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Cannabis is worth bothering with

The ‘explosion’ that never happened; crack and cocaine use in Britain

Promoting recovery through employment

Hepatitis C ‘giant’ still growing

Cannabis is worth bothering with

Investigating the proposition that cannabis is worth bothering with, this hot topic looks at reports that stronger cannabis on the market is increasing harms to users, prospects of recovery from disorders and dependence, and the emerging response to synthetic forms of cannabis like ‘spice’.

In 1990s Britain a common reaction to allocating resources to treating cannabis users was, ‘Why bother? We have more than enough patients with problems with serious drugs like heroin.’ The typically calming use of the drug by adults was seen as preferable to the main alternative – alcohol and its associated violence and disorder. Calls for a treatment response were seen as pathologising what in many societies is both normal and in some ways desirable youth development: trying new experiences, challenging conventions, and exposing the hypocrisy of alcohol-drinking adults.

In 1997 the Independent on Sunday launched a campaign to decriminalise cannabis, culminating in a mass ‘roll-up’, and 16,000-strong pro-cannabis march from Hyde Park to Trafalgar Square. Its Editor Rosie Boycott wrote in the paper about her own coming-of-age experience smoking cannabis, telling readers:

“I Rolled my first joint on a hot June day in Hyde Park. Summer of ’68. Just 17. Desperate to be grown-up. … My first smoke, a mildly giggly intoxication, was wholly anti-climatic. The soggy joint fell apart. I didn’t feel changed. But that act turned me – literally – into an outlaw. I was on the other side of the fence from the police – or the fuzz, as we used to call them. So were a great many of my generation.”

The campaign was explosive, but short-lived, apparently subsiding when Boycott left to take up her role as Editor of the Daily Express. A decade later, the Independent issued an apology for the campaign. ‘If only they had known then, what they knew now’, was the message of the article, referring to the reportedly damaging impact of the more potent strains of cannabis and its links to “mental health problems and psychosis for thousands of teenagers”.

Are stronger strains creating more problems?

There has been a long-standing, but controversial, association between cannabis strength and harm. Reading newspaper articles on the subject, it wouldn’t be unusual to see a headline drawing a straight line between ‘super-strength skunk’ and addiction, violence, deaths, or psychosis. In 2008, then Prime Minister Gordon Brown spoke in a similar vein, telling a breakfast-television viewing audience:

I have always been worried about cannabis, with this new skunk, this more lethal part of cannabis.
I don’t think that the previous studies took into account that so much of the cannabis on the streets is now of a lethal quality and we really have got to send out a message to young people – this is not acceptable.

Brown was warning of a dangerous new strain of cannabis on the market, that caused very severe harms to users – contrasting starkly with the common perception of cannabis as a ‘low harm’ or ‘no harm’ drug.

The strength or potency of cannabis is determined by the amount of ‘THC’ it contains. THC produces the ‘high’ associated with cannabis, and another major component ‘CBD’ produces the sedative and anti-anxiety effects. As well as potency, the relative amounts of THC and CBD are important for understanding the effects of cannabis – something explored in a University College London study during the programme Drugs Live: Cannabis on Trial. The research team compared two different types of cannabis: the first had high levels of THC (approx. 13%) but virtually no CBD; and the second had a lower level of THC (approx. 6.5%) and substantial amounts of CBD (approx. 8%). They found that CBD had a moderating or protective effect on some of the negative effects of THC, and that “many of the effects that people enjoy are still present in low-potency varieties without some of the harms associated with the high-potency varieties”.

At least in the US over the last two decades (between 1995–2014), potency has increased from around 4% to 12%, and the protective CBD content of cannabis has decreased, from around 28% to less than 15%, significantly affecting the ratio of THC to CBD, and with it, the nature and strength of the psychoactive effect of cannabis.

Until the 1990s, herbal cannabis sold in the UK was predominantly imported from the Caribbean, West Africa, and Asia. After this time, it was increasingly produced in the UK, being grown indoors using intensive means (artificial lighting, heating, and control of day-length). A study funded by the Home Office analysed samples of cannabis confiscated by 23 police forces in England and Wales in 2008, and found that over 97% of herbal cannabis had been grown by intensive methods; its average potency of 16% compared with just 8% for traditional imported herbal cannabis. This matched other reports of home-grown cannabis being consistently (around 2–3 times) stronger than imported herbal cannabis and cannabis resin.

In 2015, observing a decrease in the use of cannabis in England and Wales, but parallel increase in demand for treatment, a UK study examined whether the trend could be explained by an increase in the availability of higher-potency cannabis. Over 2500 adults were surveyed about their use of different types of cannabis, severity of dependence, and cannabis-related concerns. The researchers found that higher potency cannabis was associated with a greater severity of dependence, especially in young people, and was rated by participants as causing more memory impairment and paranoia than lower potency types. However at the same time, it was reported to produce the best ‘high’, and to be the preferred type.

By definition cannabis is a psychoactive substance, which means it can change people’s perceptions, mood, and behaviour. Higher potency cannabis contains more of the psychoactive component, so it makes sense that higher potency cannabis could increase the risk of temporary or longer-term (adverse) problems with perceptions, mood, and behaviour. However, there is a particular concern that cannabis use could be linked to ‘psychosis’, a term describing a mental illness where a person perceives or interprets reality in a very different way to those around them, which can include hallucinations or delusions.

Whether cannabis causes psychosis, precipitates an existing predisposition, aggravates an existing condition, or has no impact at all on psychotic symptoms, has for decades been hotly contested. With our focus on evaluations of interventions, Drug and Alcohol Findings is in no position to pronounce on this issue, nor on the possibility that the drug might sometimes improve mental health, but some examples of research informing this debate are included below.

A 2009 UK study examined whether daily use of high-potency cannabis was linked to an elevated risk of psychosis, comparing 280 patients in London presenting with a first episode of psychosis with a healthy control group. The patients were found to be more likely to smoke cannabis on a daily basis than the control group, and to have smoked for more than five years. Among those who used cannabis, 78% of the patients who had experienced psychosis used higher-potency cannabis, compared with 37% of those in the control group. The findings indicated that the risk of psychosis was indeed greater among the people who were using high potency cannabis on a frequent basis, but couldn’t show that the cannabis use caused the psychosis, or even that the cannabis use made the group more susceptible to psychosis. The wider literature on mental health and substance use would suggest that the association is more complex than this.

A recently published paper from the University of York has demonstrated the complications of attributing any association between cannabis use and psychosis to a causal effect of cannabis use rather than other factors or a reverse causal effect. A calculation based on data from England and Wales helped to put this into perspective, indicating that even if cannabis did cause psychosis more than 20,000 people would need to be stopped using cannabis to prevent just one case of psychosis.

The apparent steady increase in cannabis potency in the UK since the 1990s is important context for further research. Where higher potency cannabis is increasingly becoming the norm, and is the preference for cannabis users, it would be relevant to generate more evidence of the health-related problems with high potency cannabis, and the treatment and harm reduction solutions based around these health-related problems.

Cannabis accounts for half of all new drug treatment patients


First-time treatment entrants in the European Union by primary drug, 2006–12

The most widely used illegal drug in Europe, many seemingly enjoy cannabis without it leading to any significant negative social or health effects. However, numbers entering treatment for cannabis use problems have been on the rise (both in the UK, and the rest of Europe), while heroin treatment numbers have fallen chart. According to Public Health England, this is not because more people are using cannabis, but perhaps because services relieved of some of the recent pressure of opiate user numbers are giving more priority to cannabis, because they are making themselves more amenable to cannabis users, and because of emerging issues with stronger strains of the drug.

Whatever the causes, across the UK figures submitted to the European drug misuse monitoring centre show that the proportion of patients starting treatment for drug problems who did so primarily due to their cannabis use rose steadily from 11% in 2003/04 to 22% in 2011/12. With the caveat that data from 2013 onwards is not directly comparable due to changes in methodology, in 2014 and 2015 the proportion of patients who entered treatment primarily because of a cannabis issue hovered above previous years at 26% (25,278 and 26,295 respectively). Among first ever treatment presentations, the increase from 2003/04 was more pronounced, from 19% to 37%. By 2013, cannabis use had become the main prompt for half the patients who sought treatment for the first time (at 49%), and stayed relatively constant at 47% in 2014, and 48% in 2015.

Primary drug of patients starting treatment, UK, 2003/04 to 2015

Showing that more users was not the reason for more starting treatment, over about the same period, in England and Wales the proportion of 16–59-year-olds who in a survey said they had used cannabis in the past year fell from about 11% to 7% in 2013/14, then stayed at that level in 2014/15 and 2015/16.

The treatment figures largely reflect trends in England, where in 2013/14 the number of patients starting treatment with cannabis use problems had risen to 30,422, 21% of all treatment starters, up from 23,018 and 19% in 2005/06. Subsequently the number dropped to 27,965 in 2015/16, still around a fifth of all treatment starters. Among the total treatment population – starting or continuing in treatment – cannabis numbers rose from 40,240 in 2005/06 to peak at 64,407 in 2013/14 before falling back to 59,918 in 2015/16; corresponding proportions again hovered around a fifth.

As a primary problem substance among under-18s cannabis dominated, accounting for three-quarters of all patients in treatment in 2015/16 and in numbers, 12,863. The dominance of cannabis increased from 2008/09 as numbers primarily in treatment for drinking problems fell.

‘All treatments appear to work’

According to the two main diagnostic manuals used in Europe and the USA, problem cannabis use can develop into a cannabis use disorder or cannabis dependence, identifiable by a cluster of symptoms including: loss of control; inability to cut down or stop; preoccupation with use; neglecting activities unrelated to use; continued use despite experiencing problems; and the development of tolerance and withdrawal.

This level of clinical appreciation for cannabis use problems didn’t exist when researcher and writer William L. White entered the addictions field half a century ago:

“When I first entered the rising addiction treatment system in the United States nearly half a century ago, there existed no clinical concept of cannabis dependence and thus no concept of recovery from this condition. In early treatment settings, cannabis was not consider[ed] a “real” drug, the idea of cannabis addiction was scoffed at as remnants of “Reefer Madness,” and casual cannabis use was not uncommon among early staff working in addiction treatment programs of the 1960s.

Many in the field remain sceptical of the idea of cannabis dependence, specifically whether problem users at the severe end experience physiological withdrawal. However, reviewing what they believe is mounting evidence, these authors suggest there can be confidence in the existence of a “true withdrawal syndrome” – albeit one that differs qualitatively from the “significant medical or psychiatric problems as observed in some cases of opioid, alcohol, or benzodiazepine withdrawals”. In the case of cannabis, the main symptoms are primarily emotional and behavioural, although appetite change, weight loss, and some physical discomfort are reported. A brief review aimed at practitioners in UK primary care provides guidance on how to manage symptoms of withdrawal among patients trying to stop or reduce their cannabis use.

