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Chapter 3: Reducing harm from psychostimulants

32. To successfully reduce long-term demand for drugs, including psychostimulants, action must be taken to address the underlying causes of drug use such as reducing poverty, enhancing early years experience, improving mental health and creating more employment, education and training opportunities. The Group understand that this will be addressed by the Government's new drugs strategy.

33. This chapter sets out action to reduce the harm from psychostimulants by improving:

• current drugs education and information to increase knowledge and understanding and help people make informed choices; and
• the access, range and quality of services for people who are using psychostimulants - irrespective of where they might be on their drug using career.

DRUGS EDUCATION AND INFORMATION

Public information campaigns

34. Know the Score is a public information campaign, run by Government, which aims to increase knowledge about drug use and promote positive lifestyles and avoidance of drug use. Information is provided through a website, 24 hour helpline and a suite of materials. As well as informing potential drug users themselves, Know the Score offers a wealth of information for families and friends (from whom there is often the most demand). In relation to psychostimulants, the Government ran a Know the Score cocaine campaign in 2005-7 (which included TV and bill board advertising and awareness weekends in licensed premises). National organisations such as Crew 2000 and local partners also provide information about substance use.

35. The Group felt that it was critical that credible information is provided to people about substance use as only providing messages about the negative effects of drugs is out of step with substance users' reality or lived experiences and may turn them off important messages. It was also recognised by the Group that many people will use drugs despite Government and other messages aimed at reducing demand and therefore messages should also be focused on harm reduction. ²⁵

36. Therefore it is recommended that information campaigns, at both national and local level should:

• target messages according to the different categories of users (i.e. experimenters, regular stimulant users, problematic stimulant users and opiate/stimulant users);
• include harm reduction messages and be linked into self-assessment for those most at risk, including regular users;
• raise awareness of the health risks that might be a result of, or exacerbated by, psychostimulant use e.g. mental health - depression, paranoia;
• highlight the risks of poly-drug use, in particular the risks of using alcohol with psychostimulants, and linking it with alcohol campaigns where possible;
• update the suite of materials to include GHB and ketamine;
• ensure that delivery of national and local campaigns are synchronised where appropriate and where there is obvious common purpose and assured mutual benefit to maximise impact and achieve the best outcomes; and
• develop national materials that can be used at a national and local level for the targeted group.

37. It is the Group's expert opinion that substance use can change in a relatively short time due to availability and trends and therefore it recommends a responsive, intelligence-led approach to education and ready availability of a wide range of resources for use at the times when they become most relevant. Information often only makes an impact, especially with young people, when it relates directly to their current experience (not their future or past experience).

38. At a general level, it is recommended that there is a universal education programme on substances, including alcohol and tobacco, for the public. This type of general education and information needs to be real, relevant, and above all credible. It should include the possible (not 'definite') dangers of mono and poly-drug use. Normative education around substance use would appear to have some modest effects when used in this way. Providers of training packages for kinship and foster carers, funding for which is being provided to local authorities at present, could be designed to include this within their drug and alcohol provision.

Role of families

39. It is recommended that there should be a greater role for parents and other adult family members such as grandparents in educating their children and grandchildren about the risks of using psychostimulants. This might include specific information for parents. Central Government and local partners also need to be more innovative in the ways they communicate with young people, such as using text messages and social networking sites which are increasingly being used by young people to exchange information.

Role of employers

40. The Group is of the view that there is a considerable gap in terms of employers providing education, information and support about drugs and specifically psychostimulants in the workplace. The previous SACDM report recommended that employers include psychostimulants in their workplace drug policies. There is no evidence of whether or not this has happened consistently at a local level. It is recommended that further work is carried out by the Government to ascertain the current position and, if needed, the Government works with employers to ensure that psychostimulant information is provided to employees as part of a broader package of information about substance use. It is also recommended that the Government considers how it might ensure employers, themselves, are educated about substance use, especially those in small or medium sized business which are likely to be hit hardest by lost productivity due to substance use, the licensed trade, as well as industries with a zero tolerance philosophy such as oil and gas.

