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The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Contents

Judged by ‘successful’ completions, three official reports tell a tale of improving alcohol, drug and youth substance use treatment systems in England, albeit with the alcohol caseload going up, the drug one down – but for how long? In Scotland alcohol-related death rates have fallen by a third since 2003 but remain almost twice those in England and Wales; without the national strategy, it might have been worse.

Record alcohol treatment numbers in England still not enough ...

2013 could have been a turning point for drug treatment in England ...

Youth treatment in England improving but contracting ...

Scotland’s alcohol strategy judged partly successful ...


Alcohol treatment in England 2013–14.

Public Health England.
Public Health England, 2014.

In England a record 114,920 adults were in specialist alcohol treatment in 2013/14 and nearly 4 in 10 left as planned free of dependence. A good record, but probably still most dependent drinkers who might have benefited from treatment did without it, partly because relatively few found their way there via GPs and emergency departments.

Summary The featured report presents and comments on data from the National Drug Treatment Monitoring System on adults (aged 18 and over) who received specialist treatment for alcohol problems in England between 1 April 2013 and 31 March 2014. This account draws on the data source as well as the featured report. For the treatment of under-18s see this analysis instead.

Main findings

Alcohol treatment numbers in England 2008/09 to 2013/14

Headline findings were that, compared to last year, more people were in treatment during the year – up from 109,683 to 114,920, the highest number since this figure was first published 2008/09. The total included slightly more who initiated treatment during the year (for the first time or returning), up from 75,773 to 80,929, again the highest since 2008/09 chart. These numbers should be set in the context of estimates that 1.6 million people in England may have some degree of alcohol dependence, of whom 250,000 are moderately or severely dependent and may benefit from structured alcohol treatment.

Despite the increase in numbers entering treatment, 93% of people waited under three weeks for it to begin, up from 89% in 2012/13 and continuing the steady improvement since 2008/09.

43,530 patients successfully completed treatment, continuing the steady upward trend since 2008/09. Of these, 58% were not drinking at all when they left. 38% of all patients in treatment at some time during the year successfully completed it, continuing the yearly increases from 26% in 2008/09. Of all treatment leavers, successful completers constituted 59%, also up steadily since bottoming at 48% in 2009/10. In contrast, the proportion of patients who ‘dropped out’ of treatment was (as in the previous year) 26% of all those leaving, down from a peak of 33% in 2009/10.

In 2013/14, 70% of all people in alcohol treatment were aged 30 to 54 and nearly two-thirds (64%) were men. Despite the general growth in the caseload, as a proportion of the total and in numbers, 18–24-year-olds have become less prominent, numbering 4768 in 2013/14 after falling each year from a peak of 6328 in 2009/10.

At 42% of all entrants during the year, self-referral was the most common route to treatment. Next at 17% was referral from primary care surgeries. Referrals from hospital accident and emergency departments accounted for just under 2% of all treatment entrants, 1268 patients.

2013/14 was the first full year for a new classification of the settings patients were treated in and the type of interventions they received there. Some individuals will have been treated in several settings and/or received several types of interventions. 101,782 drinkers equating to 89% of all in treatment during the year were treated in non-residential community settings, including day programmes and services offered by community drug and alcohol teams. Nearly all these patients were recorded as participating in psychosocial therapies such as cognitive-behavioural therapy or motivational interviewing and (usually in addition) 16% were prescribed medications. Prescribing was near universal in inpatient units, which offered assessment, stabilisation and/or assisted withdrawal to 8885 patients, about 8% of all the total number in treatment. GPs treated 4948 patients and 3903 were treated in residential rehabilitation centres.

The authors’ conclusions

The data for 2013/14 indicates that the alcohol treatment system in England is performing well. However, a challenge remains to ensure alcohol treatment services are accessible and appropriate. While the system has absorbed increased numbers, commissioners face a greater challenge to maintain these gains while improving outcomes from the system and making sure all who need help are steered towards treatment.

Short waiting times demonstrate that it is easy for people with problems to access specialist treatment, and the data shows this treatment is effective – people who seek specialist help do get better.

Treatment is one important component in the range of responses to alcohol-related harm. Other parts of the system need to rise to the challenge of harmful alcohol use. The NHS has a key role in reducing alcohol-related harm – for instance, by improving the availability of alcohol care teams so they can seize the opportunities that emergency department attendances and hospital admissions present to engage people and encourage them to change their behaviour. Similar opportunities need to be grasped at any point in the social care and criminal justice systems to help people address the effect of harmful alcohol use on themselves and others.

The continuing challenge for local authorities and their strategic partners will be to ensure a coordinated strategic approach to the interventions that are proven to prevent and address alcohol-related harm, ie, licensing, health-improvement messages, hospital alcohol services and specialist treatment, remembering that is everybody’s business to change attitudes and behaviour to reduce alcohol harm.