Research has come a long way, says William L. White, with now “clear data supporting the dependency producing properties of cannabis, a clear conceptualization of cannabis use disorders (CUD) and cannabis dependence (CD)”, but until recently, very little evidence about the prospects of long-term recovery. Yet, key papers – found here and here – indicate that:
• Full remission from cannabis use disorders is not only possible, but probable.
• Stable remission takes time – an average of 33 months.
• Abstinence may not be initially realistic for heavy cannabis users – but those in remission are usually able to reduce the intensity of their use and its consequences.

At least in the United States, it seems dependence is more quickly overcome from cannabis than the main legal drugs. A survey of the US general adult population found that within a year of first becoming dependent, 3% each of smokers and drinkers were in remission and remained so until they were surveyed. For cannabis the figure was nearly 5% and for cocaine, nearly 9%. After ten years the proportions in remission had risen to 18% for nicotine, 37% for alcohol, 66% for cannabis and 76% for cocaine. About 26 years after first becoming dependent, half the people at some time dependent on nicotine were in remission, a milestone reached for alcohol after 14 years, for cannabis six years, and for cocaine, five.


Specialised treatment programmes for cannabis users in European countries

Generally for people with cannabis use problems, the European Monitoring Centre for Drugs and Drug Addiction concluded in 2015, and before that in 2008, that “all treatments appear to work”. For adults, effective treatments include motivational interviewing, motivational enhancement therapy and cognitive-behavioural therapy, and for younger people, family-based therapies seem most beneficial. Less important than the type of treatment is the treatment context and the individual’s determination to overcome their problems through treatment. And there is “no firm basis for a conclusion” that cannabis-specific interventions (designed around the risks and harms associated with cannabis) are more effective than general substance use treatment tailored to the individual needs of the cannabis user seeking treatment chart.

In some studies brief interventions have been found to work just as well as more intensive treatment, but when the patients are heavily dependent, and the most difficult cases are not filtered out by the research, longer and more individualised therapies can have the advantage.

When the World Health Organization trialled its ASSIST substance use screening and brief advice programme in Australia, India, the United States, and Brazil, just over half the identified patients (all had to be at moderate risk of harm but probably not dependent) were primarily problem cannabis users. Among these, risk reduction in relation to this drug was significantly greater among patients allocated to a brief advice session than among those placed on a three-month waiting list for advice. In each country too, risk reduction was greater among intervention patients, except for the USA, where the order was reversed. Suggesting that severity of use was not a barrier to reacting well to brief intervention, only patients at the higher end of the moderate risk spectrum further reduced their cannabis use/risk scores following intervention. The ASSIST study was confined to adults, but young people in secondary schools in the USA whose problem substance use focused mainly on cannabis also reacted well to brief advice.

The relative persistence of opiate use problems versus the transitory nature of those primarily related to cannabis seemed reflected in an analysis of treatment entrants in England from 1 April 2005 to the end of 2013/14, the last time this particular analysis was published. At the end of this period just 7% of primary cannabis users were still in or back in treatment compared to the 30% overall figure and 36% for primary opiate users. The figure peaked at 43% for users of opiates and crack. Over half – 53% – of primary cannabis users had left treatment as planned, apparently having overcome their cannabis problems, compared to 27% of primary opiate users and just 20% with dual opiates and crack use problems. Another 40% of cannabis users had left treatment in an unplanned manner, a slightly higher proportion than among opiate users. The figures tell a tale of relatively high level of success which enables cannabis users to leave treatment, though even in the absence of recorded success, few stay long-term.

However, the forms patients in England complete with their keyworkers while in treatment seem to tell a different story. Compared to how they started treatment, around six months later 45% of primary cannabis users were assessed as using just as often (including a few using more), compared to 30% of opiate users and 42% whose main problem drugs were both opiates and crack, suggesting more rapid and/or more complete remission for opiate users than for cannabis users. One interpretation is that the widespread use of substitute drugs like methadone more reliably reduced the illegal opiate use of opiate users and also helped retain them in treatment, while cannabis users tended quickly to leave treatment, having done well or not. However, these figures relate only to patients who completed the forms at their six-month review, which in practice could have happened anywhere from about one to six months after their assessment for treatment. What proportion of primary cannabis users were still in treatment at that point and available to complete the forms is not clear, but they may have been the patients whose problems were deep seated enough to require extended treatment.

Enjoyable and trouble-free for many, but not without harms

Harm reduction – the “set of practical strategies and ideas aimed at reducing negative consequences associated with drug use” – is mostly associated with ‘harder’ drugs like heroin, for which blood-borne viruses and drug-related deaths are clear and severe risks. Yet while “many people experience cannabis as enjoyable and trouble free”, there are also varying degrees of harm with this drug depending on the characteristics of the person using, the type of the cannabis, and the way they consume it.

Many formal cannabis harm reduction programmes borrow from the fields of alcohol and tobacco. Advice includes:
• safer modes of administration (eg, on the use of vaporisers, on rolling safer joints, on less risky modes of inhaling)
Many people experience cannabis as enjoyable and trouble free … some people require help to reduce or stop • skills to prevent confrontation with those who disapprove of use
• encouraging users to moderate their use
• discouraging mixing cannabis with other drugs
• drug driving prevention and controls
• reducing third-party exposure to second-hand smoke
• education about spotting signs of problematic use
• self-screening for problematic use

In some parts of the UK, National Health Service tobacco smoking cessation services incorporated cannabis into their interventions with adults; and Health Scotland, also addressing the risks of tobacco and cannabis smoking, published a booklet for young people titled Fags ‘n’ Hash: the essential guide to cutting down the risks of using tobacco and cannabis.

Vaporising or swallowing cannabis offers a way to avoid respiratory risks, but only a minority of cannabis do this, most choosing to smoke cannabis joints (or cannabis and tobacco joints). While not all will know about the different health risks, cannabis users may choose against safer consumption methods anyway for a range of reasons (including their own thoughts about safe use):
• Users may find it easier to control the effects (eg, severity, length of effect) of cannabis when inhaling in the form of a joint or spliff
• Preparing and sharing joints can be an enjoyable part of the routine, or part of a person’s social activities
• Alternative methods of smoking (eg, bongs and vaporisers) may be inconvenient to use, or expensive to buy

Most harm reduction advice is delivered informally long before users come into contact with drugs professionals – for example through cannabis magazines, websites, and headshopshighlighting the importance of official sources engaging with non-official sources to promote the delivery of accurate, evidence-based harm reduction messages.

A new high

In May 2016 the Psychoactive Substances Act placed a ‘blanket ban’ on new psychoactive substances (previously known as ‘legal highs’), including synthetic cannabinoids (synthetic forms of cannabis).

Prior to this, in 2014, there had been 163 reported deaths from new psychoactive substances in the UK, and 204 the year after. The average age was around 28, younger than the average age for other drug misuse deaths of around 38. The fact that these psychoactive substances – which produced similar effects to illicit drugs like cannabis, cocaine, and ecstasy – could be bought so easily online or on the high street, appeared inconsistent; and each fatality prompted “an outcry for something to be done to prevent further tragedies”. This was the context (and arguably the political trigger) for the introduction of the Psychoactive Substances Act. While possession of a psychoactive substance as such wasn’t criminalised;, production, supply, offer to supply, possession with intent to supply, import or export were – with a maximum penalty of seven years’ imprisonment.

Just seven months after the Act came into effect, the Home Office labelled it a success, with a press release stating that nearly 500 people had been arrested, 332 shops around the UK had been stopped from selling the substances, and four people had been sent to prison. But did the Psychoactive Substances Act have the presumably desired effect of limiting access to psychoactive substances (and reducing deaths), or did it just push the drugs the way of dealers? It is perhaps too early to tell, but former chair of the Advisory Council on the Misuse of Drugs Professor Nutt had warned before the Act came into effect that the ‘blanket ban’ would make it harder (not easier) to control drugs. And while Chief executive of DrugWise Harry Shapiro had said the new law would make new psychoactive substances harder to obtain, he also agreed that sale of the drugs would not cease, but merely be diverted to the illicit market: “The same people selling heroin and crack will simply add this to their repertoire.”

The paper “From niche to stigma” examined the changing face of the new psychoactive substance user between 2009 and 2016, focusing on people using the synthetic cannabis known as ‘spice’. It looked at the transition of (then) ‘legal highs’ from an “experimental and recreational” scene associated with a “niche middle class demographic”, to “those with degrees of stigma”, especially homeless, prison, and socially vulnerable youth populations (including looked after children, those involved in or at risk of offending, and those excluded or at risk of exclusion from mainstream education). In 2014, the DrugScope Street Drug Survey also observed a problem among these particular groups, recording a “rapid rise in the use of synthetic cannabinoids such as Black Mamba and Exodus Damnation by opiate users, the street homeless, socially excluded teenagers and by people in prison”.

‘Spice’ and other synthetics

Cannabis contains two key components:
• ‘THC’ (tetrahydrocannabinol), which produces the ‘high’
• ‘CBD’ (cannabidiol), which produces the sedative and anti-anxiety effects

Synthetic forms of cannabis contain chemicals that aim to copy the effects of ‘THC’ in cannabis. But the effects of synthetic cannabis can be quite different (and often stronger): firstly, because synthetic production makes it easier to manipulate the amount of the THC-like chemical; and secondly, because of the absence of the moderating equivalent of ‘CBD’.

Some synthetics are purposely designed to resemble herbal cannabis, and can be consumed in the same ways (eg, smoked or inhaled). The names also often have deliberate cannabis connotations. The risk of this is that people wishing to take cannabis may be initially unaware that they have been sold the synthetic form, or may believe from the look of it that it will produce similar sought-after effects. The greater intensity of synthetic cannabis at lower dose levels ( box) ensures that it has an appeal in terms of potency and affordability, but may put those with fewer resources at greater harm.

In 2014, the prison inspectorate for England and Wales raised concerns about the rise in the use of psychoactive substances in prisons, in particular synthetic cannabis. A study set in an English adult male prison found that the nature of the market was posing significant challenges to the management of offenders. There, the primary motivation for consumption was being able to take a substance without it being detected. Given this motivation, and the greater likelihood of harms from synthetic versus natural cannabis, the researchers concluded that it was imperative for mandatory drug-testing policies to be revised, and instead rooted in harm reduction – something which would also apply to people on probation subject to mandatory drug-testing.

Cannabis throws up a range of issues rather different from those associated with the drugs treatment in the UK has normally focused on. If current trends continue, understanding the findings will become yet more important to British treatment services.

