Drink and Drugs News

News | Round-upOur drug strategy works – but what next, asks HoggLowest ever waiting times for treatments, lowestrate of drug-related deaths and 89 per cent moreusers in treatment than in 1998, and stabilisationof class A drug use in young people were someof the successes of the government’s drugstrategy according to Vic Hogg, Head of theHome Office’s Drug Strategy Directorate.Mr Hogg had been asked to tell delegates atRelease’s Fifth Drugs University whether thegovernment’s drug strategy was working.Progress was being made, he said, and DrugIntervention Programmes were bringingacquisitive crime down. The Proceeds of CrimeAct was ‘hitting the big criminals in theirpockets’.The effect of interventions on supply wasmore difficult to gauge, said Mr Hogg, as‘when you take an organised gang out, anothersteps in’.Mr Hogg was keen to face challenges of thefuture, through more effective partnershipworking between agencies, governmentdepartments and countries.‘Much is lost by not operating properly,’ hesaid. ‘There’s a lot of good practice out there,but we’re not very good at communicating.’The media did not like celebrating good news,said Mr Hogg, ‘but we have a duty tocommunicate it’.More work needed to be done on growingthe workforce and skills training, such as therecent Home Office campaign to expand theworkforce.Making sure wraparound services wereavailable was equally important, and governmentdepartments such as the Office of the DeputyPrime Minister and Department for Educationand Skills must do their part in making sureservices were in place, according to Mr Hogg.Vulnerable young people were ‘at the very top ofthe government’s agenda’, he said.With the current drug strategy running out in2008, government was gearing up to acomprehensive spending review. ‘We need toevaluate effectiveness, refine best practice, andknow what works,’ said Mr Hogg. Money fordrug treatment would plateau after this time, hewarned, ‘so there is a need to prove that moneytill then has been used for maximum benefit’.What should the strategy post 2008 looklike?, he asked delegates. ‘Do we want radicalchange? Do we want a radical new drugstrategy?’ Should delivery and funding bemainstreamed where possible, through the NHSinstead of the NTA for example, he wanted toknow. Should there be individual strategiesrelating to different groups such as youngpeople, or would it be better to channel drugstrategies into other mainstream departments?,he asked.The existing strategy was effective, Mr Hoggconcluded, with data showing that it was movingin the right direction. ‘But it’s a long and difficultjourney,’ he acknowledged. ‘There’s more to do,and we need to do it together. I am confidentprogress is taking us in the right direction.’Addaction appointsnew chief executiveDeborah Cameron has been appointed as the new chiefexecutive of drug and alcohol treatment charityAddaction.With a background of senior roles in both public andvoluntary sectors, Ms Cameron was most recently directorof The Alcohol Recovery Project (ARP), which recentlyestablished the alcohol treatment project ‘Choices’ inBrixton, for minority ethnic communities. Other rolesinclude ten years as director of social services at theLondon borough of Newham.Her first task on joining Addaction is to get on theroad and meet the charity’s 700 staff and as many clientsas possible, said Ms Cameron.‘Empowering users to become more involved in theirtreatment, and supporting and motivating the people weemploy, will be among my first priorities,’ she added.Awards seek drugs field’s unsung heroesFDAP membershipcontinues to growAs of the beginning of the year FDAP’s membershipstood at 2,700 individual practitioners, and 64affiliate agencies, with a total of 3,800 drug andalcohol specialist staff. For more information seeunder ‘membership’ at www.fdap.org.uk.New Chair for FDAPAfter two years at the helm, Chris Hannaby (chiefexecutive of Vale House) has stepped down as Chairof FDAP, to be replaced by Noreen Oliver (Director ofBAC). Simon Shepherd, FDAP’s Chief Executive, toldDDN - ‘We are extremely grateful to Chris for hercommitment and support over the last two years –which have seen a period of rapid growth in theorganisation’s membership and profile.’ANSA is new DDN partnerAn awards scheme to find thedrug worker and team of theyear has been launched by theHome Office, to find ‘workerswho are making a real differencein the local community’.Part of the Tackling DrugsChanging Lives campaign, theawards are open to public andvoluntary sector workers in theUK, who can be nominated bycolleagues, friends, family,current or ex-service users.Prize money of £10,000 willbe awarded to both the winningindividual and the winning teamwho, the Home Office suggests,might be drug treatmentproviders, police teams, prisonofficers, social workers, housingofficers or youth workers, orfrom criminal justiceinterventions teams and DATs.DrugScope chief executive,Martin Barnes, one of thejudges, said that the awardswould ‘recognise theoutstanding work that ishappening around the country,as well as the range ansdiversity of local projects’.To make a nomination foreither category, visitwww.drugs.gov.uk/awards2006before the end of March. Winnerswill be announced on 23 May.DDN welcomes The Association of Nurses inSubstance Abuse (ANSA) as a new partnerorganisation.Formed in 1983, the association hasinfluenced and responded to changes in thedrug and alcohol field that relate to nursing,and the nurse’s role in the caring for serviceusers and their families.We look forward to benefiting fromANSA’s expertise in enhancing our editorialcoverage of nursing issues.4| drinkanddrugsnews | 30 January 2006www.drinkanddrugs.net

News | Round-upIHRA to block change in drug statusA rushed decision by the World HealthOrganisation to reschedule buprenorphine isbeing contested by the International HarmReduction Association (IHRA).WHO’s Expert Committee on DrugDependence (ECDD) has included a ‘finaldecision’ on rescheduling the drug on theagenda of its meeting on 28-31 March inGeneva.What this means in practice is thatbuprenorphine, which is used to treat pain andreduce dependence on opiates, is likely to bemoved to a stricter UN drug convention, whichwill mean tighter controls, more reportingrequirements, and possible changes in law.The move could represent a significantbackward step for countries that rely on thedrug as a tool to reduce HIV transmission –particularly those where availability ofmethadone is restricted, according to IHRA.Executive director of IHRA, Professor GerryAlcohol Concern has extended the deadline toreturn postcards for their ‘Spend £1, get £5free’ campaign to allow readers of this issue ofDDN to catch it in time.A portion of the card, supplied by AlcoholConcern should be signed and returned tothem, so they can send the cards to theDepartment of Health. AC is co-ordinatingrepresentations from treatment providers,service users and activists, to call ongovernment and primary care trusts to makealcohol treatment a priority.‘Every single postcard can make adifference, so please take this opportunity tomake your voice heard to government aboutthe vital importance of investing in alcoholtreatment services,’ says the charity.Stimson, has written to WHO’s directorgeneral, Dr Lee Jong-Wook, to request that thedecision is postponed to allow a proper reviewof the scientific, public health and socialimplications of the proposal.A hasty decision to reschedule was farmore than a technical issue, said Prof Stimson.It could mean ‘increased HIV infections, greatlylimited access to opiate dependence andantiretroviral treatment, and more lives lost inviolation of drug users’ fundamental rights tohealth and life’, he told WHO.Deferring the item to a later meetingwould allow an adequate review of data andtime for essential canvassing of opinion ofNGOs and others whose work would beaffected by the decision.As well as pressure on the WHO ExecutiveBoard, IHRA has contacted affected UNagencies and key UN staff to alert them to thesituation, ahead of the Geneva meeting.Make your voice heard now – AlcoholConcern extends deadline for DDN readersEmail campaign@alcoholconcern.org.uk tohave postcards posted to you immediately.Please sign and return them by the extendeddeadline of Friday 3 February.(For background to AC’s campaign, see DDN14 November, page 14, or visitwww.alcoholconcern.org.ukKarl from Broadreach will be sorely missedKarl Branston, treatment team manager atBroadreach, died of cancer on 19 January2006, aged 48.Karl worked in the field of drug andalcohol treatment for over 12 years, including10 years at Broadreach as a Counsellor, alwayswell-liked and respected by both clients andstaff, and making a profound difference to thelives of a countless number of people.He had a particular interest in developingnew treatment approaches, and brought awealth of experience and understanding toimplementing these at Broadreach, making animmense contribution to the high quality andeffectiveness of treatment.Throughout his 20 month struggle withcancer, Karl continued to work wheneverpossible. His dedication to his work and hisabsolute commitment to the highest standardsof care will be a great loss to Broadreach House.His compelling enthusiasm, intelligence,warmth and wonderful sense of humour will besorely missed by all of us who work here.Staff at Broadreach House.Latest FindingsGet effective!The NTA’s new emphasis on effectiveness andcorresponding developments in Scotland means UK policyis now aligned to the mission of the Drug and AlcoholFindings magazine, writes its editor, Mike Ashton.Produced by a partnership of national charities (NationalAddiction Centre, Alcohol Concern and DrugScope), themagazine translates latest research on the effectiveness ofdrug and alcohol interventions into the practical implicationsfor UK practitioners.Highlights in the new issue include American researchthat shows how treatment services can implement thenational push to link clients to housing, training, medical, andother services, building a stable platform for recovery. Whatthe Philadelphia researchers found is probably familiar tomany in Britain: comprehensive assessments of these needswere done using the system mandated by the regulators (theAddiction Severity Index – an international standard) – andthen filed rather than prompting referral to services.A simple system within the reach of any local network ofservices transformed this redundant paperwork into apractical route to the ‘wrap-around’ care now being advocatedin Britain. The secret was to create a tailored, computeriseddirectory of local services keyed to the needs identified inthe assessments, making it easy for counsellors to identifyhow to respond. As intended, clients assessed through thissystem received more of the services they needed, but theclincher for managers with an eye on performance targetscould be a remarkable ‘side-effect’ – over twice as manycompleted the core addiction treatment programme.At the more subtle end of counselling practice, we foundconfirmation that the directiveness of the therapist is a majorfactor in how clients respond. It came from a new videobasedanalysis drilling down to what actually happenedduring therapy sessions in Project MATCH, the blockbusterUS alcohol treatment trial. It confirmed findings from verydifferent settings and caseloads, all converging on theproposition that clients prone to react against direction dobest when allowed to take the lead, while those morewelcoming of direction lose out when therapists fail toprovide direction and structure.It seems common sense, but the research goes furtherthan most of us could simply intuit, identifying which particularelements of being directive make the difference and providingways to identify in advance what is most likely to suit whichclient. It seems a fair bet that the ability to make suchjudgements and adjust accordingly is one way empathictherapists with good social skills improve outcomes.These ‘X factor’ qualities are explored further in part fourof the ‘Manners Matter’ series, focusing on whethermotivational interviewing can help legally coerced clientsengage with treatment. It can, but only when the conditionsare right – and often they are not.Drug and Alcohol Findings issue 14 is now available – moreinformation and free downloads atwww.drugandalcoholfindings.org.uk or phone the NationalAddiction Centre on 0207 848 0437 and ask for Findings.www.drinkanddrugs.net 30 January 2006 | drinkanddrugsnews | 5

