a guest blog for Alcohol Change UK.

I’ve been researching and working in the drug prevention and education field for about 15 years, and have been lucky to meet many dedicated people working in policy and practice both in the UK and internationally. My research has looked at what kind of approaches are effective, and knowing this, how we might best deliver and implement support for those who need it. I’ve also been fortunate to have been involved in a lot of national UK and European policy work as well, where I’ve been able to promote evidence and science based approaches, and advocate for prevention in strategies to promote health and social development. This has sometimes been difficult, as the prevention and education field sometimes attracts people and organisations who have very good intentions but who might not appreciate that prevention is difficult to ‘get right’. If done badly, some approaches can actually increase harm, whether through directly increasing risk, or indirectly through wasting scarce resources that could have been spent on approaches we know can help.

For me, prevention activities are justified on the basis that they serve to protect health and promote healthy development – the fact that drug prevention also concerns illegal behaviours is irrelevant to me. Prevention activities are all around us, and are not just delivered in the classroom. They can include those approaches that aim to improve health and social decision-making more generally, and foster positive social relationships between participants and protective family, community, and social structures. This means that discussions of drug prevention are sometimes also political discussions, and we should be willing to challenge politicians and decision makers when we feel that their policies are creating the conditions that make drug use, and harms from drug use, more likely.

If I remember back to my own secondary school years in the late 1980s and early 1990s, we didn’t receive anything that could be considered evidence-based prevention. On one occasion, a local church group came into our class and informed us that all drug use leads to disaster and that it was only a matter of time after taking our first LSD tab that we would be jumping out of windows or putting our head in a jet engine (!). Even today I hear of drug education and prevention approaches that still rely on these fear arousal tactics, that make the assumption that all drug use leads to harm, or that we just need to give recipients ‘the facts’ in order to help them make healthy choices.

An unhelpful distinction is also sometimes made between drug prevention and harm reduction approaches, particularly for young people. Some people have argued that harm reduction is incompatible with prevention – but I disagree. I think this is a throwback to those assumptions underlying my experiences of prevention at school; that prevention should be focused on abstention at all costs. To be clear, not using substances or delaying substance use for as long as possible reduces the risk of harm, but prevention is just one component of a series of responses to substance use, and this also includes treatment, recovery, and harm reduction. Harm reduction approaches don’t necessarily seek to prevent drug use, but aim to reduce the adverse consequences of use if people do decide to use drugs. So this might include practical strategies such as breaking up an ecstasy tablet and only taking a small part of it, or giving advice and information about keeping safe and looking out for friends. But this is seen as controversial to some people, because it suggests that we are giving our approval for people to break the law and to put their health at risk by taking drugs.

In the public health field we talk about a concept called ‘proportionate universalism’, and applied to drug prevention this means that everyone can potentially benefit from education and support, but more specialist and intensive activity might be needed for those people at greater risk of harm. So in schools, for example, all pupils can benefit from universal activities delivered through relationships, sex and health education, or through structured programmes such as Unplugged or SHAHRP. Those groups of people who might be more likely to use drugs, whether because of leisure choices (e.g. active participants in nightlife) or other factors (e.g. involvement with youth offending teams), or who might already be using drugs, benefit from what we call selective approaches. Similarly, individuals screened at a higher risk of drug related harms because of particular personality or behavioural factors, benefit from what we call indicated prevention actions. For each of these categories of activity, the types of work delivered and the aims and outcomes of prevention will be different. In universal approaches, the aim is to prevent the onset of substance use completely, or for as long as possible. These are still important aims for selective and indicated prevention, but because participants might already be using substances then prevention might instead aim to stop their use becoming more regular, or to persuade them to use less frequently and to eventually stop use. We can begin to see here why harm reduction approaches might also be useful. For those young people who have chosen to use drugs and want to continue their drug use – despite our advice – harm reduction approaches might be more appropriate, as the priority in the first instance is to reduce the risk of immediate harm.

I still think we need to be cautious about harm reduction approaches. We need to make sure that all activities are age appropriate and relevant to the experiences of participants. Despite media headlines suggesting otherwise, only a minority of young people use substances and so more traditional prevention and educational approaches are still the most appropriate approach for most young people. In keeping with my criticism of those prevention approaches that are just based on ‘good intentions’, we also must be honest about harm reduction, as we still don’t know a great deal about the impact of many approaches in young people and if they are even effective. Someone might be provided with lots of advice and information about drugs, but that does not necessarily equip them with the skills to apply that information to their own particular circumstances. This is why the solid foundation provided by good drugs education and prevention is important, because these focus on developing core health decision making skills and behaviours, upon which any harm reduction advice can be built.