Last revised 10 July 2017. First uploaded 01 March 2011

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The ‘explosion’ that never happened; crack and cocaine use in Britain

Much of this hot topic is devoted to challenging beliefs that cocaine and especially its smokable form crack are uniquely addictive, and their adherents, uniquely hard to treat. Those beliefs have multiple roots which stretch back to lurid concerns that cocaine would undermine the World War I war effort. Then and up till relatively recently, the cocaine concerned came in powder form ‘snorted’ up the nose or injected, generating what could be an intense stimulant and euphoric impact with residual effects lasting about an hour. Though the effect was similar to amphetamine, it was much more short-lived, lending itself to repeat-hit ‘binges’. However, the modern-day resurgence of concern over cocaine in Britain can be traced back to 20 April 1989, when Robert Stutman, head of the US Drug Enforcement Administration’s New York Division, addressed Britain’s chief police officers.

What the concern was all about – crack ready for the retail market

What the concern was all about – crack ready for the retail market

‘Bob’ Stutman’s concern was not cocaine powder, but the new form manufactured as small ‘rocks’ called ‘crack’. In the mid-1980s crack was developed as a smokable form easier and cheaper to produce than freebase cocaine, an earlier smokable derivative. While cocaine powder had a reputation as the drug for the ‘champagne set’ and business high-flyers, crack lent itself to mass production and mass distribution in small quantities to the “persistent poor”. Rapidity of onset and intensity of effect joined to create what to some was an appealing ‘rush’ otherwise available only at greater expense and/or by injecting.

To this day in Britain, cocaine powder is associated more with affluence, recreational use and ‘good times’ than crack. Though these are the same drug in different forms, the modes of use, the uses, and the users, demand where possible separate consideration.

By redressing the balance tipped so graphically by Bob Stutman and others, this hot topic entry does not mean to imply that use of these products is a trivial issue – just that even in the form of crack, cocaine dependence is not uniquely destructive of the resources needed to recover from dependence, and that even among drug treatment populations, most do so relatively quickly compared to the general treatment caseload largely dependent on opiate-type drugs. By not addressing these here, neither do we mean to discount the “significant harm” that can arise even from episodic use of cocaine, stressed by the UK’s Advisory Council on the Misuse of Drugs in their report on cocaine powder published in 2015.

‘Three Hits Can Get You Hooked’

Bob Stutman: Still a “powerful” speaker. “No one else presents the hard facts like The Stutman Switalski Group.”

Still a ‘Powerful’ speaker. Bob Stutman pictured on his web site: “No one else presents the hard facts like The Stutman Switalski Group.”

A powerful speaker credited on an earlier version of his web site with bringing crack to national attention in the USA and “single-handedly changing the policy of the United States DEA”, Bob Stutman set about waking up the UK to the imminent threat. His story of an “explosion” of crack use and related violence in New York ignited rumbling worries that cocaine and crack could turn Toxteth, Handsworth and Deptford into US-style drug ghettos. Most startling was his revelation that “A study that will be released in the next two to three weeks will probably say that of all of those people who tried crack three or more times, 75 per cent will become physically addicted at the end of the third time … We now know that crack is the single most addicting drug available in the United States of America today and certainly the most addicting drug available in Europe. Heroin is not even in the same ballpark.” Unless forestalling action was taken immediately, Britain would, he warned, see the US experience replicated within two years.

Describing the effects of crack to the UK’s chief police officers in September 1989, Dr Tuckson, Commissioner of Public Health in Washington, directly challenged notions that the welfare-cushioned and less racially divided Britain would not react to crack in the same way as some of the USA’s poor black neighbourhoods: “Cultural differences are certainly not great enough to make me suspect that you have any inherent immunity to the effects that this drug will have or can have on your society. I know there is nothing particularly unique about the water … in your country that would prevent the neurotransmitters and the pleasure centres of the brains of your citizens [being] overwhelmingly affected by the instantaneous and powerful euphoria that this drug presents. All you have to do is do it once and I guarantee you any, almost any human being would want to do it again.”

Later in 1989 in London Bob Stutman was paired at a conference on crack with Dr Mark Gold, founder of the USA’s Cocaine-800 helpline. While Stutman told his tales from the street, Dr Gold offered scientific evidence of crack’s addictiveness and violence-inducing properties. Officer Stutman and Dr Gold had been invited to the conference by the Corporation of the City of London, whose delegation had been “deeply shocked” by a visit to New York. The conference ended with an address from the City’s Lord Mayor. He’d had to leave for part of the day and came back with a resounding attack on the “doubting Thomases” in Britain who were the “biggest problem” because they did not believe the clear evidence about crack, such as that three shots can “effectively kill the brain”.

On these claims much else hinged: if crack was this addictive, as well as directly provoking violence, it could lead users to commit violent crimes to get it, promise massive profits to its dealers, and devastate whole communities. The month after his address to police officers Stutman’s key statement appeared as a headline in the Sun tabloid newspaper (25 May 1989): “Three Hits Can Get You Hooked” was their version of his “terrifying statistics”. Before the Sun’s report, the as yet unseen study cited by Stutman had become a “survey” which “showed” these disturbing facts (Times, 19 May 1989). Later the “survey” was attributed to an impeccable source – the Home Office itself (Grimsby Evening Telegraph, 2 August 1989).

Study, survey and source were illusory, but Stutman’s riveting message lived on. Senior British police officers “attempted to trace the studies and the figures he quoted and found they don’t exist” (Independent, 27 July 1989). Still, the House of Commons Home Affairs Committee released an emergency interim report on crack with these same discredited ‘facts’ highlighted in bold. The following year a BBC Radio File on Four investigation (10 April 1990) nailed down the credentials of Stutman’s address. It was, they concluded, “littered with misinformation”. The claim that 73% of child-battering deaths in New York in 1988 were perpetrated by crack-using parents was based on just two such deaths, one of which also involved chronic alcoholism, and Stutman was still unable to produce the ‘three hits and you’re addicted’ study.

It was not that crack never became a problem in the UK. It did, and in some localities, a big one, but Britain’s crack and cocaine problems never rivalled the US experience. The supposed hooking power of the drug, if it emerged at all, emerged from a constellation of circumstances, not deterministically from merely trying it a few times, and circumstances were different in the UK from those in the USA. Rather than the explosively destructive epidemic foreseen by officer Stutman, crack crept up to become an established featured of the UK drug scene and of the treatment caseload. In line with population-wide trends, that caseload has been declining since around 2008. Instead of being hard to stop using, crack as well as cocaine turned out to be hard to continue to use at excessive levels. And rather than being ‘out of the ball park’, heroin seems a drug much harder to leave behind – themes elaborated below.

Slow-burn spread now on the way down

A UK-wide perspective on the cocaine and crack treatment caseloads is provided by reports collated for the European Union’s drug misuse agency. Before 2015 the figures included prisoners only for Northern Ireland. From 2015 prisoners in England were included, but unless specified otherwise, the figures reported here exclude them in order to maintain continuity.

Primary drug of patients starting treatment, UK, 2003/04 to 2015

As the primary drug in relation to which adult patients started treatment (either for the first time or returning after a break), across the UK since 2010 cocaine powder or crack have accounted for about 1 in 8 treatment starters, down from a peak of about 1 in 7 in 2008/09. Though in recent years the proportions were relatively stable, the total number of treatment starters has been falling, meaning that the numbers of cocaine/crack treatment starters has also been falling, down from about 20,200 in 2008/09 to about 12,500 in 2015, a drop of nearly 40%. Where in the early 2000s crack was the main form in which cocaine was used by treatment starters, by 2015 its use as the patient’s primary drug had diminished to just 3% of all treatment starters and cocaine powder accounted for three times as many, just over 9% chart.

Of treatment starters a minority (in 2015, 34,358 out of 101,919) are starting treatment for the very first time. Among these neophytes crack as a primary drug of choice is even less apparent, accounting in 2015 for just over 2% of all first-time treatment starters, in numbers, only about 722 patients across the whole of the UK. Cocaine powder is much more prominent, accounting for 14%, in numbers, about 4810 patients. Commenting on these figures, Public Health England argued that the greater relative prominence of crack among patients re-starting treatment after a break than among those entirely new to treatment, meant crack users are more likely to undergo multiple episodes of treatment than patients primarily dependent on cocaine powder. In turn, the implication is that crack use is associated with a higher post-treatment relapse rate, leading more often to a return to treatment.

Substance use problems among patients in treatment, England from 2005/06

Though uncommon as the main substance on which patients starting treatment are dependent, crack is much more common as a secondary drug. In 2015 it was noted for 23,540 patients (this total includes prisoners in England) in the UK primarily dependent on other substances, of which heroin (94% of cases) was by far the most common. The proportion of primary heroin clients entering treatment in the UK reporting secondary use of crack cocaine has been increasing since 2003/04, in 2015 accounting for 45% of all primary heroin presentations, up from 38% in 2013. However, these UK averages hide a very different picture in different countries. In England, crack use was reported by 43% of primary users of drugs like heroin, but in Scotland and Northern Ireland, only 3.3% and 1.6% respectively.

For England, figures for treatment starters can be supplemented by figures for all patients treated for drug or alcohol problems some time during a year, whether treatment starters or continuing in treatment. Of all 288,843 patients during 2015/16, 27,958 were recorded as problem users of cocaine powder and 66,208 of crack, of whom 93% were also problem opiate users. Just 4585 were problematically using crack without also having problems with opiates chart.

Crack use diminishing in population

As well as being a peak for treatment numbers, at 3%, 2008/09 was also the peak in the proportion of 16–59-year-olds in England and Wales who when surveyed said they had used cocaine or crack in the past year. That figure fell to 1.9% in 2012/13 before rising slightly to 2.3% or 2.4% from 2013/14 to 2015/16. In the final of those years all but 0.2% of the 2.4% of the population who had used the drug said they had used it in the form of cocaine powder, making it the second most commonly used illegal drug after cannabis. For this variant of cocaine, use levels seem similar in Scotland. Across the UK, most of these past-year users have taken the drug just a few times during that period, well short of any suggestion of dependence; just 2% in Scotland considered themselves dependent.

Problem drug users estimates; England from 2004/05

However, household surveys can greatly underestimate use of stigmatised drugs and those commonly used by people not residing in settled households. Studies of problem drug use conducted between 2004/05 and 2011/12 (2004/05 2005/06 2006/07 2008/09 2009/10 2011/12) in England have instead estimated crack use by triangulating from treatment and criminal justice statistics. The resulting estimates are probably more realistic than those from household surveys, but are confined to problem users, defined as users of opiates and/or crack whose use has brought them into contact with treatment services or the criminal justice system. Corresponding estimates for Scotland do not include crack.