Letters | Notes from the AllianceNotes from the Alliance –Methadone and beyondKeeping it dirtyTackling prejudice and unfair treatment is about more than justturning a blind eye to it. Come on! Let’s look at options for longtermmaintenance as well as abstinence as part of the TreatmentEffectiveness Strategy, says Daren Garratt.Last December I attended the ‘Making It Clean’ conference inManchester. Organised by the North West NTA Regional Office andaimed specifically at commissioners and providers, the aim of theday was to promote abstinence as a viable treatment outcome,which actually supports the Alliance’s core philosophy that serviceusers have a fundamental right to develop a care package that istailored to their own individual needs and aspirations – includingabstinence.This may surprise some people whom, I suspect, have ourorganisation marked as blinkered, unquestioning methadoneevangelists. We know, though, that methadone is inappropriate andunsuitable for a lot of users, and sadly, society’s continuedprejudicial stance against the drug can result in some users beingdenied full citizenship.However, evidence also shows that when it is appropriatelyadministered as part of an effective treatment package, it is thegold standard in maintenance prescribing; it helps users achievestability and it saves lives. These qualities should never bedismissed or underestimated.Unfortunately, not everyone seems prepared to strike thatpragmatic balance and accept that being methadone maintained isnot somehow inferior to being drug free.Take Stuart Honor’s keynote speech on ‘the social reality of drugtreatment’ and his ‘outing’ of the accepted practice of blindreductions as perpetrated by a DAT in the North East. Blindreductions are when a key worker – not the GP – can decide toreduce scripts involuntarily after a failed urine test but ‘top up’ theremaining methadone with water so that users don’t becomesuspicious. If users then complain that their script isn’t holdingthem, the notion’s dismissed – and if they do finally get anadmission, they’re informed of a waiver they signed whilst rattlingand desperate at their first appointment.Stuart then went on to imply that it is somehow methadone thatshould be outlawed and not the inadequate care planning anddehumanised treatment systems that fail and endanger those theyare designed to support and protect by summarising the ‘options’ ofmethadone maintained users as: ‘a life on benefits, the incapacitybook (I’m sick – Hallelujah), underemployment (shootin’ chickens), alife on methadone, a life of crime, a mixture of the above’; andstating that ‘poverty is not soluble in methadone hydrochloride’.Amazingly, these distortions and examples of gross medicalmalpractice were greeted with a number of wry smiles from somedelegates and zero public response from the NTA (‘More treatment,better treatment, fairer treatment’), which undoubtedly led somedelegates to assume that this is a philosophy increasingly endorsed,shared and promoted by the organisation.So, come on NTA! Let’s redress the balance and host a jointconference that focuses solely on promoting long-term maintenanceoptions and controlled drug use as effective, viable components ofthe Treatment Effectiveness Strategy.And let’s give it a title that sums up the prejudices, attitudes andtreatment that many users experience if they’re not interested in‘Making It Clean’; let’s remind them how they’re ‘Keeping It Dirty’.The power of words. Don’t take it for granted.Living proof that fuel can help recoveryI am a 47-year-old worker for the Hepatitis CResource Centre, Otago in New Zealand. Ifound the ‘Fuel for Recovery’ article veryinteresting (DDN, 16 January).The evidence that essential fatty acid (EFA)levels predict future cocaine use better thanpast cocaine use (in other words, nutritionalstatus has more influence on drug takingcompulsions than behaviour does) confirms myexperience from treating my Hep C withL-methionine and selenium.I inadvertently corrected some underlyingchemical imbalance, and as a result gradually lostall my compulsions to abuse drugs – just lostinterest. I’ll still use if I think it will make me feelgood (in the longer term as well as immediately),but there just aren’t many options like that, so I’mbecoming drug free.Three years ago I injected my 120mgmethadone takeaways, IV Ritalin two or threetimes a week, took 40mg valium a day, pot all dayif possible, opium twice weekly, coke or speed ifpossible. Now, after three years on supplementsand no real willpower, effort or pain, I am on 80mgmethadone, and reducing. I haven’t used IV orritalin for six months (speed, orally, once in thattime), no valium for a year, opium only veryoccasionally, and no more than one joint a day.Most of those were compulsions, not trueaddictions, and those are the habits that went.When you do a drug, or an action like injecting,even though you know you don’t need it or won’tenjoy it, that’s a compulsion that becomesvulnerable when you find your chemical balance.What interested me about your article is,separate from the effect on HCV – and I wentfrom having next to no life, hadn’t been happy fordecades, to being happy most days – was thedelayed effect on my drug taking.It has become obvious to me that my attitudeto drugs (not that I enjoy them, not that I want totake them – but I was compelled to take themwhen I didn’t expect to enjoy them, or want totake them) was the result of a chemicalimbalance. Thus, the reference to EFAs andcocaine made perfect sense.‘Three years ago I injectedmy 120mg methadonetakeaways, IV Ritalin two orthree times a week, took40mg valium a day, pot allday if possible, opium twiceweekly, coke or speed ifpossible. Now, after threeyears on supplements andno real willpower, effort orpain, I am on 80mgmethadone, and reducing.’This attitude wasn’t so strong to start with.Bad diet, alcoholism and malnutrition caused itperhaps more than the effects of the drugs (Iwas still a polydrug used when I started toimprove). It doesn’t follow that every compulsivedrug-taker has the same imbalance (probablyhistadelia, or high brain histamine, which L-methionine helps correct) or will respond to thesame nutrients (though everyone here with HCV,especially autoimmune hepatitis, seems torespond to them).Eating fish and seeds has been a big part ofmy diet for the last three years, so the EFAs arethere too. I don’t intend to avoid taking drugs if Ifeel I’ll enjoy them – that’s just hardly ever thecase – or if I need them because of my habit.But now I feel better on a reducing dose ofmethadone, where I used to need gradualincreases to feel secure.I suppose the difference is, I really do feel‘high on life’, and love, and I resent drugs if theyinterfere with that. Also, I do believe thatmethadone and HCV don’t mix; I’ve seen peopleget very sick and don’t believe reassurances thatit’s not hepatotoxic. Maybe it won’t causecirrhosis, but with HCV there are many ways liverfunction can be adversely affected.But it’s not as if I’m on natrexone, antabuse,or something that stops me getting high – it’sjust that highs don’t compare with an averagenormal day. And things that don’t interfere withthat – like good speed – don’t entrap me either,perhaps because they wear off so slowly (andwithout depression) that I’m never tempted torepeat doses. Also I’m not tempted to spendmoney I don’t have any more.So much for the ‘addictive personality’. I wasnever able to get addicted to nicotine howevermuch I smoked when I did.My personality may have improved, but I thinkpeople I used to know still recognise me. Somepeople instinctively reject what I’m saying becauseit insults their sense of free will, but to me it’s theopposite; I have more free will now than I hadbefore, I’ve undone one of the ties thatpredestined me to certain unwanted behaviours.I’m sure others will be offended because Iseem to have found a shortcut to a place others6| drinkanddrugsnews | 30 January 2006www.drinkanddrugs.net