This article was first published as a guest blog for mentoruk.org.uk.

On November 1, 2018, the UK changed the law on medicinal cannabis. Medicinal cannabis products were moved from schedule 1, meaning they have no medicinal value, to schedule 2, which allowed doctors to prescribe them under certain circumstances. This change to the Misuse of Drugs Regulations 2001 was partly a response to a rapid evidence review commissioned by the Home Secretary for the Chief Medical Officer, which concluded that some medicinal cannabis products were effective for some medical conditions, and formal advice from the UK government’s Advisory Council on the Misuse of Drugs to change the schedule.

Perhaps a more powerful driver of the rescheduling was a well-organised publicity campaign that received public support due to a compelling and difficult-to-challenge emotional narrative of sick children, the use of confrontational tactics, large financial backing, and privileged access to national media and senior politicians. But did this wave of media publicity and public support lead to unrealistic expectations about accessing medicinal cannabis?

Difficult to access

Since rescheduling, many NHS patients have been frustrated by what they see as a slow and bureaucratic system that has denied them access to cannabis treatments. Formal figures are not available but the number of NHS prescriptions since rescheduling is low – perhaps less than 100.

Difficulty accessing medicines on the NHS is not unique to cannabis, as seen with other medicines in the news, such as expensive chemotherapies and Orkambi for cystic fibrosis. Drugs available on the NHS are often a source of great controversy and provoke discussion about the affordability of medicines, their effectiveness and the ethics of providing or denying access to particular patient groups. Rescheduling to allow prescriptions on the NHS means that cannabis products are now also subject to the same types of debate.

Some cannabis medicines are available to patients regardless of the rescheduling decision. These are products developed by pharmaceutical companies and have been formally licensed for use in the same way as other medicines. Sativex is licensed to treat multiple sclerosis, and Epidiolex is undergoing a licensing review and is expected to be approved for treating severe forms of epilepsy.

However, rescheduling means that herbal cannabis and cannabis oil preparations that have not gone through this formal licensing process can now also potentially be prescribed as medicines. Although some of these products are manufactured to a high standard, they have not been formally licensed as medicines. Hence, while these are the types of products that people in the media spotlight, such as Billy Caldwell, have been using, many doctors resist prescribing them.

In other countries where medicinal cannabis has been available for longer and is more widely prescribed, special regulatory systems have been developed to oversee access. In the Netherlands, for example, the national Office for Medicinal Cannabis, part of the Ministry of Health, regulates a system where people under the care of their family doctor can access a prescribed unlicensed herbal cannabis or cannabis oil product from an authorised provider through their pharmacist.

In the UK, a dedicated medicinal cannabis regulatory system doesn’t yet exist and patients can only access cannabis under a system designed for traditional medicines. This was partly because the decision to reschedule cannabis was taken so quickly, but also to allay fears that cannabis products would be diverted to the recreational market.

While NHS England and professional associations have published guidelines for doctors on prescribing medicinal cannabis, these are cautious and reflect the uncertain evidence.

Cannabis products which have yet to be formally approved as medicines are only available on the NHS under what are known as “specials”, and only after other types of treatment have been tried. Only consultants can prescribe these specials and many of them don’t think cannabis is as effective as existing treatments.

Several NHS Trusts have also refused to pay for cannabis treatments, even if prescribed by a consultant, as they are not convinced they provide good value for money for the NHS. Patients can still get private medicinal cannabis prescriptions from a consultant, as they can with any other medicine, but this creates unequal access based on the ability to pay.

Cannabis medicine is a new area of therapeutic practice, so regulatory systems need to be carefully developed and fine-tuned, new cannabis medicines have to be licensed, healthcare providers need to be trained and prescribing guidelines need to be formalised. Definitive clinical guidance on these medicines is expected from NICE in October 2019. This will help to clarify and standardise clinical decisions on prescribing. But for many patients, this might be too long to wait, and it is possible that the guidance may even conclude that there is limited use for medicinal cannabis products in the NHS.

Conflicts of interest

Perhaps the biggest winners from medicinal cannabis rescheduling will be early financial investors (including the tobacco industry) who seek to capture a growing market and who have supported campaigning groups and private medicinal cannabis clinics. As the UK medicinal cannabis market matures, awareness of conflicts of interest need to be made more apparent.

In light of perceived barriers to access, provocative and well-publicised patient actions designed to evoke public sympathy and a response from ministers have continued. In impassioned parliamentary debates, MPs have called for patient access to medicinal cannabis to be prioritised over formal evidence that they are effective and affordable medicines. They have also direct criticised professional clinical bodies that are perceived to be blocking access to these products. However, reactive decisions based on a fear of bad headlines do not lead to good policy.