The English figures confirm that problem crack use is rare – in 2011/12 (latest estimates) involving 166,640 adults aged 15 to 64, equivalent to about half a per cent (or 1 in 200) of the population of that age in England. Most were using crack alongside opiates like heroin; it can be estimated that very roughly about 38,000 adults were using crack without also using opiates, equivalent to under a quarter of all problem crack users chart.

Crack’s peak in this series of estimates came in 2005/06 with an estimated 197,568 problem users or about 0.6% of the 15–64-year-old population. The upper range of that estimate remained well above the lower range in 2011/12, suggesting that the 16% fall in the estimate between those years was no fluke of sampling, but real. Neither was it entirely due to diminishing opiate use leading to a corresponding fall in the accompanying use of crack, because numbers using crack but not opiates seem also to have fallen from a peak of roughly 59,000 in 2008/09 to 38,000 in 2011/12, down by about 36% chart.

Most patients stop using

For heroin there are effective pharmacological treatments like methadone to more safely and legally meet the patient’s need for opiate-type drugs, and naltrexone to block the effects of opiates and promote abstinence. For cocaine, decades of searching have failed to find a recognised drug-based treatment (1 2), and no specific psychosocial therapy has been constructed which can fill the therapeutic gap. Instead, services have turned to less conventional methods such as acupuncture, yet studies show that too fails to help.

England treatment starters sampled in 2006 and 2007: % of baseline users of that drug not using at follow-up. Of the heroin users who could be followed up (many patients were not), three to five months after starting treatment 44% had stopped using, and about a year after, 49%. Corresponding figures for stopping crack use were higher at 53% and 61% respectively, and for cocaine powder, 75% and 68%

Serial disappointment in research terms might lead some to conclude that in practice too, when it comes to cocaine and crack, ‘nothing works’. But unlike many drug trials with their placebo controls, research on psychosocial treatments is usually about whether the evaluated intervention works better than an established or alternative therapy, not whether it works at all. The findings can be interpreted to mean that just about any bona fide counselling or therapeutic approach helps some people some of the time, often many much of the time, and usually to roughly the same degree. Though no specific approach has been proven, the consensus is that “Psychosocial interventions such as [cognitive-behavioural therapy] and contingency management remain the mainstay of treatment.” These do not have to be very sophisticated, though severe cases may need continuing support and residential care (1 2).

As to the ‘not in the same ball park’ claim about the respective addictiveness of crack and heroin, that seems partly true, but in the opposite direction to that suggested by Bob Stutman. In the latest English national drug treatment study, primary users of crack and cocaine powder were more likely to stop using than were primary heroin users. Of the heroin users who could be followed up (many patients were not), three to five months after starting treatment 44% had stopped using, and about a year after starting treatment, 49%. Corresponding figures for stopping crack use were higher at 53% and 61% respectively, and for cocaine powder, 75% and 68% chart.

Routinely collected statistics tell a similar story. In England in 2015/16 assessments of patients still in treatment after about six months indicated that two-thirds whose drug problems included cocaine powder and around 45% for crack had become abstinent from those drugs, compared to 39% recorded as having stopped using opiates. When not complicated by opiate use problems, around 60% of patients had stopped using crack. If (as usually it did) crack use accompanied opiate use problems, it more often persisted, but still 43% of opiate/crack patients had stopped using crack compared to 32% who stopped using opiates. When cocaine treatment numbers peaked in England in 2008/09, a special analysis showed that if patients stopped using or reduced their use of powder cocaine, they also reduced their use of other substances, indicating that cocaine use reductions had not been at the expense of increased use of other drugs.

In Wales and Scotland too, similar assessments tell a story of abstinence as the most common known outcome for cocaine-dependent patients. In Wales between 2009 and 2016, 68% of cocaine users were recorded as no longer using the drug at their treatment exit reviews compared to 56% of opiate users. In Scotland in 2011/12, reviews three months after treatment entry recorded that 80% of powder cocaine users and all the (small number of) crack users were no longer using these drugs.

Statistics based on in-treatment assessments are dependent on patients being still in treatment and available for assessment, the assessment being conducted, recorded and notified to the relevant database system, and the patient and their keyworker accurately documenting the patient’s drug use. Many patients are lost track of along the way, a major limitation not applicable to the same degree to records of treatment exit and re-entry. In England, some 44% of primarily crack-dependent patients (re)starting treatment between 2005/06 and 2013/14 were recorded as having completed their treatments, left free of dependence, and not later having to return. For cocaine powder, the corresponding proportion was 55%, both much higher than the 27% for opiates. The implication is that treatment failure and/or post-treatment relapse are more common for patients treated for problem opiate use than for those treated for problem use of cocaine powder or crack. For cocaine powder, the completion and non-return proportion was slightly higher than the 53% for cannabis, not normally considered an extraordinarily addictive substance. Add in what was probably a substantial number of patients who left treatment prematurely but nevertheless overcame their dependence, and a clear majority of patients once dependent on cocaine or crack can be presumed to have been able to manage without having to return to treatment.

Proportion of dependent users in the US population in remission after 1 or 10  years and predicted over lifetime: shows that remission rates are higher for formerly dependent cocaine users than for those formerly dependent on alcohol, tobacco or cannabis

For the USA we can broaden the picture beyond treatment to the general population of cocaine users. Among the general US population, within a year of first becoming dependent nearly 9% of cocaine/crack users were in remission and within ten years, 76%, both substantially higher than for drinking, smoking or using cannabis chart. That African Americans were half as likely to be in remission from cocaine/crack dependence as their white counterparts suggests that the resources available to the individual to make and sustain their break from cocaine are a critical factor.

Such differences as there are between the recovery rates from dependence on crack and cocaine powder can largely and perhaps entirely be explained not by the greater inherent addictiveness of crack, but by the nature of its regular users. Even among the treatment caseload, in Britain users of cocaine powder are on average endowed with greater recovery resources than the typical drug treatment patient. They are less likely to have had their resources eroded by conviction and imprisonment and more likely to be in paid employment or education. Alongside the US figures, it can be inferred that the relatively good prognosis of the average user of cocaine powder is partly due to their having a better stock of ‘recovery capital’ resources with which to extricate themselves out of dependence. In the general population too, despite some spread to poorer neighbourhoods, still in 2013/14 in England and Wales, cocaine powder use remained most common in the more affluent urban areas and among regular pub and nightclub goers, signs of its association with the ‘good time’ available to the well-off rather than the less favoured demographic associated with dependent heroin/crack use.

Thanks for their comments on this entry in draft to Tim Millar of the University of Manchester in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 06 July 2017. First uploaded 01 March 2010

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Promoting recovery through employment

Almost wherever you look among the UK’s national drug policies in England, Scotland and Wales (and perhaps only peripherally in Northern Ireland), employment is seen as both an asset to rehabilitation and recovery from dependent drug use, and a social obligation for drug users who can work and contribute to society. In contrast, employment is more likely to feature in alcohol strategies as a benefit of leisure industries.

Setting the stage for a discussion of employment interventions, this hot topic first examines the prominence of unemployment in the population of problem substance users, and the many barriers to work. It also raises questions about: how realistic competitive employment is for people whose lifestyles have revolved around obtaining drugs (rather than honing their CVs) and perhaps gaining a criminal record in the process; at what point in a person’s journey the goal of employment should be on the table; and if employment is predominantly a ‘means to an end’ of achieving recovery and reintegration, whether it would be more fruitful to look beyond the binary outcomes of ‘being in work’ or ‘not being in work’?

Unemployment and other social factors compound social exclusion

Unemployment is remarkably high amongst people in treatment for substance use issues, yet arguably one of the under-reported socioeconomic characteristics of this group. In England between 2015 and 2016, only 24% of patients were in paid work at the start of treatment (much lower for opiate patients at 16%) according to the National Drug Treatment Monitoring System, and this was increased only very slightly at the six-month re-assessment to 25% (and 18%).

There is arguably a tendency for low levels of employment among this and other stigmatised groups to be framed in the pejorative, as ‘worklessness’ or being ‘workshy’. But for many, unemployment is one of a multitude of factors that signify social exclusion, and have the cumulative effect of obstructing their ability to participate fully in society (including finding gainful employment). Across Europe, for example, many problem drug users have unmet housing, education, employment, and other social needs, often evident before their substance use. This includes income below the poverty line, insecure or no housing, fewer years of education, and fewer educational qualifications than the general population.

At an individual level, reasons for being unemployed could include being too unwell or having a lifestyle too unstable to work, and being unable to find or maintain work, as well as official figures not recording engagement in unpaid work or work not recognised by the state.

For those who are employed, it can be seen as a sign of recovery, and a way to increase financial independence, build new social networks, and improve self-esteem. Yet sometimes overshadowed by urgent health, social and housing needs, employment is not always the immediate priority.

In the Drug Treatment Outcomes Research Study, which predated the 2008 English national drug policy that adopted ‘reintegration through employment’, treatment-seekers themselves reported that they didn’t prioritise this objective. At treatment entry most prioritised ending drug use; for half their goals included “Sort life out/get it together”, but just 1 in 5 specified employment as a way of sorting their lives out, and for just 1 in a 100 was this a primary goal. This was despite the fact that over three quarters (77%) were unemployed. As background notes on the study explain, it could be that they saw it as too early in treatment to contemplate such a goal, except that for 71% it was not actually early in their treatment careers because they had been in treatment before.

A realistic ambition?

In December 2016 Professor Dame Carol Black published the findings of her independent review into the impact of drug and alcohol addiction on employment outcomes, which she assessed alongside obesity. She identified three areas of action:

Addiction treatment does not, in itself, ensure employment, though it brings other social gains. Work has not hitherto been an integral part of treatment, and it needs to be if progress [with employment outcomes] is to be made.
The benefits system, which has a central role in helping people enter or return to work, requires significant change. The system is hampered by a severe lack of information on health conditions, poor incentives for staff to tackle difficult or long-term cases, and a patchy offer of support for those who are reached.
Employers are the gatekeepers to employment and, without their co-operation employment for our cohorts is impossible. Employers are understandably reluctant to hire people with addiction and/or criminal records. They have told us that they need Government, quite simply, to de-risk these recruitment decisions for them.

Although the “mutually-reinforcing relationship between employment and recovery” was acknowledged, the focus of the review was on employment as the endpoint, rather than employment as a way of boosting recovery – made clear in the foreword where she prefaced the report by saying, “The aim is not to offer utopian solutions to deeply complex problems, but rather to offer, as far as possible, an evidence-based analysis of the factors that stand in the way of employment”.

Employment along with housing and education are the pillars of ‘social reintegration’ – an approach to substance use (and an aim beyond substance use) that looks at building a person’s involvement and stake in their community. In a 2012 report, the European Monitoring Centre for Drugs and Drug Addiction identified an urgent need to increase access to social reintegration interventions for problem drug users; and, although unable to pin down the best approaches, stressed that reintegration measures should be embedded into drug treatment at an early stage.

