Scottish Government

Chapter One Introduction

Overview

1.1 The pilot psychostimulant drugs project, Incite, was set up in Aberdeen in September 2003. It was established to provide services to people experiencing drug problems and who are primarily psychostimulant drugs users.

1.2 Factor Analysts Ltd ( HFAL) were commissioned to carry out an evaluation of this project in 2004-2005, looking at both service processes and outcomes. The aim of the exercise was to assess the effectiveness of Incite, highlighting areas of good practice and indicating how the service might be developed and improved in the future.

1.3 This document summarises the evaluation report and suggests how its main findings might be applied constructively to the implementation and operation of similar psychostimulant drugs projects in Scotland.

Identifying the need for psychostimulant drug services

1.4 Psychostimulant drugs are substances that excite the central nervous system, having the potential to produce feelings of well-being and alertness. They include cocaine, crack cocaine, ecstasy and amphetamines (Effective Interventions Unit [ EIU] 2002).

1.5 Research indicates that the use of psychostimulant drugs has increased in Scotland in recent years, especially in 'hotspot' areas such as Glasgow, Edinburgh and Aberdeen (Scottish Advisory Committee on Drug Misuse [ SACDM] 2002; EIU 2002). Recommendations from the National Psychostimulant Working Group ( SACDM, 2002) have highlighted the need for basic stimulant services in these 'hotspots'.

1.6 The EIU publication, Psychostimulants: A Practical Guide (2002), splits psychostimulant drug users into 3 groups. These are:

• opiate users who also use psychostimulants
• primary (and heavy) psychostimulant users
• recreational users

Prevalence

1.7 The numbers of new service users reporting psychostimulant drug use on admission to services in Scotland in 2003/4 are shown in Table 1. These figures are based on the Scottish Drug Misuse Database ( ISD, 2004) and a report on the prevalence of drug misuse in Scotland by the Centre for Drug Misuse Research ( CDMR, 2005). Every instance of reported use has been included, which means that people who report using both cocaine and ecstasy, for example, will have been counted twice. The figures for Grampian for those identifying a psychostimulant drug as their 'main drug of choice' are reported separately.

Table 1.1 New service users reporting psychostimulant drug use

1.8 In Scotland overall, cocaine was the psychostimulant drug most likely to be used by those being admitted to services. Grampian users made up 8% of the total for cocaine. A striking feature was that the use of crack cocaine in Grampian was more often reported, with the users of this drug in Grampian making up 40% of the national total.

1.9 The high incidence of crack cocaine use suggests an already established market in Grampian; police intelligence suggests this may, in part, be due to prostitutes using crack cocaine from the Midlands moving to the Aberdeen area and therefore stimulating demand ( SACDM, 2002). It is then perhaps not surprising that 70 of the 80 seizures of crack cocaine in 2002 were made by Grampian police ( ISD, 2004). ISD figures are likely to under-estimate stimulant use compared with opiate use because a high percentage of reporting agencies would concentrate on opiate treatment e.g. methadone prescribing.

Designing services

1.10 Psychostimulants - A Practical Guide ( EIU, 2002) and other published research discuss the types of services that can be offered to people using psychostimulant drugs. One of the main issues appears to be whether or not stimulant users can, or should, use traditional drug services which have a history of dealing predominantly with opiate users. Evidence from other areas suggests that stimulant users often regard generic drug services as not having anything to offer them ( COCA & Turning Point, 2005).

1.11 The research clearly indicated that the more people who present to services with poly-drug use, the greater the demand for services that can competently address the demands of different drug use. This may include further provision for psychiatric/ mental health services and alternative therapies. Rapid access is another dominant theme as stimulant users have a particular need for rapid response services.

1.12 The National Treatment Agency in England and Wales ( NTA) highlights a need to offer more psychosocial-based services to psychostimulant drug users, particularly as there is little in the way of evidence for in the absence of a validated effective pharmacological treatments substitute. Examples of these services include Cognitive Behavioural Therapy techniques, counselling and relapse prevention techniques ( NTA, 2002; EIU, 2002). It is also recognised that a key factor of the successful retention of service users in most drug services is not just the services that are available, but the manner in which they are delivered, i.e. the rapport built up between service user and key worker (Bottomley et al, 1997).

About the Incite project

1.13 The Scottish Executive has worked closely with Grampian NHS Board and Drugs Action Aberdeen to design and set up a pilot service for psychostimulant drugs users. The design of the service was based upon the findings of an initial needs assessment, and through observation of other existing services located across the UK.