It is important that the proper regulatory development process is allowed to proceed. The UK needs a medical cannabis system that is responsive to patient needs but also one that is palatable to regulators and conforms with medical practice and standards. Otherwise, progress in this important field will stall.

This article was first published in The Conversation.

Gabapentin and pregabalin, two widely used prescription drugs, are now subject to increased controls in the UK, which means they are now reclassified as class C controlled substances.

These drugs are licensed to treat epilepsy, anxiety, peripheral and neuropathic pain (pain caused by damage or injury to the nerves), but they are known to produce feelings of euphoria, calmness and relaxation. It is this mixed profile of effects that has contributed to their wide use. But these drugs can also have serious side effects, especially when combined with other drugs – and have been associated with use of illicit street drugs.

Under the new classification, prescribers can no longer issue electronic prescriptions – they will have to be handwritten. It is also now illegal to possess these drugs without a prescription, and it is illegal to supply or sell the drugs to others.

The Advisory Council on the Misuse of Drugs (ACMD), the government’s independent scientific advisers, alerted the Home Office to a growing illicit market and the potential harms these drugs were causing. A 2016 ACMD report into these type of drugs highlighted that prescriptions for pregabalin had increased by 350% in the preceding five years and by 150% for gabapentin.

Although not as popular as other illicit drugs, there were particular concerns about their use in prisons, where there was a high number of prescriptions, as well in some parts of the UK such as Northern Ireland. Accompanying this was an alarming rise in deaths associated with their use.

One reason these drugs are particularly harmful is through the practice of combining them with other drugs to amplify the desired effects. For example, using gabapentin and pregabalin with heroin can increase their euphoric effects. Unfortunately, this also increases the risk of harm, as the combination has an can create breathing difficulties and reverse the tolerance that the body may have built up against heroin’s effects on breathing. This increases the risk of respiratory failure, which underpins many heroin overdose deaths.

The potential misuse of gabapentin and pregabalin has been known about for some time, but the challenge has been how to respond and reduce harm. This is not the first prescribed medication to be reclassified in this way. Tramadol, a synthetic opiate, was made a class C drug in 2014. The circumstances leading up to this change were very similar to the concerns relating to gabapentin, namely an increase in prescriptions, which was accompanied by a rise in fatalities.

Since the reclassification of tramadol, deaths have fallen as have the number of prescriptions. By this measure, it would appear that the reclassification decision for tramadol was a success. Unfortunately, it’s not that straightforward.

Shifting use

Banning or restricting the supply of drugs, whether they are legal or illegal, can produce unintended consequences. One of these is displacement, where tightening up access to one substance shifts use onto another.

It is possible that this has happened with tramadol given the rise in use of gabapentin and pregabalin – as it became harder for people to obtain, they found gabapentin and pregabalin easier to get hold of, so they became desirable alternatives. This suggests that the new restrictions on gabapentin may move the problem onto another drug, although it is likely that it will be the same group of higher risk people who are most affected. The problem is we don’t know which drug that will be, and we are unlikely to find out until the same prescribing and mortality data provide fresh information.

When we are assessing the impact of changes to drug laws, we shouldn’t solely focus on what happens to the harms associated with the drug that is banned but whether the total burden of harm from all drugs has been affected. Data showing a very high level of drug-related deaths and hospitalisations suggests that we are failing to make much of an impact.

Most people who use these drugs know the risks they face, so thinking we can simply educate or arrest our way out of this problem is unlikely to be successful. People are often attracted to using these drugs to alleviate a range of problems beyond the physical, they are often trying to mitigate psychological pain and social problems.

Accessing support for such issues has become increasingly difficult. Treatment services have faced budget cuts that restrict their ability to respond quickly. Little surprise then that people turn to drugs that have no waiting lists, can be accessed 24 hours a day and where dealers don’t ask intrusive questions.

This article was first published in The Conversation.

Britain seems to be slowly changing its relationship with alcohol, according to new data from the Office for National Statistics (ONS). Although alcohol continues to be heavily marketed and advertised, the number of people who are teetotal has risen sharply since 2005. Around one in five adults (about 10.4m people) now abstain from alcohol.

Even among those who do drink, fewer are drinking every day, and total consumption has stabilised after sharp falls a decade ago. It would appear as though the British public are developing a healthier relationship with alcohol. However, this broad national picture disguises the relationship some sectors of the population have with alcohol. For example, Public Health England recently reported that 4.4% of drinkers consume just under a third of all alcohol and 10% of adults drink alcohol at least five days a week.