The focus on reintegration into mainstream society through employment is not new. In the 1960s it was fundamental to the original US methadone programme organised and evaluated by Vincent Dole and Marie Nyswander of New York’s Rockefeller Institute for Medical Research. However, when their treatment had become a mass programme, the economic climate had changed and patients more often had multiple needs while their reintegration was impeded by diminished access to affordable housing and suitable jobs.

Problem use of drugs like heroin and crack tend to be concentrated in areas of high unemployment and deprivation, where finding a job is even harder than the national average. For example, in 2011 the most deprived areas of Scotland saw over seven times more GP consultations for drug problems per 1000 of the practice population than in the most affluent areas, a differential not seen for non-drug use consultations. And in 2015/16, half (51%) of patients with a hospital stay for an acute issue related to drug use lived in the 20% most deprived areas in Scotland. Unlike recreational drug use, addiction to illegal drugs thrives in areas distinguished by poverty, few job opportunities and a lack of community resources.

Though employment is at the heart of the government’s ‘recovery’ agenda, finding a job has been omitted from national payment-by-results criteria which determine how treatment services in some areas will be funded, perhaps an acknowledgement that in the recessionary times when the criteria were drafted, jobs were an unrealistic target for this patient group. At local level too, only a minority of areas have exercised their discretion to include employment-related criteria.

Reticence to set payment-by-results schemes up to fail is understandable given the barriers to employment faced by problem drug users, enumerated in a report commissioned by the Department for Work and Pensions: lack of education and skills; physical and mental health problems; low self-confidence; social disadvantage; drug use itself; inadequate access to support services; problems engaging with employers and support professionals; dealing with stigma; criminal records and spells in prison; the need to attend for (especially methadone) treatment; fear that job-related stress might precipitate relapse; reluctance of employers.

Under-resourced effort

Rather than more resources to help overcome these barriers, the recent picture has been one of the withdrawal of resources or the abandonment of support plans. Lost on the way were the Progress to Work scheme for problem drug and alcohol users, and funding for dedicated JobCentre coordinators to organise support for drug-using claimants. Lost too were the planned Welfare Reform Drug Recovery Pilots, a voluntary set of extra supports for benefit claimants being treated for their drug problems, relieving them of the need to look for work while they focus on their recovery.

Under previous Universal Credit benefit arrangements, patients in addiction treatment could be relieved of the need to look for work for six months, though by the end of 2014 this benefit was available to few claimants and just 0.3% of the anticipated recipients were receiving it. In April 2017, guidance on Universal Credit support for people dependent on drugs or alcohol was withdrawn, and is no longer being updated. The latest guidance omits to mention whether this group specifically is entitled to any support.

The decision whether to offer time free of the requirement to seek work for patients in addiction treatment lies in the hands of local JobCentre officials, a sign of the localism which has taken over in the JobCentre front line, anything more than the minimum being subject to the priorities and flexibilities afforded to district managers.

Government programmes

At a national level the main initiative is the Work Programme launched in June 2011 for people at risk of long-term unemployment. As with other claimants, problem substance users on job-seekers’ benefits can be mandated to this programme after nine or 12 months depending on age or other circumstances.

People often face a steep climb before paid employment is an option

Like some addiction treatment services, the Work Programme operates on a payment-by-results basis. The large companies responsible for delivering the programme are free to do more or less what they think best to achieve these results, including arranging addiction treatment for claimants. A prime disadvantage is the programme’s binary ‘working or not’ criterion for rewarding these companies, one out of kilter with the gradualist approach more suitable for people facing a steep climb before paid competitive employment is an option, who generally want and need to traverse education, training, job-finding skills, volunteering, and supported employment, and may get stuck at any of these stages.

According to the (now defunct) national drugs charity DrugScope, the result is that the Work Programme “is delivering very little for people with histories of drug and alcohol use … because the funding model has failed to incentivise the provision of specialist services”. Addicts and ex-addicts are among the jobseekers furthest from the job market who tend to be ‘parked’ by Work Programme companies, which gain more from lower hanging fruit. With little to prompt this, the partnership working between job centres, treatment services, and Work Programme providers expected to benefit problem substance users “is generally absent”, said DrugScope. These shortcomings were also identified by the parliamentary Work and Pensions Committee as obstructing progress to work for the most disadvantaged jobseekers in general, and drug and alcohol users in particular.

Seemingly acknowledging that routine arrangements were not working well for problem substance users, in January 2013 the Department for Work and Pensions announced two pilot schemes involving extra payments to Work Programme providers which help these clients find jobs, or for closer working between the Work Programme and addiction treatment providers. It appears these fell under the scope of the Drugs and Alcohol Recovery Payment by Results Pilot Programme – the interim report of which was published in June 2014. The follow-up report was expected in October 2014, and final report in March 2015, but these, if they were published, are not readily available.

Whilst acknowledging shortcomings, guidance published in 2012 by the National Treatment Agency for Substance Misuse (now part of Public Health England) determinedly accentuated the positive, highlighting examples of good practice developed locally, which support the rather limited conclusion that since 2009 there has been significant progress “in some parts of the country” in addressing the employment-related needs of people in drug and alcohol treatment. For this guidance, “progress” was defined mainly in terms of improving the process (rather than outcomes for clients), for example: partnership working between job centres, treatment services, and Work Programme providers of the kind (see above) DrugScope and the Work and Pensions committee found generally missing; good communication facilitated by a single point of contact in each treatment system, JobCentre Plus district office and Work Programme provider or local subcontractor; shared training; outreach in the form of JobCentre Plus and Work Programme staff in treatment and recovery services, and vice versa; three-way review meetings between client, treatment keyworker and either JobCentre Plus or Work Programme advisor; and continuity of care afforded by treatment, recovery and employment support providers working in a joined-up way.

Seemingly not so positive for those using the services, people with drug and alcohol problems participating in a 2017 Public Health England review experienced Jobcentre Plus and Work Programme staff as having few signs of knowledge or awareness of drug use and recovery, and as sometimes being unfriendly and unwelcoming. This changed, however, when Jobcentre Plus work coaches were co-located within the user group or treatment service, when users saw this as a much more positive and valuable feature.

From 2017, the Work Programme is expected to be replaced by a new Work and Health Programme, aimed at people who “require additional support than that available through Jobcentre Plus to enter employment”. Though the full remit is still to be determined, it is expected that this would include people with drug and alcohol issues.

Treatment programmes

Outside and predating the Work Programme framework, addiction treatment services have tried to promote employment to progress and embed their clients’ recoveries. Assessing links between drug treatment outcomes and employment over a 20-year period (1995–2015), the Learning and Work Institute found:
• A strong relationship between being in work and positive drug treatment outcomes.
• Improved likelihood of entering into employment after successful drug treatment.
• Employment plays a role in improving engagement with, and adherence to, drug treatment.

From Scotland, came evidence that treatment services may indeed be able to help, as patients who received employment-related support as part of their addiction treatment package were three times more likely later to find work. However, the study observed normal treatment processes rather than deliberately allocating patients to receive or not receive employment-related help, maing it impossible to be sure that the help actually caused the elevated employment rates it was associated with. Further analyses established that patients who had started the study in residential rehabilitation were over twice as likely to have received employment-related help, yet were not significantly more likely to have found work – 29% had done so, but so had 20% in methadone services or other non-residential treatments. Another approach trialled in England was to place treatment staff in job centres to facilitate referral to treatment, intended to help ready claimants for employment. In three high drug use urban areas, it did raise the treatment entry rate, but not enough to recommend a national roll-out.

Background notes in the Effectiveness Bank examining the Drug Treatment Outcomes Research Study (DTORS) in detail suggest that an important component of treatment-generated employment outcomes is services presenting themselves as facilitators of employment – meaning that patients see employment-related goals as being achieved by going to those services. Only a minority of patients in DTORS recalled receiving employment-related help from any source, and presumably fewer still would have received this help from the treatment service. With few patients aiming for employment progress, few being offered help to progress, plus for many an unappetising CV, it was no surprise that little progress was made: 9% employed at baseline barely rose to 11% at three to five months and 16% at about a year, but the high proportion not followed up casts doubt on whether any progress was made at all, or whether it was just that employed people were easier to find and re-interview. Little progress was made too in laying the foundations for stable employment in terms of improved mental health and housing. The former would have been impeded by poor partnership working with mental health services, the latter was for some a major barrier to life changes, reportedly made intractable by the unavailability (physically or because of housing priorities) of suitable housing. In general, in-depth interviews with clients and staff suggested that individualisation of treatment in response to broader client needs and aspirations was limited.

Generally across the world the evidence for employment-promoting initiatives within addiction treatment is at best patchy. Among the studies is one from New York which found that even though it helped welfare applicants overcome substance use problems, intensive case management did not help men find a job, but women did benefit to a small extent. The traditional ‘gradualist’ approach taken in this study has been contrasted with appropriate support targeted at rapid competitive employment, among which the most prominent is the Individual Placement and Support model.

A “well-evidenced approach” for people with severe mental illness (with research spanning 20 years), Individual Placement and Support provides employment support alongside clinical treatment – uniquely casting employment specialists as equal members of multi-disciplinary teams. The evidence base for substance use clients is comparatively small, but promising, for example showing that it could help substance users find employment in the open labour market, rather than sheltered placements. Professor Dame Carol Black’s independent review recommends a robust trial of high-fidelity Individual Placement and Support, as well as an arm of the trial that tests the approach with a limited duration of support. An expensive approach, cost–benefit estimates suggest that those who find employment would need to sustain this for 145–181 days with the high-fidelity approach in order for the Exchequer to break even, or 93–116 days if the wider benefits to society were taken into account.

If the evidence that treatment promotes employment is patchy, so too is the evidence that employment programmes promote recovery from addiction. This disappointing record could partly come down to how success is being defined, and informing this, the extent to which the dual motivations of ‘employment for the individual’s sake’ and ‘employment for society’s sake’ are informing policy and practice. Edging away from the tendency to see employment as the only desirable outcome, the UK Drug Policy Commission’s 2008 report on getting problem drug users into jobs suggests an ‘employment continuum’ – where, sandwiched between long-term unemployment and long-term employment, are: treating mental and physical health problems; building motivation and aspirations; stabilising drug use; providing appropriate stable accommodation; developing ‘soft skills’ (eg, through volunteering); training; building financial skills; work trials and job placements; and in-work support.

Run this search to pick out the bright spots in the topic of employment and recovery, and, perhaps as importantly, get a feel for what does not work and what it is reasonable to expect.