Findings logo commentary One of the concerns of this and previous years’ reports was that while those receiving treatment are doing reasonably well and progressively better, many who might benefit from treatment do not receive it. Depending on the criteria, England’s performance in ensuring problem drinkers enter treatment can look anywhere from poor to excellent. Explained in this hot topic entry, treatment can be seen as capturing numbers equivalent to just 7% of harmful drinkers up to a creditable 40% or more of those also at least moderately dependent. The lower figure can be justified as the percentage of all those who might benefit from treatment, the higher as perhaps closer to those likely to need extended and structured treatment to sustainably overcome their dependence. The report seems to limit the need for or benefit from structured treatment to the 250,000 drinkers in England it says are at least moderately dependent, but there is an argument for extending briefer forms of structured treatment – sometimes seen as extended brief interventions – to dependent drinkers further down the severity scale.

Another reason why the gap between need and access to help is not as large as it appears is that structured specialist treatment is not the totality of support available to problem drinkers. But whatever its dimensions, figures from Scotland suggest the gap might be narrowed much further; there it seems the proportion of possibly dependent drinkers who enter treatment is over three times the figure in England.

Alcohol treatment referral sources in England 2008/09 to 2013/14

One reason for the treatment–need gap is what – in its last report on alcohol treatment before being absorbed by Public Health England – the National Treatment Agency for Substance Misuse (NTA) saw as the low numbers successfully referred to specialist treatment by GPs or accident and emergency departments, despite estimates that one in five patients seen by GPs is drinking at risky levels, and that 35% of emergency attendances are alcohol-related. An ambition for the coming years was “that these two key routes will become more active in identifying and referring people who need treatment”.

If there was cause for concern in 2011/12, there is more cause now. Referrals from GPs fell from 14,330 in that year to bottom at 13,541 the following year, only partially recovering to 13,864 in 2013/14 chart. From 22%, since 2008/09 the proportion of all treatment entrants accounted for by GPs seems to have fallen each year, ending at 17% in 2013/14. Accident and emergency department numbers and proportions are both up, but from a very low base, peaking in 2013/14 at 1268 patients equating to 1.6% of all referrals, still a small proportion of the potential. From a peak of 15,900 in 2009/10, in 2013/14 these two sources accounted for 15,132 treatment starts in 2013/14; as a proportion of all treatment starts, the trend has consistently been down from 23% in 2008/09 to 19% in 2013/14. Almost uniformly in what the NTA would see as the wrong direction since figures became available, these trends suggest screening and intervention rates and/or quality in these two prime settings for identifying dependent drinkers have yet to approach their potential.

In contrast, hospitals – identified as a referral source only since 2011/12 – have since then rapidly increased their referral rates by 46% to account for 4711 patients, perhaps aided by the widespread deployment of alcohol liaison nurses.

The record of hospitals and the surge in self-referrals to treatment – up by almost a quarter over the three years since 2011/12 – suggests that trends in GP and accident and emergency department referrals are not due to any diminution in the demand for treatment. It could however be that some self-referrals were prompted by advice, information, screening and brief interventions conducted in surgeries and departments and in other settings.

Thanks for their comments on this entry in draft to James Morris of the UK Alcohol Academy. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 20 December 2014. First uploaded 12 December 2014

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Top 10 most closely related documents on this site. For more try a subject or free text search

DOCUMENT 2013 Alcohol treatment in England 2012–13

DOCUMENT 2013 Alcohol treatment in England 2011–12

STUDY 2009 The Drug Treatment Outcomes Research Study (DTORS): final outcomes report

STUDY 2010 Gender differences in client-provider relationship as active ingredient in substance abuse treatment

REVIEW 2011 Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence

STUDY 2005 'Real-world' studies show that medications do suppress heavy drinking

REVIEW 2009 Continuing care research: what we have learned and where we are going

REVIEW 2011 Medical treatment of alcohol dependence: a systematic review

STUDY 2015 Specialist substance misuse treatment for young people in England 2013–14

STUDY 2010 Naltrexone and combined behavioral intervention effects on trajectories of drinking in the COMBINE study





Drug treatment in England 2013–14.

Public Health England.
Public Health England, 2014.

Authority responsible for promoting addiction treatment in England cautions that the gains of recent years in reduced drug use, lower demand for treatment for heroin and crack problems, improved treatment performance, and curbing drug-related harm, have all stalled or gone in to reverse.

Summary Within its brief to protect and improve the nation’s health and address inequalities, Public Health England promotes addiction treatment by supporting the local authorities responsible for local treatment systems. This report documents England’s progress in respect of the treatment of adults (18 and over) receiving treatment for problems related to their use of illegal drugs; a corresponding report deals with alcohol. This account draws on the featured report and source data from the National Drug Treatment Monitoring System. For the treatment of under-18s see this analysis instead.

Main findings

Numbers of patients in treatment in England 2005/06 to 2013/14

The backdrop is a long-term downward trend in drug use over the last decade which reversed slightly during 2013/14, along with an increase in drug-related deaths. According to the 2013/14 Crime Survey for England and Wales, the proportion of adults aged 16–59 who used any illicit drug during the past year went up from 8.1% to 8.8%, and 19% of 16–24-year olds said they had used illicit drugs compared to 16% the previous year.