Binge drinking

The latest ONS data reveals that 29% of males report binge drinking compared with 26% of females (16 to 24-year-olds being most likely to report this). The ONS defines binge drinking as the consumption of eight units of alcohol for males and six units for females, in a single session. Eight units of alcohol is equal to four pints of beer, and six units is equal to two large glasses of wine.

Despite binge drinking being more common among the young, it is middle-aged people who suffer most harm from alcohol. These harms include several cancers, problems with the liver and, of course, addiction. Harms from alcohol are also related to income. For example, people living in more deprived areas suffer more harm from alcohol use than those in more affluent areas, despite consuming the same amount. We still don’t fully understand why this might be.

Mental Health

The physical harms associated with alcohol are well documented, but the risks to mental health also need to be addressed. Alcohol is known to be used as a way of coping with problems like depression and anxiety.

Although people develop problems with alcohol and mental health in tandem, the policy and treatment responses are often separate. With mental health services only dealing with the person’s mental health problems and referring them to specialist alcohol and drug services, rather than trying to address both issues.

Minumum unit pricing

After a long and hard-fought battle with the alcohol industry, the Scottish government has introduced minimum unit pricing. Minimum unit pricing prevents alcohol being sold for less than 50p per unit of alcohol.

Research shows that minimum unit pricing will reduce alcohol-related deaths and other harms associated with the drug. Importantly, this policy is thought to have the biggest impact in those drinkers who suffer most harm.

Minimum unit pricing is a good start (for Scotland, at least), but it’s not the whole solution. Specialist services for people addicted to alcohol are still needed. However, alcohol (and drug) treatments, particularly in England, are under unprecedented strain, and despite some welcome funding for programmes aimed at helping families affected by alcohol, they are against a background of major funding reductions to treatment services in England.

The Scottish government has taken a bold step to reduce alcohol harms. Policymakers in England, Wales and Ireland might want to consider taking action, too. The alcohol industry thinks and acts in a national way, so should our politicians.

This article was first published in The Conversation.

The number of individuals engaged in structured drug treatment programmes in England has declined over recent years, but this has been a trend which has occurred alongside another development, that of an increasing number of drug related deaths (DRDs), culminating last year with ONS reporting the highest number of DRDs on record. Delivery of needle and syringe programmes (NSP) in England is not monitored in the same way as drug treatment programmes, at least at a national level, but local monitoring systems provide information which points to a different picture than that which national drug treatment programme data might suggest.

In the North West of England, NSP provision within the nine local authorities which cover Cheshire and Merseyside has been monitored for over 25 years by Liverpool John Moores University’s Public Health Institute (PHI), with comprehensive coverage for the last 10 years. Over 1.9 million needles and syringes were distributed across Cheshire and Merseyside during 2016/17, and of these over 1.25 million were to people who inject psychoactive drugs (including heroin), the highest number on record. When this data is matched to that from the National Drug Treatment Monitoring System (NDTMS), the proportion of individuals injecting psychoactive substances who were not in structured treatment within the past year was 80.1%. This is the first year that we have been able to match the data looking at this cohort only, so it is not yet clear whether this is a growing issue or consistent with other years. Either way, it appears that there is a substantial proportion of individuals injecting psychoactive substances who are not currently in structured treatment.

NSP services within Cheshire and Merseyside use a client attributor comprising of initials, date of birth and gender as part of PHI’s data monitoring, and one of the regular queries concerns the authenticity of this attributor. In theory, a random fictional attributor might be supplied by clients who fear their anonymity could be breached, particularly in the case of services where the NSP is located within the same building as the structured treatment provider. Two factors we’ve explored suggest that this may not be the case, or at least not extensively so. In the first place, research undertaken by PHI over the summer of 2017 surveyed agencies and pharmacies delivering NSP from across the spread of local authorities and asked them about this specific issue. Over two thirds (72%) responded by stating that they believed individuals using their service used the same consistent attributor on each visit. Moreover, as part of the drug related death monitoring process, operational in several of the same local authority areas, a substantial number of individuals whose personal details are confirmed to be correct by both the treatment service and the coroner have matching NSP records. This suggests that there is widespread use of genuine details, and that the numbers highlighted by the system will probably not be wildly over inflated. At the least, since the same model based on attributors has been used for counting the number of individuals using NSP for the last 25 years, the direction of travel is important. If we look solely at the number of NSP transactions without looking at individuals specifically, we can see that they have doubled over the last 3 years. With only 19.9% of NSP client attributors matching to data from NDTMS, even if this figure was doubled, it would still represent a majority of individuals using NSP who are not engaged in treatment.