Letters | Drug testinghave suffered to reach. But I’ve suffered to getdrug-free before, and it’s not the same thing atall – not for me anyway.I’m quite happy to admit that, withoutsupplements (and the right ones – I’ve oftenused vitamins to ameliorate withdrawals orcomedowns, without more success than that),my willpower alone would never have achievedanything.George D Henderson, Hepatitis C ResourceCentre, Otago, New Zealand (who can be emailedwith any questions at hepcotago@gmail.com)East-West MassiveI read the letters in your last issue (DDN, 16January) and felt the need to add furthersupport for the East-West Detox alternativedetox and rehab programme, which I wasfortunate to have taken part in over two yearsago. This enabled me to deal with my demonsonce and for all. I was a chronic heroin,methadone, subutex and crack user for sixyears.I met Mike Sarson when I was sleeping roughon the streets, leading a very chaotic lifestyleand felt very drawn to the spiritual element ofthe process and taking a journey to a safe placeaway from familiar territory. Over the years I havetried many different conventional detox/rehabprogrammes in the UK, which never worked forme, as I always relapsed.I have now been clean for over two years andleading a productive life, working in the caringprofession supporting others.In the West we tend to over medicalise andjust deal with symptoms, which does not dealwith the underlying reasons for becomingdependent on substances. My experience at themonastery gave me the time and space to dealwith my issues and go through a healing processby reconnecting with my spirit and findingstillness within. The East deals with the problemof addiction in a very different way, which we inthe West could learn a lot from by workingtogether and supporting charities like East-WestDetox who have so much to offer.I am also aware of others who were fortunateto have gone through the East-West Detoxprogramme and remain clean. Please supportthis charity’s important work, which producespositive results.Sarah SowinskaEntitled to a choice... and factsIn response to Wendy Gregory’s letter ‘Analternative way’ (DDN, 16 January) I would liketo inform your readers that there are a numberof different options available to obtaintreatment at Thamkrabok other than throughEast-West Detox.Although it might not be advisable in everycase, it is possible for addicts to travel toThailand independently. The ThamkrabokMonastery gives its services free.Addicts must let the monastery know by emailwhen they will be arriving at Thamkrabok. Itshould be noted that the monastery is closed tonew admissions each year from 15 March until 5May. It is recommended that addicts stay for aminimum of 10 days but the longer they can staythe better (up to a maximum of 28 days).Full details, and lots more besides, can befound on the Thamkrabok IndependentInformation Network website athttp://www.thamkrabok.net.Professionals and the public alike shouldhave the facts available to them upon which tomake informed choices. The higher the claimedsuccess rate of a particular treatment model,the more likely it is to be perceived as a catch-allmiracle cure. Unfortunately, Wendy Gregory doesnot reveal East-West Detox’s success rate butdraws our attention to a figure of ‘70 per centover the past 58 years’.I think Wendy has been misinformed on twocounts. Firstly, the monastery has only been inexistence for 48 years and secondly theThamkrabok Monastery has never claimed norpublished such statistics. Thamkrabok does notoffer miracle cures. The monastery simplyprovides a rapid herbal detox and theopportunity for addicts to view the worlddifferently, from a Buddhist perspective,allowing them to reassess their life and theirplace in the world.The only ‘recent’ official figures are from anindependent report to the World HealthOrganisation in 1993, which sets success ratesat between 20 and 30 per cent, depending uponcertain criteria.Addicts should understand that undertakingtreatment at Thamkrabok is not an easy option.However, success rates and relapse preventioncan usually be enhanced by ongoing support. SoI’m pleased to say that there is an onlinesupport group for ex-addicts who have completedtreatment at Thamkrabok (or anyone consideringtreatment at the Monastery in Thailand) athttp://groups.google.com/group/Friends-of-Thamkrabok-Monastery.Of course sometimes it is not possible, orindeed desirable, for individuals to travel aloneand unprepared to Thailand. There are a numberof private organisations, such as the Alba-Thaigroup in Dundee ( http://www.alba-thai.org ) orTARA Detox in West Berkshire ( http://www.taradetox.org), who can facilitate treatment atThamkrabok. These organisations are independentfrom the monastery and provide varyinglevels of service to addicts usually at a cost.Some organisations will provide basicunescorted travel arrangements to themonastery, while others will provide fullyescorted detoxification trips to Thailand,including before and after services. Obviously,the Thamkrabok Monastery cannot, and will not,enter into disputes between individuals and theirchosen independent service organisation.I very much agree with Wendy Gregory whenshe says ‘surely everyone seeking recovery isentitled to a choice’.As the provider of an ‘alternative’ detoxservice, I too feel disappointed by the presentrecommendation from the NTA, but hope thatfunding for treatment at the ThamkrabokMonastery will be reviewed favourably in the future.Vince Cullen, TARA Detox Organisation,www.tara-detox.orgBetter standards in drug testing: part fourEffective screeningCarrying out a screening test can indicate what drugs havebeen taken, but a back-up procedure must follow. In thefourth of his six-part series, Phil Houldsworth tells youhow to read the result and what to do next.Once a sample is collected, the next step is of course to testwhat’s in it. The level of testing depends on what you will bedoing with the final result. The evidential value is important. Ifall you need is a presumptive look at what’s in the sample, thenall you have to do is carry out a screening test. The evidentialvalue is low, as the screening test can’t conclusively prove thepresence of a drug. For instance, a screen can tell you that anindividual has taken an opiate but it won’t be able to tell whichone. If you need to pinpoint which opiate has been taken thenyou will need to carry out a confirmation test to confirm thefindings of the screen and identify the opiate. The evidentialvalue of a confirmation test is therefore very high.At one time screening tests could only be carried out in alaboratory, but now it is possible to carry them out at the pointof collection of the sample as well. The following describesscreening tests in general and can be applied to both laboratorybased and point of collection screening.The drug in the sample binds to an antibody, which eitherstarts a reaction or prevents a reaction from happening. This iscalled an immunoassay and the vast majority of screening testsare based on this principle. This can be done either withinminutes at the point of collection, or by a laboratory.However, the problem with any screen test is that it is onlyan indicative test and all positives should be confirmed. Youcan confirm the screen test in one of two ways. You can eitherhave a laboratory carry out a test to confirm the screen result,or you can simply ask the donor. If the sample donor agreeswith the screen, then they have confirmed the screen; if theydisagree, then send it to the laboratory.You have to be careful when looking at the result. If you get anegative response from your screen test this does not mean thatthere is no drug in the sample; it means that there was either nodrug present or not enough drug present to get above the cut offlevel of the test. Remember the screen test indicates thepresence of a drug above a certain level, which is called the cutoff level. They may have taken the drug you are looking for, butthe level is now too low for the screening test to see. Negativedoes not mean nothing; it means we maybe cannot see it.The other problem with any screen test is that itsometimes shows up positive for a drug when there is actuallyno drug there. This is called a false positive. What’s happenedis that a compound that is in some way similar to the drug hasbound to the antibody and produced a positive result; forinstance, Sustiva, an anti-retroviral drug, can cause falsepositive result for cannabis. This is not because Sustiva ismade of cannabis, but the antibody used in the screen testsometimes gets confused. This is why sometimes, when yousend a positive screen sample to the laboratory forconfirmation testing, it comes back negative. The next articlewill describe the process of confirmation testing.Phil Houldsworth is managing director of Tackler AnalyticalLtd, which sets up and administers drug testing qualityassurance programmes.www.drinkanddrugs.net 30 January 2006| drinkanddrugsnews | 7