Education in schools

41. It is also important to maximise the impact that schools can have. Encouragingly, there appears to have been a significant drop in the reported use of drugs by both 15 and 13 year olds in the last 8 years. Between 2004 and 2006 prevalence of drug use among 15 year old boys declined from 21% to 14%, and among 15 year old girls declined from 20% to 12%. Prevalence among 13 year olds also halved ²⁶. However, a review of the effectiveness of drugs education in school showed that although there is good practice there is also room for improvement ²⁷. The Government has recently established a steering group to advise it on developing more effective substance misuse education in Scottish schools within the wider context of the Curriculum for Excellence. Membership includes experts from education, drug agencies, NHS Health Scotland, the Police and officials from across Scottish Government.

42. The group is due to publish an interim report early in 2009 and will produce advice, guidance and proposals aimed at helping schools and authorities to achieve the improvements sought through Curriculum for Excellence and the 2007 Act so that:

• appropriate teaching materials are available and are being used most effectively;
• comprehensive, evidence-based approaches to substance misuse education are integrated into wider health education and promotion in the school;
• education is planned in partnership with inputs from Health, the police and the community;
• delivery is by appropriately trained practitioners, for effective pedagogy (e.g. with interaction to develop skills);
• there is student-centred, culturally appropriate and relevant education, targeted to needs and context;
• training, networking, delivery and evaluation by practitioners is coordinated; and
• there is appropriate engagement with parents.

Peer Education

43. Peer education has an important role to play in drugs education and building up resilience to the harm associated with its use. Experience of organisation's such as Crew 2000, Fast Forward and others in Scotland has shown that whilst peer education is not the only way to deliver education around substance use it has an important role to play.

44. It benefits both the peer educators and those being targeted and takes learning out into the communities to combat ignorance and some of the mythology around substance use. Young people will often listen more closely to their peers and assess the value of what is being said taking into consideration the relevance, experience and authenticity of both the message and the messenger ²⁸.

BETTER ACCESS, RANGE AND QUALITY OF SERVICES FOR THOSE WITH PSYCHOSTIMULANT PROBLEMS

45. Action to tackle problem substance use in Scotland has evolved significantly over the last 20 years, with significant increases in investment in recent years in particular. Although treatment for psychostimulants has featured among treatment services, the focus has been on opiates which historically have been, and continue to be, the main problem in Scotland. As set out in Chapter 2, we are now facing a shift in patterns of substance use with more people using psychostimulants. This is complicated by a growing trend in poly-drug use.

46. In 2005-6 approximately 9% of drug treatment services in Scotland targeted and provided specialist interventions for psychostimulant users²⁹. Some of these are general drug treatment services which offer specific support to psychostimulant users, others are specialist stand-alone services such as Crew 2000 (Edinburgh) and INCITE (Aberdeenshire). INCITE also provides education, training and support to families of psychostimulant users. The evidence in Chapter 2 would suggest that the proportion of services offering treatment to psychostimulant users needs to increase in order to satisfy the growth in psychostimulant problems.

47. The paper will now go on to set out some of the barriers to providing effective services to psychostimulant users to help them recover and suggest how the barriers may be overcome by redesigning services and up-skilling existing drug workers.

Barriers to services

48. For historical reasons services are structured to focus on opiate users or people with alcohol problems. This, alongside the lack of established cocaine treatment programmes, may have resulted in primary cocaine users being reluctant to present themselves for treatment. They are also less likely to have knowledge of drug services and less willing to identify with the 'junkie' lifestyle ³⁰. There is also evidence that because of the nature of cocaine use - often sporadic binge patterns - that users seeking treatment should ideally be able to access flexible and immediate walk-in services rather than scheduled appointments³¹. In the case of opiate users who also use stimulants, they may already be in treatment, so access in itself is not an issue. However, as discussed in Chapter 1 it may be that only their opiate use is being addressed while in treatment.

49. Improving access to services must address both of these 'hidden populations'.

50. Evidence also suggests that there is a lack of knowledge and confidence among professional staff, working mainly with opiate users, to provide support for people with psychostimulant problems. However, there is a growing body of literature that identifies the basic principles of helping people make changes in their substance use and how these skills are transferable across categories of substances ³².

51. Scottish Training on Drugs and Alcohol ( STRADA) already provide two specific courses on psychostimulants ( An Introduction to Working with Psychostimulant Users and Working with Psychostimulant Users: Cocaine and Crack) as well as other courses on mental health and children and families which have sections in them which deal with the use of psychostimulants and also their interaction with alcohol. Crew 2000 and INCITE also provide training to frontline professionals and parents, as do some specialist agencies.