The 2016 report from the Advisory Council on the Misuse of Drugs (ACMD) identified a number of potential causes of the recent upsurge in opioid related deaths, including the ageing drug using population, changes in the availability and purity of heroin at street level and socio-economic changes (i.e. increasing deprivation and cuts to support services in deprived areas). However, it also suggested that changes in the commissioning and provision of drug treatment might be a factor and it is accordingly vital that the large numbers of individuals outside of the treatment system do not go unnoticed by those commissioning services. With research showing that individuals using heroin become more vulnerable to death from overdose as they grow older, the increasing proportion of people who use NSP services that are older highlights the importance of ongoing engagement in order to encourage attendance in treatment services and monitoring numbers to ensure the problem is not becoming exacerbated. It is also important to note that treatment has been identified as a protective factor by Public Health England (PHE) and other bodies: “There are risks associated with the move towards abstinence. For example, there is a higher risk of death for heroin users who have left Opiate Substitution Therapy (OST) than for those who stay in it, especially in the first few weeks.” (ACMD, 2016, p31). While elements of the latest guidelines on clinical management of “drug misuse” focus on the importance of not being solely recovery focussed, the high number of individuals outside of the treatment population make them a vulnerable group, particularly in the light of funding cuts which the ACMD warned would result in a dismantling of the drug treatment system, citing the lack of resources as “short sighted and a catalyst for disaster.”

Continued monitoring of NSP provision by local authorities is more important than ever to provide a clearer picture of service need, and to gain a more rounded picture of the prevalence of injecting substance use compared with focussing solely on nationally reported treatment data. Given the increasing move from agency to pharmacy for NSP provision, it’s vital that those delivering NSP services in whatever setting are equipped with the expertise and integration to mainstream treatment services so they can offer individuals who inject the same quality of service. People who inject drugs have a right to be well and to be able to access the same health related interventions as those who have made the decision to go down the route of recovery. Being outside of the treatment system should not make those who inject outsiders from good quality healthcare.

This blog was first published as a guest article available on the NNEF (National Needle Exchange Forum) website: www.nnef.org.uk

Anyone with a manager will probably recognise that situation where you’re enthusiastically presented with a ‘great opportunity’, but all you hear is a lot more work is coming your way! Two years ago my manager announced “I think you should enrol on our Public Health Masters programme”. My initial response was a slightly less than enthusiastic “I’ll think about it”. It was, after all, many years since I’d written an academic essay, sat an exam, or worse still completed a dissertation project. What if I couldn’t do it? To quote from the philosophy of Homer Simpson: “…you tried your best and you failed miserably. The lesson is never try”. However, that’s the other thing you might already know about managers; they aren’t so good at taking ‘No’ for an answer. So after some persuasion, I reluctantly agreed, “Okay, but I’ll just take a couple of modules, I’ll see how it goes”.

So now having just completed my final project on the Public Health Masters programme, and reflecting on the last two years, I can appreciate how much I’ve learnt. Yes, the course did involve more work, but it also built on my existing knowledge and experience. The lectures have been a great forum for discussion, and I’ve had the chance to hear many really interesting lecturers and guest speakers. And what about all those essays? Well, luckily there are some really great study support sessions available at LJMU. I’d particularly recommend the session for ‘critical essay writing’, which was one of the first support sessions I attended. As a result, I know how to structure and write those essay assignments.

In the introduction to his book ‘The Health Gap’ Michael Marmot^[1] talks about his experience whilst training as a doctor in the 1960’s. Realising that both behaviour and health are linked to people’s social conditions, he observed that “treating [the patient] with pills might help to put out the fire. But should we not be in the business of fire prevention as well” ^[2]. This revelation for Michael Marmot came with the realisation that is was possible for him to study how social conditions affected health and disease. ‘Epidemiology’ which is often referred to as ‘the cornerstone’ of public health, considers the distribution and determinants of health-related states, and the application of epidemiology is concerned with the control of diseases and other health problems.

The revelation for me was the realisation that these concepts of public health policy, epidemiology and research, that all featured as modules in my course of study were also already part of my current job. Working within the Public Health Institute’s intelligence and surveillance team, our monitoring and data collection systems provide intelligence and evidence to inform public health policy and practice.

Whether like me you’re already working in a Public Health related field, or if you’re looking to start a career in Public Health, our study programmes at the Public Health Institute are a great opportunity to broaden your knowledge. Whether you’re interested in an Undergraduate, Postgraduate or even a Continuing Professional Development (CPD) course, they build on your existing knowledge and experience and are really valuable for either your current role in Public Health or the one you aspire to achieve.

So “the lesson is never try” - you might surprise yourself.

