SCOTTISH ADVISORY COMMITTEE ON DRUG MISUSE: Psychostimulant Working Group Report
CHAPTER 7: PLANNING SERVICES
7.1 There is limited evidence about the effectiveness of drug services designed to meet the needs of stimulant users. What evidence there is comes mainly from England and the United States. Evaluations generally show that services need to be designed to take into account the socio-demographic profiles of psychostimulant users, and that a range of support and treatment must be available to address the diverse needs of this group.
7.2 What is clear is that stimulant drug users perceive existing drug services to be the preserve of opiate users. This is reflected in both the research literature and in findings of the consultation conducted by the Scottish Drugs Form for the Working Group. It is clear that decisions on how to re-configure or redesign services to meet the need of stimulant drug users should be based on local needs assessments. The Piper Project in Manchester conducted a local needs assessment early in the project's development to help assess the number of stimulant users in the area and to assess their needs. The results of the assessment were then used to plan a specific service for cocaine and crack users.
Graduation of need
7.3 The research literature, analysis of existing data and the consultation with users show that stimulant drug users are not a homogeneous group. There are (at least) four broad categories of stimulant users, each with differing needs.
Firstly, there is the group of youthful drug experimenters who are likely to use stimulants as part of a pattern of poly-drug experimentation. They are unlikely to be in touch with any Scottish drug service, other than those providing drug information. Their social and demographic profile is mixed and reflects the increased acceptance of drug use within the youthful population. These are the youthful experimenters.
Secondly, there is the group of established primary stimulant drug users. These individuals will typically be using stimulant drugs regularly (weekly). Their social and demographic profile matches that of the youthful experimenters. They may have had some contact with drug information services but are unlikely to have used any other drug service. These are the regular stimulant users.
Thirdly, some of the above are beginning to experience problems.. They will have been regular stimulant users for at least a year. They have a similar social and demographic profile to the first two groups. This is the groupthat is most likely to be looking for services which do not currently exist. These are problematic stimulant users.
Finally, there are the individuals who are primarily opiate users who use stimulants as well. These are the individuals who are most likely to be in touch with existing services but whose needs in relation to the stimulants, may not be well served. It is from this group that the Scottish Drug Misuse Database figures about crack use have come. We could call this group the opiate/stimulant co-users. Their demographic profile is similar to the opiate drug-using group.
7.4 Given the diversity of the stimulant drug using population, and the differing needs of each group of users, it is clear that ideally service interventions should be provided at a range of levels to meet the gradations of need. However, there are likely to be a number of key principles of service provision including:
easy access to services (including opening times and location);
multiple points of entry;
person-centred and timely and shared assessment procedures;
information and support services when required;
specific pharmacological/psychological and psychosocial interventions when required;
effective referral procedures and protocols to ensure an integrated approach to providing treatment and care (including specialist mental health and detoxification services where necessary.)
support for children of psychostimulant users when appropriate; and
access to social care and accommodation.
Survey of users' views
7.5 A recent qualitative study was undertaken by the Scottish Drugs Forum of psychostimulant users to elicit the views of users on their needs and current service provision. (See Annex E for summary of this study - a copy of the study itself is available on request.)
7.6 The findings of the study indicate that:
there should be different approaches that recognise the diversity of users;
short term prescribing of dexamphetamine is helpful to keep users off the streets;
drug agency workers and health care professionals need more information and training about stimulants ;
there is a need for improved co-ordination between services;
there is a need for early access to confidential trustworthy advice and information without recourse to a GP;
the present variety of treatment approaches should be encouraged;
employment support is also needed; and
ex users should be involved in delivering services.
7.7 Turning Point Scotland reports a marked increase in cocaine use since last September, predominantly among heroin users and says that: the common issues for cocaine users are financial debt, family breakdown, the threat of homelessness, contact with the criminal justice system and post binge depression. Physical symptoms include malnourishment and respiratory problems. Immediate practical assistance and intensive one-to-one support, on occasion with a short pharmalogical intervention, brings very positive results. The service finds that complementary therapies are more than a way of retaining users in services and that they can contribute to decreasing agitation and stress. Turning Point Scotland believes that the operation of appointment systems is the reason for the low uptake of services among cocaine users, that there is only a small window of opportunity for interventions and stresses that the way in which services are marketed is important.
A model for delivery
7.8 The diagram in Annex F outlines one model (by way of example) of how services might look when fitted to the needs of stimulant users. The emphasis of the model is on 'low threshold', easy access to services, while ensuring that specific interventions are available to individuals who would benefit from them. This would include mental health specialists and detoxification services. A further feature of note in the model is the multiple points of entry into services and the availability of intermediate assessment. Further discussion of models of service delivery for stimulant users can be found in the Models of Care Guidance by the National Treatment Agency (2002).
GP role
7.9 It is important that GPs and other primary care professionals are aware of the signs of problem stimulant use, so that they can give information and make appropriate referrals. GPs are often the first point of contact for drug users, especially stimulant users who have a different socio-demographic profile from primary opiate users. It is important for this contact to be as productive as possible, that GPs adopt a non-judgmental attitude and have basic knowledge about psychostimulants and their complications. GPs can provide basic health care needs for stimulant users including assessment of physical health including assessment of injection sites if appropriate. Mental health assessment is vital in the case of psychostimulant drug users and GPs should be able to carry out a basic assessment and arrange for onward referral as necessary. Health Promotion advice is of particular importance in this area given the potential cardiac complications of cocaine use in a population with high rates of cardiovascular disease.