Despite these latest figures, overall drug use remains lower than around ten years ago, as does use of the more harmful drugs such as heroin and crack. However, if the recent increase is sustained, it may translate to more people needing treatment for drug problems.

All patients in treatment during the year

At 193,198, the number of adults treated for drug problems in England in 2013/14 was very close to the previous year’s 193,575, almost halting the decline from a peak of 210,815 in 2008/09 chart. Three-quarters of the caseload were men. As ( below) the number of sub-30-year-olds starting or returning to treatment falls, and the number over 40 rises, the treatment population is on average becoming older. In 2013/14, 23% were aged under 30 (down from 25% last year) and 36% were aged over 40 (up from 34% last year). Over 57% of adults in treatment during the year were either parents or had children living with them.

Patients starting or returning to treatment during the year

Among the total were 70,930 patients who started or returned to treatment in 2013/14, an increase on the previous year’s 69,247, reversing the consistent fall since 2008/09’s peak of 84,520 chart above right. Treatment starters are on average older than in previous years. From 38,485 in 2005/06, by 2013/14 the number aged under 30 had fallen to 24,238, while over 40s rose from 12,678 to 18,889 and now constitute 27% of all starters compared to 15% in 2005/06.

Of treatment starters in 2013/14, 46,001 were being treated for problems with crack cocaine and/or opiates such as heroin, slightly up on 45,739 the previous year, which again may indicate an end to the longer term downward trend. Nevertheless, at 9,878 the number of under-25s who started treatment for opiate problems was around a third of the 26,729 who started in 2005/06. Numbers starting treatment for problem cannabis use continued to rise, from around 7,500 in 2005/06 and 2006/07 to 11,821 this year. Also up to 7782 was the number starting treatment for problems primarily relating to cocaine powder (ie, not crack), continuing the increase since 2010/11, though still below the 8522 peak in 2008/09.

Treatment entrants for ‘club drugs’ numbered 3543, slightly up on last year and a new high, but still just 5% of all treatment starts, and recovery rates for these users remain good. Itemised only from this year, relatively few people started treatment for problem use of novel psychoactive substances – so-called ‘legal highs’. It is unclear whether small treatment numbers are because these drugs don’t cause problems requiring widespread structured treatment, or because services are not relevant or accessible to users of these drugs.

The upshot of these trends is a changed drug profile of people starting treatment. In 2005/06 the 59,642 presenting with opiate problems represented 72% of all treatment entrants. By 2013/14 these figures had fallen to 43,453 and 61%, largely due to the steep decrease in the number of newly presenting opiate users aged 18–24 from 11,309 in 2005/06 to 3,142 in 2013/14. This fall mirrors the general population trend in the estimated number of under-25s using opiates and/or crack, down from 72,838 in 2004/05 to 32,628 in 2011/12.

The average waiting time for a first appointment fell from five days the previous year to three days, and, as previously, 98% of referrals waited under three weeks.

Treatment settings and modalities

Before treatment setting/modality categories changed on 1 November 2012, at least 79% of patients were recorded as being prescribed medications, usually methadone for the treatment of opiate addiction. Under the new system, in 2013/14 147,841 patients were recorded as being prescribed medications, 77% of the total. Of these, just over a quarter (26%) had been prescribed medications without a break for at least five years, but over a third (37%) for less than a year. For several years the proportion of the treatment caseload in residential rehabilitation at some time during the year has remained at around 2–3% of the total, numbering 3,935 in 2013/14.

Indicators of treatment success

The proportion of patients who had been in treatment for at least 12 weeks, or had left having completed free of dependence, has remained at 93–94% since 2009/10 (in this latest year the figure was 94%), after rising from 82% in 2005/06.

In 2013/14, 29,150 patients ‘successfully completed’ their treatment – defined as no longer in treatment at the end of the year having left free of dependence, judged no longer in need of treatment, and not using heroin or crack cocaine chart above right. Of these, 71% were recorded as not using any illegal drug. At 15%, the proportion of all patients in treatment successfully completing during the year has remained static for three years, but represents a considerable advance on the 6–7% recorded in 2005/06 and 2006/07. Another 20,147 patients dropped out or otherwise left treatment without completing it, 10% of all patients in treatment that year compared to last year’s 18,253 and 9%, an upturn which ended the fall from 21% in 2005/06.

Younger users tend to start treatment for problems with cannabis (43% of new starts for 18–24-year olds) and generally recover and leave treatment. On the other hand, users aged over 40 mostly come into treatment for heroin and/or crack (78% of new starts in 2013/14) and tend to have far more entrenched problems. This, and their often worsening health and limited social resources, means it is more difficult for them to successfully exit treatment – though for many, being in treatment helps stabilise their lives, reduce the risk of serious harm and overdose, and improve their chances of recovering.