References

After a lifetime of visiting cold Northern towns, the furthest place I’ve ever got to with work is Reading, and for all the many nice things you can say about Reading, it’s probably not on most people’s “places to go before I die” list unless you’re a huge Mike Oldfield fan. So when my poster was accepted at the 25th International Harm Reduction Conference which took place in Montreal last month, it was a lifetime’s dream come true of coming into work with my passport. The conference itself has its roots in Liverpool where harm reduction first came on to the agenda in the 80s and in the context of HIV’s appearance in the UK made our city one of the pioneers of a new way of thinking, endorsed by government policy which despite its calculating ruthlessness in other areas, did not want to on balance risk a panicked public fearing for their lives. The Harm Reduction Coalition describes harm reduction as “a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.” You could argue that the ultimate negative consequence of using drugs is death, and so at the very least, harm reduction if it’s about anything should be about keeping people who use drugs alive. So much of the conference focussed on preventing drug related deaths, and a common theme was the need for promotion of naloxone. Naloxone is a medication used to block or reverse the effects of opioids and used to treat overdose in an emergency situation, and although used in emergency departments since the 1970s, has only recently become more widely available in some areas of the world to the general drug using population and support services, a practice which is widely accepted as being one which saves lives.

But policy development does not occur in a vacuum and part of the reason for the intense interest around the urgent roll out of naloxone is the massive increase in drug related deaths, both locally and internationally. Drug related deaths recently reached the highest level ever recorded in England and Wales, with 3,674 drug poisoning deaths registered in 2015 including 1,201 heroin related poisonings, a doubling of the 579 deaths recorded in 2012. The picture is the same globally, with opioid overdose deaths in the USA increasing by around 180% since 2002. In Vancouver alone, 174 individuals died in one week in 2017, with fire and rescue services in some provinces stating that they now regularly deal with more call outs for overdose than for tackling fires.

Canada’s Minister for Health Jane Philpott was invited to speak at the conference opening ceremony and accepted the invitation but was met with a small but significant number of people holding up protest banners and turning their backs to her as she spoke. I turned to my colleague Howard who was out there with me and said something along the lines of “they don’t know how lucky they have it. Can you imagine Jeremy Hunt turning up to a conference about harm reduction?” (Let’s face it, Jeremy Hunt probably doesn’t know what harm reduction is). But then one of the activists spoke – this wasn’t about protest for the sake of protest. They were making a public stand because this wasn’t just something that should be on the agenda, this was an urgent national crisis. If any other group were dying in the numbers that drug users were, people would be up in arms about it. When the SARS disease hit Canada, affecting less than a dozen people, emergency task forces were quickly established and millions of dollars were made available for a rapid national response, billions of dollars in some countries. And yet here were thousands of people dying, some of the most vulnerable members of the population, and the government’s response was thoughtful and serious, yes, but not anywhere near rapid enough or well enough resourced to potentially do anything about the hundreds of people who would die each week without action.

And so I came away from the conference thinking about the work that we do here at PHI to support local authorities with looking at drug related deaths and what they can do locally to at least attempt to stem the rising tide. Chairing those panels feels like the most important work I do within PHI since for all the data I stare at on a screen each day, these are real life individual cases, people who aren’t here anymore, and they should be but as a country we don’t allocate proper resources to this issue. If it was my brother or a parent or best friend, I’d want to stand up and shout – FFS, do something about this. The war against the poor and vulnerable as we’ve seen in the last two weeks can be a passive thing more than anything. To populations that are hidden away from the general public and whose deaths are so common that they don’t even make the inside pages of newspapers, the problem isn’t a group of activists disrupting a sympathetic conference to shout about it, it’s that more people don’t do that. If we don’t demand action in the same way we would for any other emergency, then those deaths become one more avoidable statistic. Fighting inequality and supporting people to live well is at the heart of public health, so we need to say: this is a crisis which demands national action now.

In both the developed and developing world poverty is linked to poor health, whether biological, psychological or environmental. Economic disadvantage is a cause of poor health (people are deprived of education, resources, or access to healthcare) and a consequence of poor health (good health is an asset upon which livelihoods depend).

The World Health Organization defines poverty using five core dimensions, which incorporate income and work, health and education, empowerment and rights, status and dignity, and security and risk. However, increasingly the harms associated with poverty are being shown to be proportional to the size of the gap between rich and poor, implying it is socioeconomic inequality which drives health harms rather than poverty itself. In other words, the key determinant is the distribution, not the absolute level, of wealth.

At a fundamental level poor environments are less healthy; the urban poor in developed countries have more fast food outlets, more off licences and less green space than their rich friends. As a consequence, people of lower socioeconomic groups have poorer diets, drink more alcohol and exercise less. But the difference in behaviour between the rich and poor cannot simply be explained by their environments; socioeconomic health gradients are found even where health behaviours are free. People of lower socioeconomic positions use less preventative healthcare services and have stronger beliefs in the influence of chance on their health.