Cover story | Value for moneyTroubleat Tier 3Too many tier 3 servicesare stuck in a rut – lowin quality, high in cost,and failing service users.Why are we turning ablind eye to this dismaldate of affairs, asksSebastian Saville"Tier 3 services represent the keyelement in the present government’sreconfigured and reinvigorated strategy for theprovision of treatment to the estimated300,000 regular users of heroin andcocaine/crack in England and Wales whowant it. The services’ vital ingredient issubstitute prescribing – including methadone,which a powerful and growing evidence basesupports as indispensable. While counselling,social support facilities and preventativediscourses all have undoubted value, notreatment strategy can be expected to workwithout substitute subscribing services.It is with considerable alarm, therefore,that I note the precarious state of currenttier 3 provision. Much of it remains low inquality and high in cost; its financial andcontractual arrangements are opaque andobscure. Telephone help and advice linesrun by drug user organisations report thecontinued existence of geographically patchyand often substandard services, which, byfailing to meet the clinical benchmarks laiddown in the Department of Healthguidelines, leave clients unsatisfied andtheir real health needs unmet.This dismal picture arises against abackground of substantial and ongoingincreases in the financial resources directedtoward drug treatment. Some £417 millionof taxpayers’ money was spent in 2004/5,with the figure set to climb to £700 millionby 2008. In view of these levels ofexpenditure, it must surely be a matter ofurgent concern that so much of the tier 3service delivery remains unsatisfactory. Howthen have these circumstances come about,and – the most important question – whyare they allowed to persist?The late 1990s saw expanded resourcesbrought to bear upon the entire drugtreatment sector. A sharpened policy focusand new forms of expertise accompaniedthem. Beneath the resultant policy spotlight,it quickly became apparent that, despiteabsorbing significant sums of public finance,many existing treatment services were ofdubious quality, had unacceptably long waitinglists, and were lacking a fundamentaltransparency in their contractual and financialpractices. These problems were at their mostacute in the tier 3 prescribing sector.Composed largely of specialist substituteprescribing clinics, these services were inthe near-exclusive grip of NHS Mental HealthTrusts. It is estimated that, in the year 2000,60 per cent of total drug treatment expenditurewas allocated to this group of providers,to whom service delivery was contracted outby local commissioners. The newly formedNational Treatment Agency regarded themodernisation and improvement of theseservices as a core component in its brief,which was to raise treatment standards inaccordance with the objectives of thegovernment’s national drug strategy.Initially, the NTA proposed that servicecommissioners would work in partnershipwith their existing NHS providers. Theprimary objectives were to reduce waitinglists, to improve clinical practice by bringingit in line with a specified evidence base, toeradicate postcode prescribing, and todevelop more transparent commissioning.While this process of ‘modernisation’ hasclearly had some positive and enduringimpact on the commissioning process, itsoon became apparent that large numbersof Mental Health Trusts were either unableor unwilling to implement the requiredimprovements. In spite of the best ofintentions, the upshot was a continuation ofthe same old bleak pattern of inadequateand exorbitant service provision.Recent years have witnessed a gradualbut undoubted transformation in the attitudesof some commissioners, and an attendantdesire to open up the field to genuinelycompetitive tender. However, while variouscommissioners are expressing an aspirationto radically improve their local tier 3 services,there remains in place a set of forces thatkeep the doors to new players seeking toenter the field firmly shut; forces that seemdetermined to obstruct any movement awayfrom the effective monopolisation of thesector by Mental Health Trusts.The stock responses to calls for a freeingup of the sector to allow the entry of newproviders are customarily twofold. Firstly, it isargued that putting tier 3 services out totender will jeopardise and disrupt broaderrelations between the commissioners andthe Mental Health Trusts. The additionalcontention is that there are no alternativeproviders out there anyway, so the questionis merely an academic one.The former point was perhaps understandablein the early years of the strategy,when there existed an implicit faith in longestablishedmodels – a faith underpinned byNHS domination. In 2005, following sixyears of massively increased investment inservices and commissioning systems – andlimited signs of improvement – such astance becomes indefensible. If, despitethese enhanced resources, service providerscontinue to demonstrate a failure to meetNTA waiting-time targets; to comply with thestandards of clinical governance set forth inthe Department of Health guidelines,Models of Care and the NTA’s best-practiceprotocols; or to present clear activity andexpenditure data that displays an accurate‘unit-cost’, then an alternative providershould be found.Under these circumstances, it is difficult8| drinkanddrugsnews | 30 January 2006www.drinkanddrugs.net

Cover story | Value for money‘While various commissioners are expressing anaspiration to radically improve their local tier 3services, there remains in place a set of forces thatkeep the doors to new players seeking to enter the fieldfirmly shut; forces that seem determined to obstructany movement away from the effective monopolisationof the sector by Mental Health Trusts.’to avoid the conclusion that there are otherfactors at work underpinning the continuedfaith of commissioners in the failed relationshipsof the past. It would appear that localNHS politics, and social networks in whichindividuals from both sides of the contractualrelation mix together, are taking precedenceover quality of care and value for money.It has already been demonstrated beyonddoubt that specialist prescribing based in auser-friendly environment can provide servicesthat are both cheaper and more effectivethan the traditional Drug Dependency Unitmodel that typifies the Mental Health Trustapproach. Kaleidoscope has been providingaccessible, user-friendly prescribing in SouthLondon for many years, and the JunctionProject, a service I managed with Dr ChrisFord in the London Borough of Brent from1997 to 2000, are both examples of servicesthat completely replaced and dramaticallyimproved on existing NHS provision. Suchopportunities, however, remain strictly limited,with the majority of commissioners apparentlycommitted to struggling along with theirexisting providers through repeated cycles of‘improvement plans’ and ‘last chances’. Stillthe impasse persists.Fed up with trying to get things movingthrough traditional pathways, I started DTL(Drug Treatment Limited). Yes, a privatesector company. It seemed the only way tooperate in the flexible and responsivemanner needed so desperately in the field. Ifind laughable the almost hysterical knee jerkreaction to the thought of good drug servicesbeing delivered by the private sector – free atthe point of delivery to users of course. Ihave worked in both the voluntary and publicsectors and have witnessed the waste ofvast amounts of resources.So yes, I could be accused of being aninterested party, with a stake in this debate.This might appear less so when looking atthe group of respected names in the UKdrugs field, all with proven track records inthe public sector, who have become involvedwith DTL over the last year. Mike Trace,Professor Gerry Stimson, MoniqueTomlinson, Dr Gordon Morse, Gill Bradburyand Martin Blakebrough are among thosewho have come together with a statedobjective of stimulating this much talkedabout ‘modernisation’ of treatment –particularly in the area of tier 3 prescribing.All of us can testify to the existence of anurgent and unmet need in this arena, andbelieve we are well positioned to meet it.But the point is that this is not rocketscience. In principle, any NHS or independentsector provider can, with the necessary will,knowledge and creativity, provide tier 3services to a much higher standard and at alower cost, than those with which commissionersand users alike have been forced tomake do in recent years. An estimate, derivedfrom discussions with a variety of keystakeholders across England and Wales’ drugtreatment sector, would look as follows: of theMental Health Trusts contracted to deliver tier3 services, 25 per cent are good, 25 per centare acceptable, and 50 per cent are of unambiguouslypoor quality. Many people appearto be fully aware of this state of affairs.And yet there remains a stubborn resistanceamong some commissioners toproperly open out tier 3 services to competition.We hear on the one hand an allegeddesire for innovation and modernisation, yetunless you can show that you have beendelivering services (however effective) formany years, it is almost impossible to beconsidered. Furthermore, some of thecommissioning structures have becomebedevilled with procurement processes soenwrapped with red tape that they appear tohave been specifically designed to stifleinnovation; a catch 22 situation whichimpacts on the public, the service user, theirfamily and the NTA themselves.It represents a truly extraordinary state ofaffairs when a large, publicly funded organisationis unable even to supply an accuratenumber of clients treated and, consequently,to put a figure on its unit costs. Superimposedon this is the further problem of disaggregatingthe actual cost of drug treatmentfrom the overall package of services suppliedby the Mental Health Trust. These circumstancesrender large numbers of Trustseffectively unaccountable for the immensefiscal sums they spend, year on year.It will be apparent to the reader that thereare no winners in such a scenario – certainlynot the service users, who are forced toaccept inadequate services or return to theillicit market. It is high time that some seniorfigures within the government began to askwhy the return on their investment in drugtreatment has been so small.www.drinkanddrugs.net 30 January 2006 | drinkanddrugsnews | 9