The long view

Because it often takes more than a year to recover from drug problems, a longer view is needed to assess the success of drug services. Since 1 April 2005, 33% of the total of 416,026 people who had come into treatment had successfully completed it and were no longer in treatment on 31 March 2014. Another 37% had left without completing and 30% were still or back in treatment, among whom were 11% who had remained in treatment without an appreciable break.

These figures include patients who started treatment before 2005/06. A more contemporary analysis focuses on the 330,022 who entered treatment for the first time since April 2005, of whom 55% were treated for their use of opiate-type drugs like heroin. By the end of 2013/14, 36% were no longer in treatment after having successfully completed, 39% were no longer in treatment but had left without successfully completing, and 25% were still in treatment, either because they had stayed continuously or left and returned. Just 7% of people treated for use of drugs other than opiates had stayed in or returned to treatment; when drug problems included opiate use, the figure was 40%.

Drug-related harm

A key area of concern during the year has been deaths from drug misuse, up in 2013 in England from 1,492 in 2012 to 1,812, a 21% increase. Heroin/morphine remains the most common substance involved in drug-poisoning deaths – in England and Wales, 765 in 2013, up from 579 in 2012, a 32% increase. Tramadol, an opiate-like painkiller, has also been responsible for a sharp rise in deaths in recent years – 220 this year compared to 87 in 2009.

Blood-borne viruses such as HIV and hepatitis spread easily among drug users who share injecting equipment. The number of injectors who reported sharing equipment fell by a quarter between 2003 and 2008, but this figure has not changed over the past five years, and two-fifths of injectors (39%) said they engaged in this risky behaviour in 2013. Sharing is more common among those who began injecting in the last three years and may be increasing: nearly half (46%) of this group reported they had shared equipment in 2013.

The authors’ conclusions

Over the past decade drug treatment services in England have helped thousands of drug users recover from their drug problems and rebuild their lives, benefiting not just these individuals and their families, but their communities and the whole of society.

While drug use has been on a long-term downward trend over the last decade, it has increased during the past year, and the decline we have seen in treatment numbers has slowed down, as have successful completion rates.

Though figures often fluctuate year to year, the increase in drug-related deaths is a major concern. Part of the answer is to do more to prevent people using drugs by building their health and social resources, and reducing inequalities. Treatment services also have a vital role to play in being available to help problem drug users. Naloxone, a drug that reverses the effects of heroin, should also be made more widely available to services and users.

The figures relating to blood-borne disease also demand action. Services need to give injecting users the advice that will keep them safe from harm, ensure injecting equipment is readily available, encourage them into treatment, and then help them stop injecting as part of their wider recovery from drug use.

New and emerging drugs are a concern, but use of heroin and crack is still by far the biggest problem, and many of the users are getting older. While the health of this large and ageing treatment group may be fragile, they should never be written off; they can and do recover, and should be given every chance to do so.


Findings logo commentary The consistent note in this year’s report is caution that the gains of recent years in reduced overall prevalence of drug use, less demand for treatment for heroin and crack problems, the performance of treatment services, and in curbing drug-related harm, have stalled, or may be proved to have gone in to reverse if the most recent trends continue. The clearest positive is what seems a wholesale turning away of young adults in England from heroin and crack. Notable too, and a departure from the reports authored by the National Treatment Agency before its absorption in to Public Health England, is the emphasis on prevention and public health, indicating that for its new national remit-holders, treatment is just one element in a broader set of concerns and responses, extending to social change to build health and social resources and reduce inequalities.

Is the system becoming more successful?

Relative austerity and the recovery agenda of government policy has focused attention away from retention towards treatment exit, in particular exits defined as ‘successful’ in terms of having left as planned and no longer in need of treatment. On this criterion, the year-by-year trends tell a tale of an improving treatment system, the success rate more than doubling in five years from 6% in 2005/06 to nearly 14% by 2010/11, then stabilising at 15%.

However, year-by-year statistics can only show whether if someone left treatment that year, they had to return during the same year. The featured report’s long-view analysis adds a further rider to the indicator of success – that whenever the patient started treatment and whenever they successfully completed, they should not (presumably after relapse) be back in treatment at the end of the multi-year period covered by the analysis. Against this yardstick, since April 2005, a third of all patients were successfully treated, outpaced by the two-thirds who remained in need of treatment or beyond its protection without having successfully completed. Many of these ( below) will actually have been successes, having left and done well without completing, or having stabilised in treatment. Nearest to counting as ‘failures’ are the 19% of patients were still in treatment at the end of 2013/14 having left but then returned, presumably because their prior treatment had not worked or if it had, still they had relapsed. Even for these patients, re-engagement in treatment can be seen as a positive.

Five-year treatment journeys for patients first starting treatment in 2005/06, 2007/08 and 2008/09

Though a step forward, the long-view analysis in the report mixes up two factors which might influence the success rate. If the treatment system is improving in the desired way, in each successive year a higher proportion of patients starting treatment for the first time should be able to complete it without having to return. But patients who started treatment in the earlier years also had longer to recover or relapse, confusing the assessment of whether it was this or year-on-year improvements which accounts for any rise in the success rate. For example, patients new to treatment in 2005/06 had nine years to recover or relapse, those entering in 2013/14, less than a year.