Thanks to Paul Anders of Public Health England for bringing the Universal Credit arrangements to our attention.

Last revised 12 July 2017. First uploaded 01 January 2010

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Hepatitis C ‘giant’ still growing

In 1993 what was at the time Britain’s magazine for the drug misuse sector alerted readers to an invisible “sleeping giant” – hepatitis C. Foreseeing that injectors “are unlikely to mount the same political lobby for funding hepatitis C prevention and treatment that the gay and heterosexual community have mounted for HIV,” the authors warned that nevertheless government should prioritise these programmes to avoid a “longer term cost that is considerably greater, both in terms of finance and human suffering. It may be wise to let sleeping dogs lie, but not sleeping giants.”

“Hepatitis C: time to wake up.” click to download

In 1993 “Hepatitis C: time to wake up” sounded a warning to Britain about the consequences of ignoring the “sleeping giant” of injecting-related infection.

The term “giant” was warranted because at that time a staggering 85% of injectors in Glasgow and 61% in West Suffolk were known to have been infected. Before in 1989 a test was available to identify it, the virus had already infected a much larger fraction of drug injectors than HIV ever would, making it more difficult to achieve the same proportionate reduction than if the starting point had been lower. Since then it has been a case of playing catch-up against a rapidly moving target: high prevalence means a high probability that anyone who passes on their used injecting equipment is infected, and the robustness and transmissibility of the virus mean a high probability (relative to HIV) of that infection being transmitted through even a small chink in the protective barriers erected by harm reduction services and practices.

It is not that the UK’s measures have been ineffective; studies and simulations have calculated that the virus would have spread even further without harm reduction services, but over the last two decades infection figures suggest no further ground has been gained. Despite fewer drug users injecting, fewer sharing injecting equipment, more being tested and treated for hepatitis C infection, and more starting treatment for their addiction, hepatitis C has continued to spread extensively among injectors. Substantial reversal of the epidemic will require a more determined, widespread and multi-pronged attack. As comprehensively analysed in a four-part Findings series, coverage is the key. Rather than a reluctantly funded trickle, only a “flood” of harm reduction services will bring the virus under greater control, supplemented by treatment of injectors already infected both for their own sakes and to prevent them infecting others.

This hot topic describes the different components of hepatitis C control, including diagnosis, treatment and prevention. It reviews the place of harm reduction, which up to now has been the mainstay of hepatitis C control, and what could be game-changing additions to this armoury in the form of new treatments for the infection.

Anti-epidemic progress stalled ...

Since 2003 the annual Shooting Up reports from the UK’s national public health authorities have documented infections among drug users in the UK, a barometer of the success of harm reduction efforts. Due to its transmissibility, the most sensitive barometer reading is the spread of hepatitis C, recorded for drug service attendees since at least 1998 in England and Wales, figures joined from 2002 with those from Northern Ireland, and from 2008 supplemented by national figures from Scotland’s needle exchanges. The figures show that though they have curtailed the epidemic, services have not been sufficiently abundant, with the result that by 2015 hepatitis C was spreading more rapidly than in the early 2000s, infecting a quarter of injectors within three years of their starting to inject.

People who have ever injected drugs and people who first injected during preceding 3 years, % infected with hepatitis C, England, Wales and NI, Scotland. Shows that since 1998 the hepatitis C virus has continued to infect a large proportion of UK injectors

Since 1998 the hepatitis C virus has continued to infect a large proportion of UK injectors

The report covering 2015 admitted that the “overall level of hepatitis C transmission among people who inject psychoactive drugs in the UK appears to have changed little in recent years”. Arguably things are a little worse. Infection among people who have ever injected may have been acquired many years ago; infection among those relatively new to injecting is more indicative of how rapidly the virus is currently spreading. In England, Wales and Northern Ireland, within three years of starting to inject, 24% of injectors tested in 2015 were infected and in Scotland, 30%. For England and Wales an earlier report takes us back to 1998 to 2000, when the corresponding figures were just 12% or 13%. In Scotland a fairly stable infection rate among sub-three year injectors since 2008 of between 20% and 24% jumped to 30% in 2015/16 chart.

More sophisticated test procedures can narrow down the infection time-window, leading to an estimate that in 2015/16 in Scotland, during the equivalent of a year of injecting 11 to 12 out of every 100 injectors had become infected, and in the rest of the UK in 2015, between 4 and 13. In England the best estimate for 2015 was 7.4, substantially down from a peak of 19.1 in 2012 but about the same as the 8.1 registered the year before.

The result of past and continuing rapid spread is that by 2015, UK-wide around half of those who had injected psychoactive drugs and been tested at drug services or needle exchanges had been infected with hepatitis C – 58% in Scotland, 53% in Wales, 52% in England, and 27% in Northern Ireland. Around a quarter will already have naturally rid themselves of the virus, its presence detectable as only as an antibody legacy, leaving in 2015 about two in five injectors living with active and chronic hepatitis C infection.

… even though behaviour risking infection has become less common

New infections among injectors will largely reflect the degree to which (without adequate disinfection measures) they inject using equipment previously used by someone else who may have been infected with hepatitis C. ‘Sharing’ is the shorthand for this behaviour, and with hepatitis C, often it means sharing infection as well as equipment. The term can mean both receiving and passing on used equipment.

Sharing injecting equipment in last 4 weeks or last month among those who had injected during that period, England, Wales and NI, Scotland. Shows that since the early 2000s sharing rates have tended to fall but have been roughly stable since 2010

Since the early 2000s rates of sharing of injecting equipment among injectors have tended to fall in the UK but have been roughly stable since 2010

Based on figures up to 2015, “Overall, the level of needle and syringe sharing (either borrowing or lending a used needle or syringe) among those currently injecting psychoactive drugs has fallen across the UK,” was the welcome message from public health authorities. By 2014–15, across the UK 16–17% of people who had injected in the last four weeks had shared their needles and syringes, down from peaks of 34–35% in the early 2000s. Among those who had injected with used equipment, 29% surveyed in England, Wales and Northern Ireland in 2015 said they had attempted to clean it – for hepatitis C, often not done to an adequate standard.

It has also been believed that hepatitis C may be spread (1 2) by the re-use or joint use of acnillary items employed during the injection process such as water, spoons and filters. When these were included, in 2015 38% of current injectors surveyed in England, Wales and Northern Ireland had shared equipment in the past four weeks, again, well down on the roughly 60% of the early 2000s chart. However, that assumption was challenged in 2017 when a laboratory simulation showed the relevant findings probably arose just because when this equipment is shared, so too are drug solutions via potentially contaminated syringes and needles. Implications are that from the point of view of preventing viral infection, supplying cookers and filters at needle exchanges wastes resources better spent on fixed-needle syringes and trying to prevent drug sharing methods that can spread disease.

An apparent puzzle is that the reduction in sharing since the early 2000s has not been accompanied by a similar reduction in the spread of hepatitis C. The most likely reason is that when hepatitis C is already very common among injectors, the degree to which it spreads further is relatively unresponsive to how widely the infection-risk door is left open, as long as there is a small chink sufficient to let the virus through (1 2). Britain has experienced a ‘natural experiment’ in the relationship between sharing levels and the spread of hepatitis C which might shed some light on whether this explanation is sufficient. Unfortunately, interpretations differ.

The opportunity to test the relationship came about because between 1997 and 1998 there was a sharp increase in the proportion of current injectors who had recently shared needles and syringes in England and Wales chart. That this was no artefact of methodology or sampling was confirmed by an analysis of the figures and by reports from patients new to or returning to drug addiction treatment.

A contrast to an increase in hepatitis B prevalence, at first analysts highlighted the fact that between 1998 and 2000 hepatitis C prevalence had remained at about 8% among injectors who had started injecting in the past two years, a sign that spread of this virus was unresponsive to the degree of sharing. Problem drug users estimates; England from 2004/05 Led by the same scientist, a few years later another analysis associated later increases in the acquisition of new HIV and hepatitis C infections with the persistence of the 1997 to 1998 increase in levels of sharing. Yet in respect of hepatitis C, if this was the explanation, by the same token, decreased sharing since around the year 2000 can be expected to have reduced the rate of new infections – an expectation for which there is no evidence.

Possibly another reason why hepatitis C levels did not fall as sharing levels fell was the countervailing influence of an upsurge in the injecting of crack cocaine since 2010. That year 31% of current injectors sampled at drug services in England had injected crack in the past four weeks. By 2015 the proportion was 51%. Used on its own or by heroin users this short-acting stimulant leads on average to more frequent injecting, and is a marker and perhaps too a generator of a more chaotic lifestyle than solely injecting opioid drugs like heroin, processes thought to increase risk of infection.

Most of the preceding figures have been expressed as proportions of injectors seen at drug services of various kinds. It is, however, worth reminding ourselves that these are proportions drawn from a diminishing pool of people using the most commonly injected drugs and the pool actually injecting – in England, figures shrinking since at least 2004 chart. An estimated 137,141 drug users injecting opiates and/or crack in England in 2004/05 had by 2010/11 fallen to 87,302 (1 2). All else being equal, the result should be fewer people exposed to hepatitis C infection via the most efficient and common transmission route.

Harm reduction the ‘cornerstone’ of hepatitis C infection control

For people who inject drugs, infection with hepatitis C is one potential negative consequence among many, including other blood-borne viruses such as HIV and hepatitis B. Generated in its modern guise by the threat of injecting-related HIV, ‘harm reduction’ is a strategy which prioritises the reduction of such harms over the attempt to reduce drug use per se.

Dr Mary Ramsay from Public Health England’s National Infection Service described harm reduction, including provisions for safer injecting and non-injecting drugtaking practices, as the “cornerstone of hepatitis C infection control”. A Consensus Statement on Best Practice published by three leading organisations in harm reduction – the National Needle Exchange Forum, UK Harm Reduction Alliance, and Exchange Supplies – identified the essential elements of harm reduction as the provision of sterile injecting equipment, facilities for the safe disposal of used equipment, and substitute prescribing. Together, these pillars of harm reduction can they said help reduce injecting-related harms, including infection with hepatitis C.

The methadone pillar

In studies methadone maintenance and allied substitute prescribing treatments for opiate addiction have usually been associated with reduced spread of hepatitis C. A synthesis of results from UK studies estimated that when injectors were engaged in these treatments for at least half of a 12-month follow-up period, the chances of their becoming infected with hepatitis C were less than half those of other injectors – substantial, but still not a statistically significant difference. In Scotland a study based on needle exchange attendees found that compared to patients who had left methadone treatment in the last six months, those still on methadone had about 70% lower odds of having recently become infected, though these results again missed statistical significance.

Recently an analysis of three Canadian surveys of drug users found that the prevalence of hepatitis C was significantly lower among methadone maintenance patients (24%) than among other participants (76%). More to the point, methadone patients were also half as likely to become infected over the next two years, and less likely still the longer they had been in treatment during that time.