Careers | OrganisationPresenting the evidence10 | drinkanddrugsnews | 30 January 2006www.drinkanddrugs.net

Careers | OrganisationKeeping a portfolio sounds as if it could be a useful move for career development.So what’s involved, how straightforward will it be – and is it worth it? DDN finds out."So you’ve made a resolution tokeep a professional portfolio. Butfirst things first: why bother? Aren’t weall resistant to extra paperwork?According to the Chartered Institutefor Personnel and Development, employabilityin today’s market largely dependson ‘self-directed development’. In otherwords, employers are increasingly lookingfor evidence that job applicants havekept themselves up to date and constantlylooked for chances to improveknowledge and increase their experience.Continuing Professional Development isabout ‘consciously’ updating professionalknowledge, and is ‘a state of mind, morethan a set of rules of a programme ofstudy’, says the Institute.So think of the portfolio as a careerpassport, to move around the field. It’snot just a formal record of qualificationsand a listed employment history;done properly it will show evidence ofyour achievements to give futureemployers a fuller picture of your ability.The investment will be long term: yourportfolio should be a living project thatgrows alongside your career. As well asresulting in a record of what you havedone, the exercise of planning andcompiling a portfolio is also meant tobe developmental. It’s aimed at makingyou consider your future aspirations –and how to get there through planningyour next move.There is no rigid format for a portfolio– but it must be structured systematically,so it is easy for someone else tonavigate and understand. Essentially youare telling your career story, usingexamples from your daily work, so youneed to plan the evidence to best reflectyour competence. The golden rule hereseems to be ‘quality over quantity’. Vastamounts of items, haphazardlypresented will not impress. Worse thanthat, they will be counterproductive anddetract from your nuggets of experience.Presentation is important, so firstof all, think how you will organise yourevidence. Most people use a lever archfile, divided into sections. You canconsider compiling an e-portfolio – adigital record of achievements, whichcan be easier to store and send – butmost people still opt for the paperformat, which is easier to pick up andlook through.Next, think about the items you willneed to collect to show yourcompetence in a range of situations.You can look for examples in yourrecent past, but try not to useevidence that is more than two yearsold as your aim is to demonstratecurrent competence and show youhave up-to-date skills. You can draw onyour experience of activities outsidethe workplace, such as voluntary work,if you need to supplement examplesfrom your current job.To compile evidence from documentsproduced at work, have a look at careplans, records of meetings andassessments, action plans, reports,letters and emails. Select examples ofthese documents, if you think theydemonstrate your competence in aparticular area or record relevantexperiences. If you need to usedocuments that are confidential andcannot be removed from the workplace,provide a written statement describingyour involvement and achievements,and state where the document can befound. You should also remember toremove references to any personalinformation when you use case studiesin your personal history.Another useful approach is tocollect statements and testimonialsfrom people who have witnessed youperformance at work. You could askmanagers or colleagues to sign anddate work, and ask service users forfeedback whenever it seemsappropriate. Get into the habit ofcollecting evidence about differentpieces to work to demonstrate yourcompetence in different situations.Organising your portfolio is quitestraightforward, but it is worth planningthe structure before you begin. Startwith the title page – your name, jobtitle, organisation, contact address,phone and email and the purpose ofthe portfolio (such as any qualificationyou are working towards). Follow it withthe contents page, listing sections ofyour portfolio that will be separated bythe file dividers.Next comes your personal profile.Give a brief summary of your job, andinclude a job description or role profile.An organisation or department chartshould also go here, if you have one,along with a copy of your up-to-date CV.A ‘professional development’section should then give evidence ofyour personal development plans.These could include documentsrelating to training and developmentyou have done, or want to undertake,and can give an idea of your futureintentions for career development.Include relevant qualificationcertificates in this section.For the next section on drug andalcohol national occupationalstandards (DANOS), copy the key unitsthat are relevant to your job. You cantake these from your current jobdescription or role profile, or from aqualification or award that you areworking towards.Then comes the section with yourevidence records. For each DANOSunit, you need to provide a writtenstatement that shows that you havemet its requirements, referenced to thesheets demonstrating your evidence. Aclear way of doing this is to include agrid or matrix, listing the items ofevidence and showing how they crossreference to each unit’s requirements.At the end of your portfolio, compileall the evidence you have collected inone section. This works better thandistributing evidence throughoutdifferent sections, as good pieces ofevidence can be relevant to more thanone unit. Number each item ofevidence for easy reference, in theorder that you have placed it in theportfolio, and make the section evenclearer by including an ‘evidence index’at the front of it.Where to get more helpSo that’s all there is to it! It goeswithout saying that the evidence mustbe your own work – or if you includeexamples from team work, make itobvious what your own contributionwas. Include each piece of evidence inyour portfolio for a clear reason – toprove your competence. If you’re notsure what an item proves, don’tinclude it. Volume is not the purposeof this exercise; you won’t get browniepoints for extra stationery.Remember to keep your evidenceclear and to the point, withoutduplication. You can reference a pieceof evidence as many times as you like,but include just one copy of each item,clearly referenced with a simple,consecutive numbering system. Makeit easy for the person reviewing yourportfolio to see easily what you aretrying to demonstrate. You are trying toshowcase your experience, so whymake the evidence difficult to find?Above all, bear in mind that much ofyour portfolio is about demonstratingwhat you’ve already done and theknowledge you’ve gained. With a littleorganisation you will realise how muchscope you have to make the next movein your career. DDNIn future issues of DDN: followFrankie’s diary as she begins herportfolio.If you have any queries relating toprofessional development, email DDNCareer Clinic, c/o claire@cjwellings.com(or write to the editor at the address onpage 3) and we will try and find anexpert answer for you.The ‘management resources’ section of our website gives a range of supporttools from different organisations to help you with DANOS and compiling aportfolio. Links from the site will take you to the DANOS microsite from Skills forHealth; DANOS implementation guides and workbooks from Pavilion; asoftware package from the Management Standards Consultancy (who helped todevelop the DANOS standards) and MAPS; and Capacity Builder – a freesoftware package produced by Skills for Justice.Visit www.drinkanddrugs.netIf you are an NVQ candidate, you should work with your assessor to agree themost appropriate evidence and the best way to present it. You can keep actionand assessment plans, developed with your assessor, in your portfolio.www.drinkanddrugs.net 30 January 2006 | drinkanddrugsnews | 11

Service User Groups | AlcoholA glass half fullWith problemdrinking takingits toll on theNorth East,Kevan Martindecided to turnhis experienceinto action byforming theservice users’forum NERAF. DDNtalks to him abouthis mission to haulalcohol treatmentup the agenda"Following intensive treatment for alcoholism,Kevan Martin was sent back home to fend forhimself. That was when the safety net was cut awayand he realised he was back on his own with aproblem that continued to overwhelm him.‘I was going home to the same place, nothinghad changed,’ he explains. ‘And I’d lost the skill tochange things because I’d been drinking dangerouslyfor some 20 years.’Spurred on by the need for support, Martin gotinvolved with the regional drug user forum. Herealised that he was not the only person in hisregion that felt swamped by alcohol problems, andbecame vice chair of the forum, so he could bringalcohol issues to the table.But his agenda was soon thwarted. ‘We were toldby the NTA that effectively there was no room foralcohol in that forum. I was incensed, to tell thetruth; I thought if it’s good enough for drugs, it’sgood enough for alcohol. So I set about starting aself-help group in Whitley Bay where I live.’From these initial frustrations sprouted NERAF –the North East Regional Alcohol Forum. Realisingfrom an early stage that he needed help to get thegroup up and running, Martin approached VODA, acommunity service agency, which gave him help withsetting it up and forming a constitution. He found aninvaluable ally in Peter Carlin-Page, alcohol coordinatorfor Sunderland Teaching Primary CareTrust, who ‘asked what I wanted to do and has been100 per cent behind me ever since’.Carlin-Page shared Martin’s concern for the stateof alcohol services in the North East. ‘We’ve got thefewest treatment services and the longest waitingtimes. Alcohol is a serious problem up here,’explains Martin. ‘There were 430 people who diedfrom liver disease last year in the region, and we’reon the increase.’There were two strands to the newly formedNERAF’s strategy: getting things moving locally, andworking out how to get more influence nationally toextend support to other service users around thecountry.Setting up drop-in centres was an obvious pointof local contact. The more difficult part of the localequation was finding people before they slippedthrough the net – just as Martin had. He set up linkswith services and the four local rehabs, intent on12 | drinkanddrugsnews | 30 January 2006www.drinkanddrugs.net