More informative is what proportion of new patients succeed over the same time period. Confirming the picture of an improving treatment system, this too has been rising, largely at the expense of presumed treatment failures who had to return after relapse chart left. If successful completion and not being in treatment five years later is a proxy for successful treatment, then the success rate increased from 20% for patients new to treatment in 2005/06, to 39% for those who started three years later. This development was at the expense of treatment retention/return, the figures for which dropped from 38% to 20% over the same period. Had this been mostly at the expense of continuous retention in treatment, it could not be considered entirely good news, but if anything, as the ‘successes’ got proportionately higher, it was the ‘failures’ who returned to treatment after relapse who got proportionately fewer. It remains possible that what looks like an improving treatment system was in fact one whose new patients became progressively easier to treat. Details below.

From an earlier report it can be calculated that five years later, 20% of patients new to treatment in 2005/06 were no longer in treatment having successfully completed. Another 42% had left without completing. The remaining 38% were still in or back in treatment. Two years later for patients new to treatment in 2007/08, the corresponding figures were 35% successfully completing, 42% leaving without completing, and 23% still in or back in treatment. From the data report for 2013/14, it can be calculated that the five-year successful completion rate for patients starting treatment in 2008/09 was 39%; another 41% had left without completing, and 20% were still or back in treatment.

The same data shows how few treatment starters are totally new to treatment, a figure which fell steadily from 64,587 in 2005/06 to 24,672 in 2012/13, only rising slightly to 25,059 the following year. It means that the great majority of patients seen in 2013/14 were not new to the system but continuing in or returning to treatment. In turn that helps explain why despite the changing drug profile of patients (re)entering treatment, the proportion of the entire treatment population whose problems primarily related to opiates (with or without crack) has remained at around 80% since 2005/06. These primarily heroin-addicted patients are the ones who stay in or relapse and have to return to treatment; 40% did so after entering treatment between 2005/06 and 2013/14 compared to 7% of patients not treated for opiate use.

Success not limited to treatment completers

The argument that increasing numbers of successful completions is evidence of increasingly successful treatment rests partly on an analysis of patients leaving treatment in 2005/06. Over the next four years, 57% who left having successfully completed avoided being officially recorded as problematic users of illegal drugs, neither being picked up by criminal justice system nets intended to identify problem drug users, nor returning to treatment on their own initiatives. This record of 57% seemingly staying recovered from their dependence contrasted with 43% among patients who left without having successfully completed treatment. The 14% difference is appreciable, but not as large as would be expected if successful completion correlated strongly with successful treatment leading to lasting recovery. Nevertheless it is enough to justify the assumption that successful completion is on average a better outcome than patients leaving treatment before the service considers them ready.

Whether successful completion is also a better outcome in terms of crime and health than staying in treatment – the usual situation within each year – is less certain. In terms of reduced convictions and presumably reduced crimes, a report from the National Treatment Agency for Substance Misuse recorded that for patients convicted in the two years before starting treatment, the greatest reductions were among those continuously in treatment for the next two years, though successful treatment leavers were not far behind (47% v. 41%). However, these figures combine big differences in the types of patients who stay and leave treatment early. When the focus was narrowed to opiate/crack users, among whom successful completers and retained patients had virtually identical pre-treatment conviction rates, the gap widened to 10% (46% v. 36%).

If successful completion is important, also important is understanding what it means. For the recording system, it means that as reported by the service from which the patient last exits, they are no longer seen as requiring structured drug treatment, and have left treatment (not just that service, but the system as a whole) no longer dependent on any drug, and not using opiates or crack cocaine (1 2). They may be using other illicit drugs in a non-dependent manner (though few are recorded as doing so) and may be drinking and smoking to any degree.

This system is critically dependent on the integrity and accuracy with which treatment services record the status of their departing patients. Within the reporting year 2007/08 the BBC exposed the tiny proportion of patients who within a single year left treatment drug-free, intensifying a national policy emphasis on successful completion. Since then commissioners and services have been under reputational pressure to produce more successful completions, and in recent years, under financial pressure too. If exits are indeed being promoted to meet national or local needs and ambitions rather than those of the patient, this would make the increased successful completion rate partly a marker of a worse rather than a better treatment system. The trends are also compatible with a scenario where in order to meet successful completion expectations, services cherry-pick patients most likely to be able to be able to stabilise and leave treatment, either not taking on the hardest cases or treating them in ways which keep them ‘off the books’ because they can be presented as not receiving treatment which is structured and care planned with clear goals and regular reviews. Arguably a patient merely being prescribed methadone with no prospect of further progress and seen infrequently could be seen as outside this definition. Increased resort to this expedient would account for falling treatment numbers, fewer new opiate and crack dependent patients, increasing numbers using easier-to-treat drugs, and falling overall numbers, as well as the rising successful completion rate. Whether this is happening is not known, but the fact that it might be demonstrates how vulnerable the figures are to manipulation.