1.14 With funding from the Scottish Executive, Grampian NHSB and Drugs Action Aberdeen set up the 'Incite Stimulant Users Project' (known as Incite) in September 2003 to provide services to people who are experiencing drug problems, and who are primarily psychostimulant drugs users. Drugs Action Aberdeen runs the service.

1.15 The aims of the project are:

• in the first instance to attract primary stimulant users into the service. This includes people with problems related to opiate misuse if they have an identified primary problem with psychostimulants.
• where possible provide a 'signposting' service to those psychostimulant drug users also using opiate drugs.
• to provide whatever service is required, such as harm reduction, crisis intervention, counselling, education, etc.
• to provide psychostimulant drug training and support to other service providers as identified in the Pilot Psychostimulant Service Training Needs Assessment for Aberdeen.

1.16 To meet these objectives, Incite was expected to undertake the following activities:

• provide outreach services to attract clients and market the service
• provide a flexible range of treatment, support and rehabilitative interventions
• increase and improve the range of pathways into other specialist treatment and generic support for clients
• provide multi-agency interventions to assist clients to capitalise on high motivation and secure good treatment outcomes
• provide easily accessible 'drop-in' and appointment-based services for referrals, as well as referrals from specialist and generic services

1.17 Incite is based within the premises of Drugs Action in the centre of Aberdeen. This set-up gives Incite staff administration support and a route for service users into the service via the Drugs Action helpline, drop-in, needle exchange, community outreach, and sex industry outreach services. It also allows staff time to work with service users on a one-to-one basis. One-to one sessions give service users an outlet in which they can discuss problems or situations with their designated worker in a comfortable, safe environment. The sessions may also include acupuncture to help service users relax.

1.18 Contact can be made with the Incite service via telephone (Incite number and Drugs Action helpline), referral from other service providers, or self- referral. The Incite telephone number is advertised on posters and flyers distributed to clubs and pubs and to other services and agencies as well as being handed out at outreach sessions.

1.19 The original staffing provision for the service was 2 full-time project workers and .5 team leader. At the time of writing, Incite have 2 permanent members of staff which make up just short of 2 full-time drug worker posts. ²

1.20 Incite offers a range of client-led interventions designed to address any service user need from harm reduction to crisis intervention, counselling and education. Types of interventions offered to individual clients include:

• General information: introduction to the project service
• Assessment: initial needs assessment, goal setting, Addiction Severity Index Assessment
• General drug information: drugs history work, drug effects information, pros and cons of drug use
• Skills building: decision making skills building, communication skills building, confidence/self esteem building, work on personal identity
• Talking therapies: harm reduction information, motivational work, identifying positive lifestyle change, identifying triggers/patterns, person-centred counselling
• Immediate interventions: crisis interventions, working with cravings, dealing with crash and comedown, developing coping plans
• Complementary therapies: relaxation techniques (Qi Gong ³), acute detox, magnet therapy, acupuncture
• Physical health support: identification and information on physical health concerns
• Mental heath support: identification and information on mental health concerns, strategies for coping with mental health issues
• Medical support: exploring pharmacological needs
• Social relationships/networks: work on removing negative relationships and building positive ones, identification of social concerns, exploring impact of drug interactions, exploration of personal support networks
• Interagency working: liaison with other services, advice referral to other agencies, advocacy work.

1.21 Although it is within Incite's remit to provide a drop-in facility, this service is not currently available because of inadequate staffing resources. Should a new service user 'drop- by', however, staff always endeavoured to provide an appointment. Service users also reported that on the majority of occasions when requesting an emergency appointment they had been seen the same day by their worker.

Aims of the Incite evaluation

1.22 The Scottish Executive Effective Interventions Unit (now the Drugs Misuse Research Team) commissioned Human Factors Analysts Ltd ( HFAL) to carry out a process and outcome evaluation of the pilot Incite project during the period August 2004-August 2005. The primary aim of the evaluation was to assess the effectiveness of the service, focusing on its ability to attract, engage and retain service users. This would highlight areas of good practice, suggest improvements for development of the service in the future and provide a basis for future learning in the development of other psychostimulant drugs services in Grampian and Scotland.

1.23 The process strand of the evaluation was designed to provide information about the processes and practices of the service. The outcome strand was designed to measure the effectiveness of interventions by monitoring the progress of service-users.

1.24 Chapter 2 details the methodology employed by HFAL in conducting the evaluation.