Service User Groups | Alcohol‘We were told by the NTA that effectively there wasno room for alcohol... I was incensed, to tell the truth;I thought if it’s good enough for drugs, it’s goodenough for alcohol. So I set about starting a self-helpgroup in Whitley Bay where I live.’partnership working: ‘We haven’t set up anopposition agency or militant group, we’ve set up tocomplement other services,’ he explains. ‘Wherethey finish, we take over. We go on to the long-termaftercare.’Visiting the rehabs each month gave NERAF theopportunity to see people before they came out,‘with the hope they’ll tap into us’. Not only did manyof the service users accept ongoing support – manyof them wanted to become involved with the group,‘to help others go through what we’ve gone through,to show them there’s a way out’. Martin took theopportunity to reinforce the group’s message withthe help of new supporters. The message is: ‘youcan be turned around, and you can go on to lead ameaningful and profitable life. Just because you’vehad a drink problem, that doesn’t mean that’s lifeended,’ he says.Alongside the immediate comfort of reassurance,Martin emphasises that NERAF has an importantrole to play in the long-term game for people withalcohol problems. His own experiences have givenhim a lasting memory of being treated only foraddiction – ‘they didn’t treat anything else’, explains.He now makes it his mission to help people addressall areas of their life, to get back control. NERAF’slong-term goal, he says, is to set up seven-day-aweekcentres, ‘one-stop facilities, where we look athousing, debt, therapies, arts and crafts, IT training’.They will help people re-establish contact withchildren, encourage them to get relationships goingagain and rebuild the fabric of their lives.Local service providers are now linking into theForum’s network of contacts, referring people forongoing counselling and care. Martin was coming intocontact with people who had been five or six yearsinto recovery but who were unable to get back intowork, and he saw the opportunity to develop a peersupport network. He knew he needed help withNERAF’s growing workload – and that there was ademand for their skills that were borne of experience:‘Service users were saying to their counsellors, “look,I want to talk to somebody who has experienced whatI’m going through now”.’ He set up a network ofvolunteers to bring the ‘vitally important’ peer supportmodel to life, and is training former users in advocacyand mentoring, to become involved in a newlycommissioned mentoring service in Sunderland.He is now seeking funding to pay a salary to hisfour full-time volunteers. In the meantime he isencouraged: ‘we have people actually coming to uswith contracts now, which is very very good.’Tapping into a national framework has been anambitious project. Undaunted – and grateful forCarlin-Page’s help in opening doors – Martin hasgained support and inspiration from Alcohol Concernand a seat at meetings of the North Eastgovernment office’s alcohol forum. Not content withbeing a self-help group for Whitley Bay, Martin wantsNERAF to galvanise the alcohol support networkthroughout the country.‘We’ve got the blueprint now, which anyone elsecan follow,’ he says. And making things happen isnot about waiting for the money: ‘A lot of people arewaiting till funding is actually available. But if you digdeep there’s some funding available,’ is hismessage. ‘OK, it might not be through healthservices or DATs – but there is funding to get thisgoing now.’ He urges colleagues in other parts of thecountry to get organised with whatever resourcesthey can find – ‘so when the mainstream fundingcomes in, you know what to do with it.’Political uncertainty (will there ever be moremoney to turn DATs into DAATs?) should not chokethe potential for local initiatives, according to Martin.Visiting liver units in hospitals, going into A&Edepartments, finding opportunities to intervene withproblematic drinkers can make a lot of difference, hesays – particularly if you can then involve serviceusers in influencing commissioning.‘Commissioners are in their own world,’ he says.‘But we’re breaking through now by showing thesuccess we’re having.’ To get the message across,NERAF is sending questionnaires to areasthroughout the North East – ‘and 99 per cent of the202 questionnaires we got back want a peer-ledsupport service.’Martin has respect for different methods oftackling alcoholism, but a key goal is promotingchoice. While AA is ‘a fantastic organisation’, it didn’twork for him. ‘We don’t care how a person achievesor maintains sobriety,’ he says. ‘What matters is theyget there.’ NERAF aims to be holistic – andencouraging, particularly when the going gets tough.‘If somebody lapses, they give themselves such ahard time – and we say don’t,’ Martin explains. ‘Ababy when it’s born doesn’t get up and walkstraightaway, it keeps falling down. And that’s whathappens with alcohol. You’ve got to stand up, brushyourself down, and carry on. You learn from it.’He used to give himself a hard time whenever helapsed – ‘I remember going 18 months without adrink and then went back. I felt so disappointed.’ Butnow he knows that’s the nature of the condition andwants to help others persist.Six years on from his last drink, Martin has a fistfull of plans and a determination that alcoholicsshould no longer languish at the bottom of thepriority list. But he knows he has a fight on hishands.He’s afraid that the extra £15 million to be spenton alcohol treatment in the next year is not only adrop in the ocean, compared to the scale of thecountry’s alcohol problem, but that governmenttargets are all heading for the criminal justiceagenda to tackle binge drinking.‘The people needing treatment very rarely breakthe law,’ he points out. ‘They’re solitary people, theygo to the off-licence and back home. They don’tcommit crime.’ To issue funding on these grounds isto miss the main issue, he says, and missing themain people that want treatment.His purpose and his passion through NERAF thenis to galvanise movement throughout the country, tounite with other groups and give a strong voice toalcohol service users, whatever kind of treatmentthey are involved in.Martin has already had vague promises ofinvolvement, but is determined that NERAF is in itfor the long haul. From wanting to get betteralcohol treatment for one of the worst served areasin the country, he is now driven by conviction thatthis is the time for alcohol services to be heard:‘Service users have got to get united behind eachother, it doesn’t matter if they’re AA or what. Peoplewith drink problems have got to be saying look, thisisn’t on.’‘I would like other groups in the country to get intouch with us,’ he says. Let’s get something goingnationally. Now’s the time.’ DDNNERAF’s newly launched website is at www.neraf.org.uk.You can get in touch with the forum by emailingneraf@hotmail.co.uk.www.drinkanddrugs.net 30 January 2006 | drinkanddrugsnews | 13