Last revised 23 January 2015. First uploaded 24 December 2014

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Top 10 most closely related documents on this site. For more try a subject or free text search

DOCUMENT 2013 Drug treatment in England 2012–13

DOCUMENT 2011 Drug treatment and recovery in 2010–11

STUDY 2015 Specialist substance misuse treatment for young people in England 2013–14

DOCUMENT 2012 Substance misuse among young people 2011–12

DOCUMENT 2011 Substance misuse among young people: 2010–11

STUDY 2009 The Drug Treatment Outcomes Research Study (DTORS): final outcomes report

STUDY 2010 A long term study of the outcomes of drug users leaving treatment

DOCUMENT 2014 Time limiting opioid substitution therapy

STUDY 2012 Estimating the crime reduction benefits of drug treatment and recovery

REVIEW 2013 Quitting drugs: quantitative and qualitative features





Specialist substance misuse treatment for young people in England 2013–14.

Public Health England.
Public Health England, 2015.

Judged by successful completion of treatment, official report documents improved specialist treatment of children with alcohol and drug problems in England. Patient numbers have fallen in line with trends in the general population, though cannabis bucked the general downturn and now dominates the treatment statistics.

Summary Within its brief to protect and improve the nation’s health and address inequalities, Public Health England promotes addiction treatment by supporting the local authorities responsible for local treatment systems. The featured report offers a commentary on England’s progress in respect of young people under 18 years of age receiving specialist treatment for problems related to their use of alcohol or drugs. The following account also draws on source data from the National Drug Treatment Monitoring System. For the treatment of over-18s in England, see instead these analyses in relation to alcohol and drugs.

Treatment figures should be set against the backdrop of declining substance use among young people in general. The 2013 Smoking, Drinking and Drug Use Survey found that compared to decade ago, pupils aged 11 to 15 were far less likely to use alcohol or drugs. For example, 9% had drunk alcohol in the past week, down from 25% in 2003. 16% said they had used illicit drugs in the past year and 6% in the past month, of which cannabis was the most commonly used. However, use of this drug has been declining, down to 7% taking it in the last year compared to 13% in 2001. Importantly, the survey highlights the high risk of drug use among pupils who truant or have been excluded from school and whose circumstances or behaviour already make them a focus of concern.

However, in 2013/14 the Crime Survey for England and Wales reported an increase from the previous year in the proportion of 16–24-year-olds using cannabis and some drugs controlled in class A (most serious) of the Misuse of Drugs Act, including powder cocaine and ecstasy. It is too early to say whether this signals an end to the long-term downward trends.

Main findings

The number of under-18s being treated for substance use in England has fallen each year from a peak of 24,053 in financial year 2008/09 to 19,126 in 2013/14 chart. The youth justice system was the most common way young people found their way in to specialist services (accounting for 29%), followed by education (26%), then referral by self, family or friends (12%) or social care agencies (10%). Almost all who started treatment during the year were seen quickly; 99% waited fewer than three weeks and the average wait was just under two days.

Young people’s drug treatment numbers in England 2005/06 to 2013/14

Cannabis was by far the most common primary drug in relation to which treatment was provided. Numbers in 2013/14 continued to increase to a record 13,659, 71% of all patients. Alcohol is next most common, though the numbers continued to fall from a peak of 8,799 in 2008/09 to 3,776 in 2013/14. Together cannabis and alcohol accounted for 91% of patients. Numbers receiving help primarily for heroin and other opiates fell to 160, continuing the steady decline from 881 in 2005/06 chart.

As one of the drugs they used whether or not their primary problem, cannabis and alcohol were recorded for 85% and 54% of patients respectively. Numbers using ‘club drugs’ (GHB/GBL, ketamine, ecstasy, methamphetamine or mephedrone) fell to 2,694, still the second highest figure since 2005/06 and representing 14% of the caseload chart. At 1,519 users, mephedrone was most common.

Over half (59%) the young people treated in 2013/14 had multiple problems and vulnerabilities, including self-harming, offending, truancy or being a looked-after child. About half were in mainstream education, and a further fifth in alternative education in settings such as pupil referral units or at home; 14% were not in education or employment. Over four-fifths (82%) were living with their parents or other relatives.

On average young patients spent just under five months at specialist services. While there, 89% received a psychosocial intervention (often in combination with other interventions, such as harm reduction advice) such as cognitive-behavioural therapy and motivational techniques. Just 157 children – under 1% – were prescribed medications.

Though relative to adults, treatments were short, the proportion of young patients who left treatment having successfully completed it was high and has increased. In the first year statistics were collected (2005/06), 48% of leavers left as planned having overcome their drug or alcohol problem and were no longer in treatment at the end of the year, a figure which has risen to 79%. Correspondingly, the proportion of leavers who dropped out of treatment before completing it has fallen from 29% in 2005/06 to 12%. Expressed as proportions of the total caseload in a year, over the same period successful completions more than doubled from 24% to 52% chart above left.