Another eight studies gathered together in a review cumulated to the near-significant estimate that the chances of becoming infected among injectors who received opioid substitution treatment were 40% less than those of comparison injectors.

Some of these associations between infection risk and treatment were very large, but with ethical and practical considerations prohibiting the randomised denial of substitute prescribing, the results might have been due to influences other than treatment. Studies do their best to compensate for known influences, but cannot compensate for those not measured. For example, in Canada very few survey respondents were in methadone treatment. The analysis adjusted for other influences on risk of infection including whether and which drugs respondents injected, but still this minority may have differed from the non-treatment majority in ways which would have reduced their risk of infection, regardless of treatment. Nevertheless, the evidence has been enough to convince European Union and UN authorities that substitute prescribing is a major component of effective anti-infection policies.

The exchange pillar

Research on services to promote safer injecting in the form of needle exchange programmes also largely relies on associations found in routine practice rather than randomised trials, making the findings vulnerable to extraneous influences the researcher cannot control or adjust for. In this case, these influences have loaded the dice against these services, making them look actually harmful.

The cause is almost certainly what we have termed the ‘magnet effect’: by attracting their intended caseload of injectors at high risk of infection, exchanges make themselves look as if they are the cause of the high risk. The result is that overall, exchange attendance has been associated with a greater chance of becoming infected with hepatitis C.

Detailed examination of research from six case-study cities revealed that their exchanges often suffered from the ‘magnet’ illusion, but rarely was it the whole story. The deeper cause of poor results was that exchanges often chose or were forced to operate under what a Health Canada publication described as “restrictions that condemn the programmes to fall far short of the needs of the persons for whom they were designed”. By under-resourcing and under-valuing this work and forcing exchanges to operate under crippling restrictions, sceptical authorities create the conditions which justify their misgivings.

By attracting injectors at high risk of infection, exchanges make themselves look as if they are the cause of the high risk

One of the case study cities was the exception both in the evaluation’s methodology and in its findings. For experts convened by the US National Academy of Sciences, studies in Tacoma in the USA constituted evidence of a “powerful retardant effect of needle exchange program attendance on infection with [hepatitis B and C]”. This judgment from 1995 remains valid, and the Tacoma hepatitis study remains a rare convincing demonstration that exchanges can intercept the spread of hepatitis C. It was the one needle exchange study in the review cited above which found a significantly reduced risk of infection, and the only one to use a case-control methodology based on identifying new cases of infection and establishing whether they had used the exchange, then comparing these figures with injectors who remained uninfected.

A distinctive methodology was not all which set the Tacoma study apart. Tacoma’s exchange benefited from legal approval (the first in the USA), a well resourced and comprehensive service including effective referral to methadone maintenance, preparedness to supply unlimited quantities of injecting equipment, encouragement for service users to act as mini-exchanges for other injectors not directly using the exchange, and an engaged set of service users who saw themselves as spearheading an activist-led fight to establish exchanges in a hostile national environment. Against a background where little else was on offer, the exchange’s anti-infection impacts became visible in ways not seen elsewhere. The study was imperfect, but the benefits of exchange attendance were so clear cut that only unrealistic assumptions would have rendered them insignificant.

Among British studies was one from Scotland based on needle exchange attendees which associated receiving at least twice the amount of injecting equipment equating to a fresh set each time with a near 70% lower chance of having recently become infected with hepatitis C. Data from Glasgow used in that study was fed into a synthesis of results from UK studies. It estimated that when injectors were engaged in needle exchange services sufficiently to obtain at least enough sterile injecting equipment to equate to a fresh set for each injection, the chances of their becoming (or having recently become) infected with hepatitis C were about half those of other injectors.

100% coverage not enough

As with substitute prescribing, despite the difficulty of providing definitive proof, the evidence has been enough for UN agencies and other authorities to promote needle exchange as a way to curb spread of the virus. Posed the question, “What level of coverage should needle and syringe programmes provide to keep HIV prevalence low and to reduce the prevalence of hepatitis C among people who inject drugs?”, Britain’s National Institute for Health and Care Excellence (NICE) called on commissioners to aim to provide more than enough needles and syringes for every injector to be able to use a sterile set each time they inject. Public Health England explained why simply equating the number of needles/syringes to the number of injections will not be enough: “some people receive more needles than they need … because they pass them on to partners or friends … Also, more than one needle is often required per injection, as needles may also be used during drug preparation and an injection may require several attempts (and therefore needles) to access a vein.” Over 100% coverage is an ambitious target, but only a flood of injecting equipment has a chance of adequately containing the virus. Adequate coverage is important also to help prevent sharing of the other equipment used in injecting, suggested a study in Scotland.

How far there is to go to exceed 100% coverage has been recorded in England since 2011. Since then just under half of current injectors surveyed at drug services have been estimated to have received sufficient needles/syringes to equate to a fresh set each time, varying only slightly from a high of 48% of injectors in 2011 and 2012 to a low of 45% in 2015. It means that slightly fewer than half the injectors already in contact with drug services reach the 100% coverage mark; include those not in contact and lift the bar to well over 100%, and the fraction is likely to be considerably smaller.

Where injectors do not (or cannot) obtain sterile needles and syringes, they may employ their own harm reduction techniques, including disinfecting used syringes and needles. The effectiveness of this tactic has been tested in a laboratory setting with readily available household products. Rinsing with bleach was found to be the most effective, eliminating hepatitis C in syringes with both fixed and detachable needles. Though promising, this practice is unlikely to safeguard all. Injectors may choose not to rinse their syringes with bleach for a number of reasons, including the fact that multiple rinses can damage the equipment.

Testing and treatment needs to be scaled up; half all infections undiagnosed

In high income countries hepatitis C is primarily transmitted through the sharing of contaminated injecting equipment, making drug users priority targets not just for harm reduction efforts but also for the treatment of infection. In the UK, around 90% of diagnosed hepatitis C infections have been acquired through injecting drug use. Estimates from Public Health England suggest that 3 in 4 people infected with hepatitis C will develop chronic infection (a total of 214,000 in the UK), a primary cause of cirrhosis and liver cancer. Treating hepatitis C not only saves individuals (already impacted by substance use) from these potentially fatal diseases, but by clearing the infection, it also helps prevents further spread of the virus. In the UK, the drive to extend treatment is starting from a very low base, though acceleration has been aided by the advent of new and less onerous treatment regimens.

Testing for hepatitis C and awareness of result. % of current and former injectors tested for hepatitis C and of those infected, % aware of their infection, England, Wales and NI, Scotland. Shows that though proportions tested have increased, in England, Wales and NI awareness rates have not improved since the mid-2000s.

Though proportions tested have increased, in England, Wales and NI awareness rates have not improved since the mid-2000s

One major barrier to extending treatment does not seem to be going away. Before treatment can help stem the spread of hepatitis C, the infection first has to be tested for and diagnosed. Among current or former injectors seen at drug services in the UK, from about half in the year 2000 the proportion at some time tested for hepatitis C rose to around 90% in 2015. Nevertheless, the infections of about half the injectors with hepatitis C remained undiagnosed, the worrying headline finding in Public Health England’s latest report on infections among injectors chart.

The problem is that having been tested years ago is not enough – injectors who test clear can soon become infected or re-infected. In 2015 in England, Wales and Northern Ireland, 18% of injectors unaware they were infected said they had simply never been tested; 41% said they had, but over two years ago.

A positive test may need to be followed by treatment of the infection to prevent the disease progressing, a second weak link in the chain. Data from people initially tested at drug services between 2005 and 2014 indicated that only 3.7% of those who were currently infected had received hepatitis C treatment within a year of diagnosis, though the figures predate the newer and more acceptable treatments. Public Health England has recommended (1 2) multiple strategies to raise uptake of testing and treatment, including employing a blood-borne virus nurse, distributing information about referral pathways to all staff in local drug and alcohol services, writing and re-writing to clients, offering appointments on a flexible and drop-in basis, and routinely testing unless injectors opt-out.

Elevating the current low treatment penetration base could intercept the virus’s spread sufficiently to substantially reduce its prevalence among injectors. One study has mapped the prevalence of chronic hepatitis C across seven sites in the UK, and projected what the prevalence would be over the ten years from 2014 if we continued with the current approach to treating the infection versus a ‘scaled-up’ programme. The findings suggest that maintaining the status quo will not generate substantial reductions in hepatitis C. However, there would be a 15% reduction after 10 years by extending access to treatment to an annual 26 per 1000 people who inject drugs (upper limit of what may already have been achieved at two of the sites) and if new medications became available and used for all variants of the virus. The 15% figure is an absolute reduction from baseline rates of just over 50% or lower; in different areas this would amount to a 12% to 86% relative reduction in these proportions after 10 years, the biggest reductions predicted where prevalence levels start relatively low.

New medication regimens pave the way for expansion

A range of new oral drug treatments called ‘direct-acting antivirals’ have been developed which according to clinical trials reviewed in 2015 promised to be more effective, more easily tolerated and more acceptable to patients than existing treatment options, though also more expensive. Britain’s National Institute for Health and Care Excellence (NICE) has directed several of these treatments to made available by the National Health Service as value-for-money lifesavers/improvers, though sometimes only if a discounted price is negotiated.

Treating those who are actively using drugs will dramatically reduce onward transmission of hepatitis C

Writing in May 2017, for a leading London-based liver specialist these medications promised not just to revolutionise treatment of infection, but also its prevention. Previous treatments involved “a prolonged course of therapy with relatively ineffective, toxic drugs” which most patients refused, remaining infectious and leading to further spread of the virus. In contrast, “The new treatments require a short course of tablets … and are almost side effect free. The cure rates are in excess of 95% … treating those who are actively using drugs will dramatically reduce onward transmission of hepatitis C and many experts see treatment in those with on-going drug use as the key to control of the hepatitis C epidemic.”

These expectations were questioned by a review published in 2017 with the cachet of the Cochrane collaboration behind it. It synthesised results from randomised clinical trials which had compared direct-acting antivirals (DAAs) to an alternative, generally an inactive placebo. The blunt conclusion was that “DAAs do not seem to have any effects on the risk of hepatitis C-related morbidity or all-cause mortality”, though the reviewers acknowledged that lack of evidence rather than negative findings was the main contributor to these conclusions. More damaging still was their questioning of the importance of these drugs’ ability to clear the virus from blood, known as a ‘sustained virological response’. They accepted that the new medications seemed to promote clearance of the virus, “but all of the trial results were at high risk of systematic error (‘bias’), and the clinical relevance of results on virological response is questionable”. The lead author explained that “Sustained virological response is a surrogate outcome. From a patient perspective, it does not matter if virus cannot be detected in the blood if DAAs do not improve survival or lead to fewer hepatitis C complications.” The review warned that “The lack of valid evidence and the possibility of potentially harming people with chronic hepatitis ought to be considered before treating people with hepatitis C with DAAs.”