Consider the glass ceiling effect of poverty on intelligence. Among those of favourable opportunities, variation in IQ is almost entirely due to genetic differences, among those of less favourable opportunities, variation is almost entirely due to environmental factors. Whether you are a product of nature or nurture depends on whether you are rich or poor. More profound than that, an individual may be both an expression of nature or nurture at different times of the same year. A study by Mani and colleagues^[1] found that Indian farmers showed diminished cognitive performance before harvesting their crops (when poor), compared to after harvest (when rich). Their study implies that poverty itself impairs cognitive function; they argue poverty-related issues consume mental resources leaving less for other functions.

I have spent six years (and counting) working on my PhD which sought to understand why people behave in unhealthy ways despite knowing the risks to their long term health. I tried to quantify and interpret various behaviours in an attempt to make sense of seemingly senseless choices. My results indicated that people from socioeconomically disadvantaged environments behaved in unhealthy ways and that such behaviours might make sense given the trade-offs that people face. If you do not have good opportunities for education, employment or secure housing, behaving in a way to maximise your short term pleasures (whether eating unhealthy food, drinking or smoking) might be your best choice, despite the likely long term costs. Poor people have consistently been found to give greater weighting to present over future outcomes.

In public health we spend a lot of time picking up the pieces. We try to help people who are addicted to drugs, who are dependent on alcohol or cigarettes, and we try to make environments healthier and happier. In my day job, I collect and share accident and emergency department data, a major focus of which is preventing violence, whether directed towards oneself or others. A lot of monitoring work is nuanced and complicated but violence prevention work can often be reduced to a simple trend – violence is associated with, and predicted by, poverty. The intervention needs to be here, in this deprived area.

Thankfully violence in the UK is on the decrease but that doesn’t mean the inequality gap is reducing. The number of households that fall below the minimum standard of living has risen from 14% to 33% in the last 30 years, 18 million people currently cannot afford adequate housing, 1.5 million children live in households that cannot afford to heat their homes, half a million children live in families where their parents cannot afford to feed them, those who are poor are typically multiply deprived, and almost half of the working poor work 40 hours a week, meaning full time wages are too low to support families.^[2] All the while, the wealth of the richest continues to explode.

While health is high on global and national agendas, it seems very unlikely that we can improve population health without addressing widening inequalities. The key to initiating change is perhaps to inspire others that change is possible, that the status quo does not need to be accepted and that power can be wrestled from the hands of the few and into the hands of the many. This blog was written as we approach a general election in the UK, and at a time when over one million adults are not registered to vote and 34% of those registered did not vote in 2015. I have not written this blog with the election in mind but it seems like an opportune time to consider the health consequences of policies which lead to widening inequalities.

References

^[1] Mani, A., Mullainathan, S., Shafir, E. and Zhao, J. (2013). Poverty Impedes Cognitive Function. Science. 341. 976–980.
^[2] Poverty and Social Exclusion. (2014). Key Findings. http://www.poverty.ac.uk/pse-research/facts-and-findings

There’s been a lot in the media recently about the prisons in England and Wales. They’re overcrowded and under-staffed. There’s been an increase in violence, in terms of self-harm, suicide, rioting and assaults by prisoners on each other and on staff. New psychoactive substances (NPS) have become a popular drug choice as they’re difficult to detect through conventional drug testing methods. Spice, a synthetic cannabinoid, is the most common NPS used in prison and seems to be part of the problem with increasing violence. As well as a general interest in prisons and the history of prisons, in the past I’ve visited around 35 prisons as part of my work at the Public Health Institute. Also, my brother was a prison officer for almost a decade.

Recently when reading another news report on the issues in the prisons in England and Wales, this got me thinking about my visit to San Pedro prison in La Paz, Bolivia, when I was travelling in South America in 2009. San Pedro prison is a bizarre tourist attraction. And it’s certainly a unique prison.

Rusty Young’s book, Marching Powder, is probably what made San Pedro prison become so popular with tourists. The book describes the encounters of an English prisoner who became known for offering tours in the prison. So why did I visit San Pedro prison? I was intrigued and fascinated that you could so easily have a tour in an operational prison. At the time I didn’t know much about the prison and hadn’t yet read the book, but other backpackers I met had described it as a prison like no other and a must see in La Paz.

Although I was travelling alone, I went to San Pedro prison with some people I met earlier on my travels. I don’t think my parents would ever have forgiven me if I went there on my own. We arrived at the plaza outside of the prison and waited to be approached, as advised. We paid our entrance fee and were taken over to the prison gates. We signed the visitors’ book and then had a number written on our arms so that we could be identified and released at the end of the tour. We were introduced to our tour guide and bodyguard, both of which were prisoners. That’s how easy it was to get into San Pedro.