Redesign of services

52. It is recommended that current opiate focused services are redesigned, where appropriate, to make them attractive, accessible and effective at dealing with clients experiencing problems with psychostimulants (and poly-drug use). Services should not wait for people to become problem users but should seek to actively engage with people starting out on their 'drug using careers'. This may well involve outreach and detached work to the nightlife or other innovative ways of engagement, and social marketing techniques which involve other elements of society such as private and public services along with National Government Organisations ³³.

53. A stepped-care approach is recommended. This approach provides different services at differing stages of peoples' substance use such as:

• Information and advice to people who are thinking of using or already experimenting, including outreach work;
• Advice: harm reduction advice and information to regular users;
• Support services for those regular and problematic users who require more intensive support such as counselling, cognitive behavioural therapy; and
• Referral on to hospital or other acute services.

54. This is visualised as a funnel which has a wide range of access points through which people are filtered down, based on self-referral or assessment, to the relevant service.

55. To make the step-care approach work some changes in practice on the ground will be required, which are described below.

Information/advice

56. Some of the ways to ensure that the information available is credible and accurate is set out in earlier in this chapter. It is also recommended that general advice and information for people using psychostimulants should be made available to anyone who seeks it on an 'open access' basis. This should include the internet, GPs, Accident and Emergency, public libraries, criminal justice interventions, workplace occupational health and licensed premises. This range of access points should act as a filter to signpost individuals either through self-referral or assessment onwards to appropriate services.

57. It is recommended that local partners consider how outreach and other innovative methods can be used to engage with people who are thinking about using drugs; experimenting; or regular users to provide information, prevent harm and funnel people into services before they start experiencing serious problems.

58. Widening access in these ways will help tap into the 'hidden population' of psychostimulant users who may not attribute the problems they are experiencing such as depression, insomnia, coronary problems and so on to their substance use.

Support

59. Decisions on how to re-configure or redesign services to meet the need of psychostimulant users should be based on local needs assessments. It is recognised that the redesign of services will differ across areas, according to local need, but where there is a proven local need it is recommended that some element of specialist psychostimulant service provision should be provided. The type of service design should take into account that the psychostimulant using population is not homogenous. In areas where there are very acute psychostimulant problems local partners may decide to offer a stand-alone service that deals primarily with those with psychostimulant problems. In other areas with less acute problems the solution may be to employ a specialist psychostimulant nurse to work alongside existing drug workers and services.

60. Services, especially those in rural areas, may wish to consider how to utilise the internet to full capacity in providing treatment to people to help them recover. For example, this could include web cast meetings between client and service users and online support although this may require specific training for workers.

61. As with opiate services, any treatment intervention should be accompanied by wider social care, including links to mental health services, to fully address the needs of the client to help them recover.

62. In redesigning services consideration also needs to be given to access issues. Services will need to be innovative in their thinking and learn from good practice elsewhere in Scotland and the UK. Access could be improved by re-branding elements of a service to attract psychostimulant users; extending opening times so that people can attend after work, college or university; providing a walk-in service one night a week; or segregating the service by, for example, using a different part of the building.

63. Consideration also needs to be given to ensuring that there is access to needle exchange facilities for those people who inject psychostimulants. It is expected that access to needles will be partly addressed in the Hepatitis C Phase II Action Plan which is due to be published shortly by the Scottish Government, however, thought needs to be given to out-of-hours availability which is essential due to the patterns of psychostimulant use. The Plan itself will set out a range of actions for Health Boards and others around the themes of treatment, testing care and support; prevention; monitoring and surveillance; and governance and co-ordination. The Action Plan will be supported by over £45m over the next three years and the intention is to impact significantly on the prevalence of Hepatitis C in Scotland.

How can change be effected?

64. The Group strongly recommends that the Scottish Government considers providing 'seed-corn' funding to kick-start service redesign and facilitate the change needed.

65. Bringing about this change will also require re-training across specialist and generalist services covering psychostimulants and poly-drug-use. It is recommended that the Government works with STRADA, who it funds, and other existing specialist providers to consider how its training packages could be strengthened and the target audience widened. Such training should highlight the barriers/perceived barriers that users may encounter/believe exist which, while addressing the training needs, which should further stimulate change and broader access. This person centred approach will enable those in need of help to reach a service which is not only accessible, but one which will truly be regarded by them as open without feeling stigmatised.

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