Question and Answers | Tobacco smokingQATobacco smoking is one ofthe deadliest addictions, yetseems to be largely ignoredby the substance misusefield. Do any treatmentproviders give advice onstopping smoking whiletreating other addictions?Jodie, smoking cessationco-ordinatorHypocrisy is the greatest luxuryDear JodieI am currently training at a Treatmentcentre in Dorset that is abstinence based.As I am doing a degree in AddictionsCounselling, I was surprised that theagency has no guidance or support for the75 per cent of service users that smokeexcessively and drink copious amounts ofcoffee, both highly addictive and providingtriggers to other addictive substances.I have currently given up smoking as Ifelt hypocritical smoking tobacco whilsthelping support clients through theiraddiction. I think treatment centres shouldfind a process of change that helps smokerscut down or give up while in treatment. Thiswould in turn help recovery as client wouldhave to find an alternative to smoking andchange behaviour to reduce cravings.Angela EarleyLife Works when you give upDear JodieI was very interested to read yourquestion on tobacco smoking and whetherany treatment providers offer options onstopping smoking while treating otheraddictions.Life Works is a private treatment centrewith both day care and residential facilitiesin Surrey and London W1. We have joinedforces with The Third Space gym to developa Holistic Smoking Cessation Programme.This will be the first UK programme thatwill offer real clinical support and treatmentto its participants within a treatmentsetting. It will be a combination of provenmethodology alongside cutting edgetherapeutic support, incorporating arelapse prevention element.The programme will include a medicalassessment, 1.5 days counselling group,0.5 days group work, 6 week gymmembership at The Third Space Soho,Acupuncture, and Hypnotherapy.We would be delighted to provide fulldetails of this forthcoming programme:0800 081 0700,www.lifeworkscommunity.comBeth Bacchus, sales & marketing director,Life WorksTackling dual dependenceDear JodieI am a qualified and experienced smokingcessation advisor now working in thesubstance misuse field at APAS (AlcoholProblems Advisory Service) in Nottingham.I give advice and support on smokingcessation alongside alcohol treatment on adaily basis. I believe this should be routinethroughout substance misuse services andam, myself, surprised that this is notalready the case.It is estimated that around 90 per centof people with alcohol problems smoke and70 per cent are heavy smokers. Alcoholproblems are 10 times more prevalentamong smokers than among non-smokers.We know that dual dependence ofalcohol and nicotine can bear up to ashocking 15-fold risk of certain cancerssuch as brain, mouth, throat, oesophageal,stomach, pancreatic, liver, bowel, bladder,breast and cervical cancers.Historically, it has been recommendedthat clients should not attempt to quitsmoking at the same time as undergoingtreatment for alcohol problems. However,latest research shows that treatment oftobacco dependence amongst dependentdrinkers who smoke does not seem tocause excessive relapse to drinking, and,in fact, stopping smoking may enhanceabstinence from drinking.Smokers with alcohol problems, as arule, are more dependent on nicotine thanthose without, and may need more intensivepharmacological and behavioural therapy.Debi WoodAlcoline co-ordinator/advice workerPatient awareness keyHi JodieI have recently set up a smoking cessationservice within a Mental Health Trust whichincludes a Substance Misuse Directorate.It is very hard for people to stopsmoking whilst receiving treatment forother addictions, but it is not impossible!Smoking cessation can be providedwithout necessarily risking a relapse withother substances. Patient awareness ofthe benefits of treating both addictions canincrease abstinence rates.In my experience many patients want toquit smoking and often feel that they aremore motivated to quit whilst receivingtreatment for other addictions. Others wantadvice on stopping smoking and will thanplan to give up smoking as their next goal.Where I work, recording a patient’ssmoking status and encouraging smokingcessation is now routine with all patients onadmission. Patients are referred to me if theychoose to quit smoking and I provide one-tooneand group support, which is maintaineduntil they have quit for a year. The service Iprovide is flexible and I try to meet the needsand choices of the individual.Smoking rates are much higher amongpeople receiving treatment for addictionsthan among the general population, but asyou suggested, tobacco smoking is largelyignored by the substance misuse field.This is concurrent with mental health, andhas to change. Not providing advice onstopping smoking for people receivingtreatment for other addictions isdiscriminatory and will continue the risk ofsmoking-related illnesses in this field.All health care professionals shoulddiscuss smoking and advise smokers tostop in all areas of health care.Helen, Help 2 Quit liaison nurse –mental health, ShropshireSmoking relapse connectionDear JodieAt Clouds we certainly do take smokingseriously. Nicotine is a powerful drug andthe negative consequences of smoking areestablished. So how do we reconcilehaving Clouds House as a treatmentcentre that promotes ‘abstinent recovery’with the issue of continued smoking?Our view of abstinence is focused on theaddictive or dependent nature of therelationship that people form with bothsubstances and behaviours. In this context itis clear that nicotine as a drug and smokingas a behaviour need to be addressed. Weare particularly interested in any connectionthat might exist between continued smokingand vulnerability to relapse into other druguse and would welcome any feedbackregarding existing evidence, or interest inresearching this issue further.It is of course ultimately up to the clientto decide if they need to abstain. We wanttheir decision to be an informed one and wewill do everything we can to support them ingathering the information they need.However, we are pragmatic and realise thatthe process of this decision-making may notbe the top priority for those in an intensiveand relatively short treatment episode. Iguess that you could say that smokingdoesn’t present the immediate or short termrisks that continued drug and alcohol usemight present to our clients, although thelong-term effects could be life threatening.Clouds House is a non-smokingenvironment but provision is made for clientsto smoke outside of the house if they wish.If our clients want to abstain from smokingwe will assist them with nicotine withdrawal(with nicotine patches) and they will be ableto utilise the 12 Step programme tomaintain abstinence. If not they will have atleast begun a process of evaluating whatthey need to do and thinking about whenthey might be ready to do it.Kirby Gregory, head of client services, Clouds.Addiction in all its guisesDear JodieFar from being ignored, smoking is anissue very much on our agenda atBroadway Lodge. Whilst the main focus ofour work is with alcoholism, drug addictionand eating disorders, we also consider itimportant to raise awareness of addictionmanifesting in all its guises.In the primary care setting at BroadwayLodge, smoking opportunities are restricted– both in time by treatment activities and inspace by having only one room in thebuilding where it is permitted. Moreproactively, all patients are provided withinformation and education about healthierlifestyles including smoking habits within alecture programme routinely delivered bystaff. We hope that as patients grow inawareness along with improving levels ofself-worth and self-efficacy, a healthier andmore productive future is considered bothdesirable and possible.In early treatment, with all theadjustments required by this, any patientwishing to stop smoking will be advised tosettle in first before embarking on a nonsmokingregime. However patientssufficiently motivated to do so will besupported in giving up smoking atwhatever stage in their treatment. Supportcomes particularly from staff trained bythe local PCT to become Support to StopAdvisors. These staff members providespecialist help for patients, includingwhere appropriate, the use of nicotinereplacement patches, stress managementand relaxation sessions.In the secondary care setting, patientsare much more actively encouraged toaddress their smoking habit. As part of theirweekly workshop programme patients will begiven specific information and help withaddressing their smoking. It is at this stagethat patients are also encouraged to bemore conscious of financial matters and theneed for budgeting and this often proves tobe the additional incentive required for themto cut down or even to stop smoking.Finally, the needs of non-smokers haveto be taken into account as well. As anorganisation we are continually exploringthe ways in which we respond to thevarying needs of the whole community. Inthis case, we are currently considering howwe might move smoking from the mainbody of our buildings and into designated,well-ventilated smoking areas and in sodoing minimise the impact of passivesmoking for everyone.Peter Smith, head of counselling,Broadway LodgeReader’s questionA question keeps coming up inour rehab about the drugnaltraxone, which is prescribedto a lot of clients through thecriminal justice system. Shouldrehabs accept people who areon naltraxone? While it is not amood altering chemical, do weknow enough about thedangers – and if someoneoverdosed in rehab, would it beour responsibility?Anna, DerbyshireEmail your suggested answers tothe editor by Tuesday 7 Februaryfor inclusion in the 13 Februaryissue of DDN.New questions are welcomefrom readers.14 | drinkanddrugsnews | 30 January 2006www.drinkanddrugs.net

Classified | education and learningwww.drinkanddrugs.net30 January 2006 | drinkanddrugsnews | 15

Classified | education and learningProfessorsBruce Alexander from Vancouver,David T. Courtwright from Florida,John B Davies from Strathclyde,Stanton Peele from New Jersey andRichard Velleman from Bathwill be joining film-makers, doctors, serviceusers, writers, policy makers, psychologistsand others to ask the unaskable:● just what is addiction?● Why do the billions governments throw atthe problem just seem to make it worse?● How can we make a difference?Unhooked Thinking starts with a civicreception and dinner in Bath’s historic PumpRooms on April 18th 2006, then moves to theequally historic Assembly Rooms for 3 days ofdiscussion, illumination and examination of theroots and culture of addiction. For all you needto know and bookings:www.unhookedthinking.comApril 19th-21st, 2006,Bath, Somerset, UK16 | drinkanddrugsnews | 30 January 2006 www.drinkanddrugs.net