The authors’ conclusions

Specialist substance use services in England continue to respond well to the needs of young people who have alcohol and drug problems. The function these services provide is vital: they intervene to help young people overcome their substance use problems and prevent them becoming problematic users in adulthood. The drop in numbers may reflect falling drug use among the general population of young people. Possibly also, contraction in the provision of general services for young people affected referrals.

Although these services are seeing fewer clients, those they do see tend to have a range of problems in their lives. Drug and alcohol problems among young people are often a symptom of wider problems, going hand in hand with issues such as offending or truancy. This means specialist drug and alcohol services need to be able work with a range of other agencies to ensure that all a young person’s needs are met, and must be complemented by other universal and targeted services, particularly for vulnerable young people at greatest risk of developing problems.

The biggest challenge continues to be cannabis. More than four-fifths of young people in specialist services have a problem with this drug (as their primary problem or as a subsidiary drug) – the highest level since comparable records began. It is too early to tell if the fall in young people seeking help for mephedrone is a trend. But the fact that numbers for the more established club drugs (ketamine and ecstasy) have increased suggests that club drugs and novel psychoactive substances will continue to be a challenge for services.


Findings logo commentary The featured report is a companion to similar ones on adult alcohol and drug treatment. Mirroring the featured report at the next age band up, the drug report revealed a sharp decline in the numbers of young adults (aged 18–24) treated for problem use of heroin or other opiates (including opiate/crack problems) from 11,309 in 2005/06 to 3,142 in 2013/14. At the same time, cannabis use has become more prominent, rising from 3,328 to 5,039 in 2013/14, when it accounted for 43% of all young adult treatment entrants. For both children and young adults, reducing treatment numbers reflect declining drug use and drinking among young people in the general population.

The crime reduction benefits of treating adult drug users derive mainly from those dependent on heroin and/or crack. Such benefits are not so clear among young patients, who mainly use other types of drugs. Nevertheless, immediate impacts plus the forestalling of future problems have been calculated to more than outweigh the costs of treating under-18s.

A striking statistic in the data report suggest a minor role for family-based therapeutic work, identified as undertaken with under 1% of patients. However, this seems an artefact of the way the figures are presented. Tables from the previous year record that 2,837 young person’s family work interventions were provided, 14% of all interventions. Even this may be thought low given that over 80% of the young patients were living with their families, and such approaches are recognised as among the most appropriate and effective for what are often multiply troubled youngsters. It could be that working with families is actually much more common, but not as a formal therapy thought to warrant recording in returns to the monitoring system, or that family dynamics are dealt with not by the addiction service, but by partner agencies. However, there does seem a real deficit. Based on the evidence, British practice standards on the care of young people with substance misuse problems from the Royal College of Psychiatrists commend family work, but say it is not standard in British services.

The standards also offer an additional possible explanation for recently falling numbers in treatment – the sometimes substantial withdrawal of funding and curtailing of young people’s substance use services, an explanation seemingly contradicted by low waiting times. However, it could be that referring agencies are sending fewer young patients to these services because they no longer have the same capacity to recognise, assess and act on those referrals, or that (as the report speculates) referral agencies have themselves contracted and are not making as many referrals as in previous years.

Last revised 19 January 2015. First uploaded 11 January 2015

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Monitoring and evaluating Scotland’s alcohol strategy. Fourth annual report.

Beeston C., Geddes R., Craig N. et al.
NHS Health Scotland, 2014.

Report evaluating Scotland’s national alcohol strategy concludes that changes to alcohol licensing laws are unlikely to have affected alcohol-related harm, but that the ban on quantity discounts in the off-trade and increased delivery of brief interventions may have contributed to recent declines in alcohol consumption and harms.

Summary The Scottish Government has tasked NHS Health Scotland with evaluating Scotland’s alcohol strategy through the Monitoring and Evaluating Scotland’s Alcohol Strategy (MESAS) programme of work. Key evaluation questions are:
• How and to what extent has implementing the measures (taken together and/or individually) in the Scottish alcohol strategy contributed to reducing alcohol-related harms?
• Are some people or businesses affected more than others?
• How might the strategy be implemented differently to improve effectiveness?

This fourth annual report from the programme includes the main findings from two studies published in 2014, one to assess the impact of increased investment in alcohol treatment and care services, the other to assess changes in knowledge and attitudes related to alcohol. It also provides an overview of results from studies detailed in previous annual reports which assessed the implementation of alcohol brief interventions in health service settings and the feasibility of their extension to youth work and social work settings, the implementation and impact of the Licensing Act, and the potential contribution of the external economic context.

Main findings

Scotland’s alcohol-related death rates have fallen by 35% since 2003 but remain 1.4 times higher than in 1981. Similarly, the alcohol-related new patient (hospitalisation) rate fell by 25% since 2007/08, but was still 1.3 times higher in 2013/14 than in 1991/92. Alcoholic liver disease hospitalisations followed a similar pattern to all alcohol-related hospitalisations: an upward trend in new patients presenting to hospital up to 2005/06, and then a decline until last year. By contrast, the new patient rate for alcohol psychosis, accounting for 17% of alcohol admissions (driven by alcohol ‘withdrawal’), continued to rise until 2007/08, and has plateaued but not declined since then.