Clearing the virus from blood should mean the patient cannot spread the disease, but if it did not equate to a cure for the patient, then the major part of the justification for spending large sums of money on these treatments would be lost, and with it the potential for extended treatment to help curb spread of the virus. After its findings were reported in the Guardian newspaper, UK clinicians, scientists and patient groups criticised the Cochrane analysis as “fundamentally flawed”. It had, they pointed out, analysed short-term clinical trials whose sole purpose was to evaluate the virological efficacy of new antiviral drugs, trials “neither designed, nor powered, to assess mortality, so it is hardly surprising that the Cochrane review was unable to identify any impact on mortality.” Far from being clinically irrelevant, “Regulatory authorities and clinicians all recognise that clearing hepatitis C virus reduces mortality.” Writing in the The Lancet, US experts agreed: “DAA therapy is safe and effective in achieving [sustained virological responses] … [sustained virological responses] are durable in most patients … hepatitis C-induced liver damage improves after [sustained virological response], and … observational data show a large reduction in morbidity and mortality” – evidence which stacked up strongly in favour of treatment.

Among the evidence were observations in the 2017 report on hepatitis C from England’s public health authority, which thought it may already be seeing the new treatments’ lifesaving impacts which Cochrane’s reviewers were unable to discern. Despite cases of relevant forms of liver disease remaining relatively stable, “an 8% fall in the number of deaths from these indications over the last year, suggests that increased treatment (around a 40% increase in 2015) with new direct acting antiviral (DAA) drugs, particularly in those with more advanced disease, may be starting to have an impact”.

For maximal preventive impact, target treatment

Even if they cure the current infection, both the old and the new treatments do not prevent later reinfection. People who engage in high-risk behaviours, such as sharing used injecting equipment, are more likely to become re-infected (and infectious), leading to some reluctance to focus treatment on high-risk groups. But while it may seem counterintuitive to treat people at high risk of becoming re-infected, it might actually be the most effective preventive strategy at a population level.

Researchers in Australia have calculated that for maximum impact, treatment for hepatitis C should be focused on people who are still injecting frequently and not engaged in methadone treatment, a conclusion to some extent conditional on the likelihood that they will follow medical advice and complete their treatments for hepatitis C. Where completion levels are the same between injectors in versus out of methadone maintenance, the simulation model estimates that over 84% of hepatitis C virus treatment slots should be allocated to those outside treatment. Focusing on methadone patients only becomes preferential when (as it can do) being in a methadone programme raises completion rates. However, completion promises to be greatly enhanced by the newer medication regimens, possibly reducing whatever gap there is between methadone versus non-methadone injectors.

Similarly, in a simulation study researchers compared the preventive impact of treating high-risk injectors who share injecting equipment very frequently against the impact among less frequent sharers. They found that when more than half of all the shared syringes in a population of injecting drug users are contaminated with hepatitis C, the greatest preventive impact is gained by treating low-risk injecting drug users first. But below this threshold, it is most efficient to treat high-risk injecting drug users first.

The strategies described above require information about the level of risk of injectors and the likelihood of compliance with treatment. Based on injectors surveyed in the city of Melbourne in Australia, another study has suggested that information about the social networks of people who inject drugs should also be taken into account when prioritising treatment. Of those assessed in the study, the most effective strategy was to ask an injector being treated for infection who they injected with, and then to offer treatment to those among their injecting circle also infected with the virus, helping to prevent the focal injector becoming re-infected.

Combination of services will make the biggest impact

Signalling the dimensions of the challenge, a simulation model suggested that getting to the point where under 1 in 10 injectors in London are infected with hepatitis C would need injectors on average to cut their sharing of used syringes from 16 times a month to once or twice. Achieving this kind of step change seems to demand the synergistic impact of several harm reduction strands. Adequate opioid substitute prescribing and other successful treatments of addiction cut the number of injections and therefore the number of opportunities for the virus to be transmitted by sharing injecting equipment. In turn this should make it easier for needle and syringe provision programmes to supply enough equipment for a fresh set to be used for each remaining injection, while successful treatment of hepatitis C infection will render infected injectors non-infectious. In reverse, effective prevention will make it more possible to engage – and to be able to afford to engage – the reduced number of infected injectors in treatment for their infection.

Simulation studies have modelled what the results might be (and might have been) of parts of such a strategy, calculating that consistent participation in methadone maintenance treatment plus adequate access to fresh injecting equipment has prevented thousands of hepatitis C infections. Given practical and ethical considerations, inevitably these models are based on associations between services and infections found in studies which could not securely establish what caused what. The results gain credibility from the face validity of the mechanisms linking service use to infection via rates of injecting and sharing, and from evidence that these mechanisms have actually been in play.

A synthesis of results from UK studies found that access to either opiate substitution treatment or needle and syringe provision to the degree set by the study (enough equipment for a fresh set for each injection; in treatment for at least six of the 12 months of the follow-up periods) is associated with a halving in the risk of infection, but that a combination of both would reduce risk by up to 80% compared to injectors who had used neither to that degree.

Those findings were fed into a simulation model for the UK (and other countries) which calculated that investment in methadone maintenance treatment and needle exchange services has already saved tens of thousands of lives from being blighted by infection. But the calculations also predicted that making further substantial progress will require comprehensive hepatitis C control integrating diagnosis, treatment and harm reduction, and a major commitment from both injectors and health service funders. For example, cutting prevalence from 40% to 30% over 10 years would require not just half, but at least 80% of injectors to be engaged in methadone maintenance and needle exchange services. Achieving this coverage means recruiting more injectors to these programmes and/or retaining those who do use them for longer. Without extended retention, the recruitment rate has to be much higher. For example, if retention averages eight months, to get 8 in 10 injectors into these programmes requires over half those not yet attending to join each month. If average retention doubles to 16 months, then just under 30% need to join each month.

In Scotland it has been estimated that the combination of needle exchange, methadone maintenance and a shift away from injecting meant that between 2008 and 2012, 1000 fewer injectors faced chronic infection than would have done had things remained as they were in 2008. Before them the authors had the results of an study based on needle exchange attendees in Scotland which combined being in opioid substitute prescribing treatment and having a supply of fresh injecting equipment into what was presumed to be an overall high, medium or low level of protection from becoming infected. Relative to the low level, both high and medium levels were associated with a halving in the chance of becoming recently infected. To different degrees, both UK-wide and Scottish analyses were able not just to link adequate service use to infection, but also to the intermediate links which connect the two via reduced frequency of injecting and a lower proportion of injectors continuing to share injecting equipment, constricting opportunities for the virus to be transmitted.

Treating the virus is also effective in reducing the overall prevalence of hepatitis C and reducing the risk of transmission. However according to an Australian study reported on above, resources must be allocated to harm reduction services as well as treatment in order to significantly reduce the risk of infection in the population. A synthesis of relevant studies by world-leading experts echoes that it is the combination of services and strategies which will make the biggest impact, and suggests that it has already substantially and significantly reduced transmission of hepatitis C by as much as 75% within populations who inject drugs.

We can … but will we?

Even within existing resources, some further progress may be possible. Public Health England recommends that regular reviews of population needs be fed into strategies for controlling hepatitis C. Attention to the characteristics of the population reflects studies examined above which found better results when levels of risk, levels of compliance with treatment of infection, and the patient’s injecting networks were factored into population-level treatment strategies.

However, better targeting of static or diminishing resources will not be enough. According to NICE, further increasing the coverage of syringe distribution and substitute prescribing programmes will not substantially curb hepatitis C. This will require a multi-faceted programme, including early diagnosis and treatment of injectors already infected with hepatitis C, a strategy reflected in the Welsh Government’s hepatitis action plan.

Based on data up to 2015, in 2017 Public Health England went further, warning that only a “radical change” in our response to hepatitis C among injectors will enable England to meet World Health Organization goals on reducing deaths related to the virus. New treatments for infection create a platform for further progress, but only if the proportion who know they need the treatment is increased, while preventive efforts in the form of needle/syringe provision are generally sub-optimal, reductions in the sharing of injecting equipment have stalled over the last five years, and there is little evidence of a fall in the number of new infections.

Not just increased, but sustained investment in services seems critical. UK studies referred to above predicted that expanded service access can further reduce the annual number of injectors who become infected with hepatitis C, but also that these reductions and the services underpinning them will need to be sustained for over a decade before the virus is substantially less common across the injecting population.

Public Health England’s “radical change” call came in a policy-oriented report for England which drew in contributions from other experts and other agencies. In contrast, its latest corporately authored UK-wide report monitoring infections among injectors argued that “Provision of effective interventions needs to be maintained.” Maintaining the status quo may not seem very ambitious and will not be enough to turn back the epidemic, but is perhaps a realistic aim in the era of austerity and of recovery as a national drug policy priority. NICE’s Public Health Advisory Committee saw fit to caution that “a focus on recovery (that is, encouraging people to stop taking drugs completely) should not compromise the provision of needle and syringe programmes and any associated harm-reduction initiatives”.

The extreme level of stigma routinely experienced by people who inject is a form of structural violence

Like the problem drug use via which overwhelmingly the virus is transmitted, hepatitis C “disproportionately affects populations who are marginalised and underserved and have poorer access to healthcare and health outcomes”. This observation from Public Health England begs the question of where the impetus will come from to radically reverse this relative exclusion, and over-serve the same populations with a flood of sterile equipment and universal testing for infection followed by treatment if required. In a similar vein, UN agencies surveying in 2017 the policy landscape for responding to hepatitis C and HIV among injectors itemised interventions, but were also aware of the broader political and social context and what that does to the chances of gaining adequate investment: “The extreme level of stigma routinely experienced by people who inject drugs is a form of structural violence. The language, policies and practices of legal, health and educational institutions and the media often create, reinforce and perpetuate this stigma. This makes it more difficult to reform harsh drug laws or properly resource HIV and [hepatitis C] prevention, diagnosis, treatment and care programmes for people who use drugs.”

Though it may be unrealistic to expect a further major contribution to stemming the hepatitis C epidemic from greatly expanding services, it would help if current resources became less stretched because (aided or not by treatment) more drug users turn away from injecting and from the main injected drugs. Population estimates and trends in the treatment caseload indicate this has been happening ( above), but without knowing why, neither can we know whether these trends will stabilise, continue, or reverse.

Thanks for their comments on this entry to Andrew Preston of Exchange Supplies based in Dorchester, England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 04 September 2017. First uploaded 01 November 2011

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