So what makes San Pedro prison so unique and appealing for tourists? It’s a once in a lifetime opportunity to visit a prison like no other. It’s a community within itself and you basically need to have money to survive in San Pedro. You need to buy everything; food, clothes, medicine and even a roof over your head. If you can’t afford to buy a cell, you can get a mortgage, rent one or rent a space in one. And if you can’t afford any of these options then you’re homeless within the prison. There are various zones or ‘neighbourhoods’ within the prison, and the price of housing varies from the poorest to wealthiest areas. Although it’s a prison for males, their wives and children often live there voluntarily, but are free to come and go, because it’s cheaper and deemed safer. Yes, I’m still talking about a prison.

Walking through the prison we saw a gym, restaurants, bars and shops selling groceries and souvenirs. There was a football match being played and children playing outside. The prisoners, women and children were going about their daily lives as anyone would outside of prison. Every now and again I was reminded that I was in a prison, for example, when we were shown the “swimming pool” as it was known, which is often used to drown rapists and child abusers.

Tourism is a huge income for the prison. Tourists can pay for tours, food and drink, gifts and even cocaine. Cocaine is the largest source of income for the prison. As well as selling it within the prison walls, it is sold outside. I imagine it’s easy to traffic drugs when so many visitors and family members come and go as they please.

So where were the prison officers? They were at the gate, monitoring who was entering and leaving the prison. But they were nowhere to be seen within the prison itself. The prisoners govern the prison themselves, managing everything from maintenance to healthcare to housing to education. Clearly this makes the management of the prison cheaper for the government.

Was I nervous on my tour of San Pedro prison? Of course I was, or at least I was in the beginning. I was in a prison without being escorted by an officer (I’m not sure the prisoner come bodyguard counts) and the prison was full of dangerous criminals; however the prisoners and their families were all very friendly and welcoming. Maybe the women and children being present made it a little less frightening. And because it didn’t look or feel like a prison at all. It felt like I was on a tour meeting the locals in a neighbourhood in La Paz, not in a prison.

During my degree I became fascinated by the role of culture in determining individual identity and ways of perceiving and being in the world. I had been encouraged to go beyond the commonly accepted and interrogate the taken for granted in society; perceiving the conditions, values and experiences that shape human behaviour, and how individuals used materials to construct their lives. Whether that was demystifying diverse eating practices, initiation rituals or how groups formed relationships of exchange, it required situating behaviours in a specific time and cultural context. Approaching such events relied on placing the subject of interest and their values at the centre of analysis and comparison, to understand things in their terms. I soon realised that this process provided the foundation of the research being undertaken. Both between the researcher and interlocutor in the field, and the network of varied skilled academics and students that made up the research teams at university, collaboration underpinned their ability to produce meaningful knowledge.

Leaving university I had been inspired to experience how knowledge could be applied to the solution of human problems. Joining the Centre for Public Health provided me with the chance to further develop my skills and work within a research department tackling health issues in local communities.

Initially, a daily routine of processing and analysing data, and producing reports for external partners led to a sense of disconnection from the people and issues behind these statistics. I began to wonder how much of the research and work was initiated top down perhaps at odds with the lived experiences of the subjects involved.

However, as I became immersed within the centre and have been able to witness the practices and values of the team around me I saw how the seemingly disconnected teams of statisticians, researchers, and administrators were embedded within a wider network. I observed how diverse skill sets are incorporated to tackle challenges, where the work of one team underpins and enables the work of another.

Working daily with different groups, such as those on the front line of emergency department or partners in community intervention organisations it became apparent that the needs of those affected by issues in daily life shaped the actions and values of those at the centre. As I witnessed, the taken for granted of our daily routines concealed a backstage of multiple actors that worked collaboratively to affect meaningful change in the lives of those people they studied.

As science evolves with new technology and an increasing varied society to become multi-faceted in its approach, increased collaboration provides the means through which advances are made. Indeed the progress of scientific knowledge in society can be viewed not as the intrinsic success of a particular method or model but the ability for multiple talented groups and individuals to contribute to and rigorously reassess the work of contemporaries and predecessors under shared principles and values.

The Centre for Public Health is situated at the heart of a complex web between those on the front line of health issues and the institutions seeking to affect change, utilising the skills of diverse set of people to respond to the needs of those in society. To witness the vital and impressive work that is undertaken by my colleagues and partners provides a sense connection and identity, where my own position fits into this wider collaborative network.

“No man is an island, entire of itself…” John Donne.