Information needs
7.10 A few opiate focused services in Scotland have adapted their provision to accommodate the needs of primary stimulant users but in only two instances have specific services for stimulant users been developed. One of these has a focus on Cognitive Behavioural Therapy (CBT). There are currently proposals for a demonstration project to establish and conduct assessment, peer support and CBT services for stimulant users in Edinburgh. (See Annex F for middle section of proposed model.)
7.11 There has been no national mapping exercise of services to identify to what extent services are addressing the need of stimulant users, although, as already mentioned, there are plans for COCA UK to undertake a mapping exercise in Scotland. However, a small case study in one DAT area with a relatively high incidence of stimulant use was undertaken for the Working Group by a voluntary sector agency. It found that services for drug users in the area had been developed in response to the increasing demand from dependent opiate users and that there was only one agency specifically targeted at stimulant users. In response to an informal survey, all of these services reported that they had generic services, catering for all groups of people who use all types of drugs. However, in practice, it appeared that the majority of referrals, services, programmes and interventions were focussed on opiate using clients. The one service set up in the area to target stimulant users did so through a project running outreach services in clubs, dance events, local communities etc. largely using peer support.
7.12 When services in this area were compared to a service delivery model ( see Annex F), numerous gaps in services for psycho-stimulant users were identified at all of the 3 service levels of the model. There were limited helpline services available to users and their families and outreach services were extremely limited. Shop front services for drug users did not exist. Only one agency provided outreach services for stimulant users. All the agencies in the area said they would provide a service for psycho-stimulant users who come to their attention from within their generic services and so stimulant users were not explicitly excluded. However, given the extent of waiting times for some services, it was doubtful that services could cope with the demand if targeting encouraged more users to access services. There were no facilities available in the area for acute interventions with psychostimulant users.
Case study of a specific service for stimulant users
7.13 Tim Bottomley from the Piper Project in Manchester gave evidence to the Working Group. He highlighted a number of lessons learned from his experiences of developing and managing the service:
service design needs to take into account the profile of cocaine users, for instance by running out of work hours sessions and by advertising services in public places instead of relying on word of mouth;
a great deal could be done to help problem cocaine users if they can be attracted and retained in a project
it is important to focus on the provision of information and early intervention and also to offer a range of services, including drop in facilities and appointments, acupuncture, work with families etc;
users come to the Piper Project through a range of different routes including relatives/friends, GPs referrals, and referrals from the criminal justice system;
word of mouth does not seem to be as effective as with heroin users;
the Piper Project has been client-led and had nonetheless developed into a predominantly abstinence service;
there is a great deal to be gained from having ex users on staff and as volunteers;
the Project is staffed only by 2 workers and volunteers, ideally it could double its size;
the Project saw 10-20 clients per month, or around 240 per year, with an average stay of 4-6months (some clients stay only one month, though one had stayed 3 years).
Case study of a service for women stimulant users
7.14 Louise Clarke of Higher Insight has worked with women crack users in the East of London over the past 10 years. In developing services for women she argues that service providers must take into account women's need for anonymity and confidentiality and their need for childcare support, particularly when attending services. Women may prefer to work with a female drugs worker. She also notes that setting up a drug project at a venue like a community centre where child care provision is already established can overcome some of the fears women have about attending a service that is labelled as a 'drug project'.
Criminal justice services
7.15 A number of opportunities exist within the criminal justice system to identify and respond to existing and new drug misuse patterns, including psychostimulant use. These include:
referral to addiction services at time of arrest;
formal diversion by the Procurator Fiscal to treatment services (as an alternative to prosecution);
Drug Treatment and Testing Orders;
using conditions of treatment as part of community sentences such as probation, prison based and post-release treatment programme;
the Glasgow Drug Court pilot, with its intensive 'enhanced probation' option along with Drug Treatment and Testing Orders bringing a particular emphasis on treatment based approaches;
Arrest Referral Schemes which provide an opportunity for intervention at a point of crisis by making appropriate referrals to local agencies;
structured programmes for those with deferred sentences offering scope for treatment;
prison-based services which medically assess all those admitted to prison and offer addictions assessment and individualised care-planning to all identified substance misusers, including those using psychostimulants.
7.16 In Fife the Drug Treatment and Testing Orders include a number of primary stimulant users and have attempted to provide alternative treatment options for this group, including psycho-social interventions. By contrast, in Glasgow, although the Drug Treatment and Testing Orders and the Drug Court have identified persons using cocaine secondary to opiate use, there do not appear to be any treatment options to deal with stimulant use.
7.17 COCA UK has developed guidelines to prison workers for use in England and Wales. ( See Annex D.) The Scottish prison population has a different profile, particularly its racial mix, and consideration would be needed to develop these guidelines to reflect Scottish conditions. There are of course similar management issues, particularly of the symptoms associated with withdrawal from cocaine on entering prison and the increased risk of suicide. There is an awareness and training issue for the Scottish Prison Service as for other services which work with drug users who may use cocaine.