Declines in alcohol-related harms are expected to follow a decline in the average quantity of alcohol consumed in the population. Per adult alcohol sales have continued to fall recently in Scotland, declining by 9% since the peak in 2009. Increases in alcohol service provision are also expected to contribute to a reduction in harms. In 2012, an estimated one in four adults with possible alcohol dependence actually accessed alcohol services, and providers and users of those services felt that increased investment in specialist treatment and care services had improved their quality and accessibility. Better understanding of the problems alcohol causes in Scotland are also expected to contribute to a decrease in harms, but except for increased awareness of the harm caused by alcohol, between 2004 and 2013 there was little notable change in population knowledge and attitudes related to alcohol.

Alcohol-related mortality rates in Scotland are almost twice those in England and Wales, but the rate peaked five years earlier in Scotland and declined more sharply. Changes to alcohol licensing laws are unlikely to have affected alcohol-related harm, but the ban on quantity discounts in the off-trade and increased delivery of brief interventions may have contributed to the declines in alcohol consumption and harms respectively. In addition, the decline in alcohol-related mortality in Scotland from the peak in 2003 may at least partly be explained by declines in disposable income in the lowest income groups. Some more detailed findings are presented below.

The Licensing Act was, in the main, perceived to have been implemented as intended and to have reduced irresponsible promotions in the on-trade. However, licensing boards found it difficult to address the public health objective of the Licensing Act and to apply assessments of the overprovision of licensed premises, and licensing forums struggled to function effectively.

The Alcohol Act implemented in Scotland on 1 October 2011 included a ban on quantity-based discounts and restrictions on the display and promotion of alcohol in Scotland’s off-trade. In its first year the Act was associated with a 2.6% decrease in per adult off-trade alcohol sales not evident in England and Wales, due mainly to reduced sales of wine. A statistically significant 1.7% reduction was estimated for Scotland after trends in England and Wales had been adjusted for in the analysis.

An earlier MESAS annual report included the results of a simulation model of the health impacts of the national alcohol brief interventions programme, concluding that it had made a small contribution to the decline in alcohol-related harm in Scotland, even under the most conservative assumptions.

The study of alcohol treatment and care services found 149 specialist alcohol treatment services in Scotland in 2012 which had treated 31,796 individuals, about one in four of all adults with possible alcohol dependence as indicated by their scores on the AUDIT questionnaire. In-depth consultation with service commissioners, providers and service users in three areas revealed that the additional resources for these specialist services and reform of local delivery arrangements were considered to have had a positive impact. The consultation also identified ongoing issues relating to service gaps, service planning, staffing, demand and missed appointments. Direct service user contact accounted for approximately one third of the time spent by staff on alcohol-related activities in services in the two areas which participated in this strand of the study.

Findings from the 2013 Scottish Social Attitudes Survey suggest adults in Scotland have a complex and sometimes contradictory relationship with alcohol. Many recognise its potential for harm, yet attitudes to getting drunk have not changed greatly since 2004. Alcohol is recognised as a ‘social lubricant’, but heavy drinking is seen as problematic and most recognise its long-term negative consequences. Slightly more support setting a minimum price per unit of alcohol than are against it, yet knowledge of the unit content of drinks has not improved over time. In 2013, around half of adults did not know the correct number of units in measures of alcoholic drinks. Just over 40% of both men and women correctly identified the recommended daily alcohol limits for their sex. Since 2004 the proportion of 18–29-year-olds who say getting drunk at weekends is acceptable has fallen from 53% to 40%, and the proportion of adults seeing alcohol as the drug causing most problems in Scotland rose from 46% to 60%. There has, however, been a small but significant increase in the proportion of people who think it easier to enjoy a social event if you’ve had a drink, from 35% in 2004 to 39% in 2013, and more people think others would see them as odd if they did not drink at all, up from 31% in 2007 to 41% in 2013.

The authors’ conclusions

Alcohol-related mortality and morbidity, and inequalities in these harms, are continuing to decline in Scotland, and on some measures are improving more quickly than in England and Wales. Alcohol sales are falling in both Scotland and England and Wales. It is likely that declining affordability of alcohol due to the economic downturn and the associated policy context across Great Britain in recent years is responsible for a substantial proportion of these improvements. However, the ban on quantity discounting of alcohol and the increased number of brief interventions delivered are likely to be contributing to the improvements seen in Scotland. Changing knowledge and attitudes around alcohol are unlikely to have had much impact.


Findings logo commentary Other MESAS reports analysed for the Effectiveness Bank deal in greater detail with alcohol treatment and care services, the implementation of alcohol brief interventions in health service settings, and the impact of the Licensing Act.

Last revised 09 January 2015. First uploaded 09 January 2015

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2016 Monitoring and evaluating Scotland’s alcohol strategy: Final annual report

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