Classified | recruitment, training and membershipSubstance AbuseSubtle Screening InventoryThe psychometric test which identifies substancemisuse problems even in clients who are unable orunwilling to acknowledge the existence orsymptoms of a problemadult and adolescent versionsidentifies – analyses – engages – motivatesNEW TRAINING DATES AVAILABLE NOWwww.sassidirect.co.ukSASSI Direct LtdTelephone 0115 964 8200Email sassi@sassidirect.co.ukThis course has been mapped to theDANOS standards and can be found onthe DANOS Learning ResourcesDatabase. It helps people develop theirknowledge, skills and competence inthe following DANOS units: AA2, AC1,AF, AG, AI1, AI2, AJ, BA, BB1, BC, BE,BG1, BG3. BG4, BI2, BI4, CA, CB,www.SamRecruitment.org.ukAre You Looking For Staff?We have a comprehensive database of specialistsubstance misuse personnel to meet your needsDAT Co-ordinators " RoB Co-ordinators " Project Workers " DIP Workers CounsellorsCommissioning Managers " PPO workers " TCAC workers " Case ManagersConsultancy, Permanent, Temporary“The staff Solutions Action Management Ltd supplied to us in theform of a team of DiP consultants and Joint Commissioningmanager, have proved invaluable in the preparation of the projectplans to carry out needs assessments and development budgetsand treatment plans/ documents for the NTA and GovernmentOffices in consultation with the Swindon staff team. I would haveno hesitation in recommending you and contacting you again in thefuture should we require staff to support our plans”Drug and Alcohol Team Manager,Swindon Community Safety PartnershipContact us today to discuss your recruitment needs:020 8987 6061 or register online at:www.samrecruitment.org.ukpip mason consultancyAlcohol anddrug workersShort courses,all mapped toDANOS now runin BirminghamTrainer Pip MasonFull details includingdates, costs and onlinebooking form atwww.pipmason.com orcontact Sue Chamberlainon 0121 426 1537 or atbookings@pipmason.comMotivationalinterviewing (2 days)Next courses March29/30 and May 17/18Advanced motivationalinterviewing (3 x 2 dayblocks) Next courseMay 8/9, June 5/6 andJuly 17/18Negotiating behaviourchange (1 day)Next course May 10Relapse (1 day)Next course June 9Cognitive-behaviouralstrategies (2 day)Next course July 12/13Substance Misuse TrainingFor drugs services staff andprofessionals in related disciplines✓ Distance learning available✓ DANOS mapped✓ Accredited at Levels 2 and 3✓ Also for service user groupsDrugs Awareness SeminarsFor professionals andcommunity groups✓ At your own location✓ Interactive & multi-media aids✓ Very cost-effective for groupsPeople in Vision32 Birch Grove, Manchester, M14 5JUWeb: www.peopleinvision.com - T: 0161 225 1055E-mail: DDN-enquiry@peopleinvision.com(10% discount, up to 18 Feb. ’06, if you quote “DDN offer”)30 January 2006 | drinkanddrugsnews | 17

Classified | education and tendersExpressions of interest for the provision ofTier Two Drugs Servicesacross the county of WarwickshireWarwickshire DAT is inviting expressions of interest for the provision of TierTwo services to the drug using populations of Warwickshire. Expressions areto be from suitably experienced organisations with a sound track record ofdelivering Tier Two services in other DAT areas. Our specific requirements aredetailed in our Tender Pack. The contract, to be managed by WarwickshireDrug Action Team, will be for approximately £0.5 million.All modalities must be provided within relevant local and national frameworkse.g. Models of Care. Further, providers will work in partnership with otheragencies as part of an integrated system of care across Warwickshire.Written expressions of interest should be made to Kate Harker,Joint Commissioning Manager, Warwickshire Drug Action Team,Pageant House, 2 Jury Street, Warwick, CV34 4EW, Warwickshire.If further clarification is required you may ringKate Harker on 01926746810 or e-mail her atkateharker@warwickshire.gov.ukThe closing date for expressions of interest is 5pm onMonday 13th February 2006 and Tender Packs will besent out on Friday 17th February 2006.18 | drinkanddrugsnews | 30 January 2006www.drinkanddrugs.net

Classified | recruitment and servicesDiscounts available forFDAP Corporate members" Alternative Therapies" Care Homes" Counselling" Clinics" Harm Reduction Advice" Hospitals" Needle Exchanges" Social Housing" Building & Contents" Business Interruption" Charity & Trustee Liability" Employers Liability" Medical Malpractice" Motor / Fleets" Professional Indemnity" Public LiabilityFor full details of this ‘Exclusive Scheme’and a quotation contact:W DENIS INSURANCE BROKERS PLCBrigade House, 86 Kirkstall Road, Leeds, LS3 1LQTel: 0113 243 9812 / Fax: 0870 705 2085mark.dutton@wdenis.co.ukHillingdon Action Group forAddiction Management (HAGAM)Regional Advocate (North West)Regional Advocate (East Midlands)Regional Advocate (South East)Salary: £24,708 pro rata (NJC scale SO2 32)Part time: 21 hours (three days) per weekThe Alliance is a user led organisation providing helpline andadvocacy services to drug users. We are looking for threeadvocates to provide services to drug users in the North West, theEast Midlands and the South East as part of a newly developedNational Model of Advocacy funded by the Department of Health.They will work from home and will be expected to travel within theregion. They will be expected to work as part of a national team whilesuccessfully managing all aspects of regional advocacy delivery.Excellent interpersonal and communication skills are essential, as isan understanding of treatment options for drug users.The successful candidate will need to have direct experience ofdrug treatment and a commitment to improving the quality andavailability of treatment in the UK.The Alliance operates an equal opportunities policy and welcomesapplications from all sections of the community. We are particularlyinterested in receiving applications from current or former drugservice usersFor a job description and application form (CVs not accepted)please contact the Alliance on 020 7713 6222 or by emailingmalliance@btconnect.com.Closing date for completed applications is 6th February 2006.Interviews to be held on 1st or 2nd March 2006.The Methadone Alliance is a Registered Charity (No. 1081554) and aLimited Company (No. 3934379)Reg. Charity No. 295068BACP Accredited ServiceCHIEF EXECUTIVESalary: £40,053 – £44,700 for 36 hours per weekFull time preferred, a minimum of 28 hours per week will be consideredHAGAM is a registered charity (295068) working with people who have substance misuseproblems. We provide tier 2 and tier 3 interventions including structured one to onecounselling, drop-in, groups, brief interventions, satellite services.We require an enthusiastic and experienced manager to lead this service. You will haveoverall responsibility for the management and day-to-day running of this service anddirectly manage nine permanent staff and 20 volunteers. You will also have overallresponsibility for delivering the strategic aims and objectives of the charity.Suitable candidates will have an excellent understanding of substance misuse and soundknowledge of the treatment systems. You will have experience of charity and voluntarysector management.You will have experience of developing projects and you should have extensive experienceof working with service users in the substance misuse field, and you will be confident inyour ability to deliver servicesYou will have the skill to build relationships with our service users, volunteers, staff,commissioners and funding bodies. Maintaining partnerships and overseeing thedevelopment of services to meet client needs, you will also ensure that both local andnational requirements are met.For an application pack please phone 01895 207788 or email help@hagam.org.ukOr write to: HAGAM Old Bank House, 64 High Street, Uxbridge, Middlesex, UB8 1JPClosing Date: Tuesday 28 February 2006Initial interviews will be held in the week commencing 20 March 2006www.hagam.org.ukwww.drinkanddrugs.net30 January 2006 | drinkanddrugsnews | 19

Shetland Community Drugs Teaminvites applications from appropriately qualified and experiencedindividuals (or couples wishing to job share) for the post ofFULL-TIME RELIEF SUPPORT WORKER37 hours/week fixed term appointment from 1 April 2006 – 31 March 2007This is a residential post. In addition to food and board,a remuneration package worth in the region of £12k is offeredWe are looking for a self-motivated andenthusiastic person able and willing to liveas part of a small Christian-basedtherapeutic crofting community providingresidential care for recovering alcohol/drugusers in a remote and rural location in theShetland IslandsFor further information and to obtain anapplication pack (closing date 13 March)please contact: Pam Williamson, ShetlandCommunity Drugs Team, 34 Market Street,Lerwick, Shetland, ZE1 0JP01595 696698pam.scdt@zetnet.co.ukPlease mentionDrink and Drugs Newswhen responding to advertisementsAddiction Counselling TrustA Company Limited by Guarantee No. 3164431 & a Registered Charity No. 1054524Counselling Supervisor (Ref: 5275)£28,630 to £30,993 per annum pro-rata 28 hours per monthThis is an opportunity to provide clinical supervision to ACT’s salaried Tier 2 and Tier 3Substance Misuse Workers. The successful candidate will have experience in integrativesupervision and a good knowledge of substance misuse issues.Counselling Supervisor (Ref: 5276)£28,630 to £30,993 per annum pro-rata 12 hours per weekThis is an opportunity to provide clinical supervision, training and co-ordination ofACT’s volunteer counsellors. The ideal candidate will have experience of supervisionwithin a substance misuse setting.Closing date for the above posts will be 10th February 2006For an application pack please contact Nicola on 01296 425329.For further details on the posts contact James Sainsbury.COMMUNICATIONS ANDPROJECT DEVELOPMENT OFFICERIHRA is the leading international NGO promoting a harmreduction approach to alcohol and drugs. The post-holderwill work with Prof Gerry Stimson to expand our globalnetworks, develop information resources, supportcampaigns and develop new projects. Alcohol harmreduction will be a significant part of the work.Based in London. Nine month post, salary to £25,000 pa.Closing date: 27th February 2006Details online at www.ihra.net, from ihra@adf.org.auor t: +61 3 9278 8104Promoting Harm Reduction on a Global Basis