Written evidence submitted by Release and Transform Drug Policy Foundation

 

Submission to Digital, Culture, Media and Sports Select Committee Inquiry on Impact of Covid-19 on the charity sector. (June 2020)

Release[1] and Transform[2] are both UK charities working on issues that impact people who use drugs, including those who are drug dependent and those utilising drug treatment and harm reduction services provided by the charitable sector. This briefing has also been informed by clinical leads and experts from the drug service sector.

We understand that the Digital, Culture, Media and Sports Select Committee are considering the impact of COVID19 on DCMS sectors. As part of this inquiry it is important to consider the demand facing charities at this time of growing financial pressures, and the potential long term impact on charities working directly with those at most risk from Covid-19. Protecting those who use drugs is vital for this wider effort to protect society as a whole. We urge the Committee to understand that a failure to increase support, and adapt policy to help people who use drugs problematically will disproportionately impact on healthcare capacity nationwide, and the work of a broad swathe of charities that work with vulnerable people.

Protecting vulnerable people who use drugs during the pandemic will remain a challenge as communities transition out of lockdown, and beyond.  We must seize this opportunity to build on progress made, and address the many long term structural problems, including homelessness, and chronic underfunding of drug services.  We would be grateful if the Digital, Culture, Media and Sports Select Committee could make the following recommendations to ensure people with alcohol or other drug dependencies can access the services and support they need.

1.              Most people who are dependent on drugs have underlying, often serious, health issues and should be assessed by health services, and where appropriate, designated as at high-risk for COVID-19, and suitably supported and protected, with charities and local authorities given the resources necessary to do this.

2.              The COVID-19 crisis has led to an unprecedented increase in demand for drug treatment services.  Long-term funding for this area should be increased dramatically to meet demand, address the needs of some of the most marginalised and vulnerable in society, and minimise COVID-19 transmission among both service providers and clients.

3.               There must be a clear, funded programme to provide sustainable long term housing and support for people who are homeless and currently in temporary accommodation, those threatened with homelessness due to current economic challenges, and those released from prisons. Support must include appropriate provision of services for those with alcohol and other drug issues.  

4.              Systems must be put in place to ensure that there is adequate provision and safe access to harm reduction supplies for people who use drugs, including sterile injecting equipment and the opioid overdose reversal medication naloxone.
 


Introduction

Those who have a history of problematic drug use, often suffer from underlying health conditions. This is a population already in the midst  a public health crisis, as drug related deaths have soared and are now the highest on record[3], for the seventh year in a row. The UK accounts for one in three drug related deaths in Europe[4].  If action is not taken urgently, including a significant upscaling in funding, there is a serious risk of further increases in deaths amongst this population, increased COVID-19 infections, and outbreaks of blood borne viruses, including HIV and Hepatitis C (which has already risen under lockdown), during and in the wake of the COVID-19 pandemic.

We understand that the Government is facing significant pressure on resources at the moment, however, people who are dependent on drugs represent a large population of vulnerable people  (estimated at around 320,000). Failure to meet their needs during  this crisis and its aftermath will dramatically escalate already dire public health and economic consequences.

Investing in alcohol and other drug treatment services and related support, will offer not only health gains but economic ones with these services shown to give good value for money. Conversely, if such community based services - predominantly provided by the charitable sector - are not shored up, the impact will be still greater pressure on NHS acute services at this critical moment, and in the coming months.

It is important to understand the growing challenges the drug service sector is facing. There is ongoing concern about disruption to the unregulated supply of illegal drugs within the UK during the pandemic, due to border closures and wider domestic and international restrictions on travel and movement of goods. Although emerging data suggests UK drug markets have been more resilient than many expected, there have been notable localised disruptions. Respondents to the Crew 2000 user survey[5] are reporting decreased availability (63%), falling quality (40%), and increased prices (38%)  since the crisis began, echoing patterns observed in Release’s survey of people who drugs[6].  These disruptions are likely to result in continuing changes in risk behaviours including displacement from heroin to other potentially more risky drugs including diverted prescription opioids, other pain killers such as the gabapentinoids, or increases in high risk poly-drug use, including rising use of solvents, alcohol and benzodiazepines.

A serious and potentially longer term challenge is that established sources of income for more vulnerable people who use drugs - both legal and illegal - have significantly contracted during the pandemic, but this group face major obstacles in accessing benefits or other government support schemes. Problematic patterns of drug use are significantly correlated with economic hardship and mental health issues, both challenges which have escalated rapidly during the COVID-19 crisis, and the effects of which will be felt for a significant period of time.

This combination of factors driven by the COVID-19 crisis - disruption of drug markets, falling income amongst established populations of people who use drugs, and rising environmental vulnerability to problematic drug use - is creating unprecedented pressures on drug service providers.  Vulnerable populations of people who use drugs are experiencing increased risks from infection (from COVID-19 as well as HepC, HIV and TB), overdose and poisoning, or going into involuntary withdrawal. The Bristol, North Somerset and South Gloucestershire NHS for example, has recently reported a four-fold increase in homeless people accessing drug services since March[7].

We have outlined below the funding needs in this area, as well as some structural issues in the delivery of harm reduction interventions and drug treatment which must be urgently addressed. These are evidence based recommendations that will not only reduce drug related mortality and other harms, but also significantly reduce COVID-19 infection rates amongst people who use drugs, that would otherwise further build pressure on the NHS, and increase infection rates across wider society. As the UK transitions out of lockdown and seeks to prevent a second wave of infection later in the year, it will be particularly important to identify highly vulnerable populations and target appropriate resources towards them. 

 

  1. People who are dependent on alcohol and other drugs must be assessed for being at high risk for COVID-19 and afforded appropriate protections and support

People who are dependent on alcohol and other drugs are a vulnerable population with comorbid conditions; including  high rates of respiratory illnesses such as COPD and impaired immunity due to a variety of different factors including nutritional status, general lifestyle, smoking related illness, or from the immunosuppressive effects of opioids. As a result they should be assessed by health services, and where appropriate, designated as at high-risk for COVID-19, and suitably protected.

To date, the numbers of people dependent on drugs infected with COVID-19 is thought by drug treatment service providers we work with to be relatively low, at least in part due to isolation of many previously homeless people in hotels, and work done to ensure social distancing is possible when accessing prescriptions. However, failure to protect and support this vulnerable population as the lockdown is eased risks rising infection rates, with potential knock-on effects for the health service and wider population.

 

  1. As the COVID-19 crises fuels an unprecedented rise in demand, ensure the funding needs of drug treatment and related service providers in the charity sector are met 

 

Local authorities became responsible for funding and commissioning  alcohol and other drug services (hereon in ‘drug treatment services’) under the Health and Social Care Act 2012, while facing an estimated 37.3% reduction in central government funding between 2010/11 and 2015/16.[8] As a result, “drug misuse treatment” faced more reductions in funding than any other public health area in 2016/17 with a 14% reduction in funding between 2015/16 and 2016/17[9]. Net expenditure on adult  alcohol and other drug services has decreased by 19% in real terms between 2014/15 and 2018/19.[10]

Despite these significant cuts, drug treatment providers  across the country, predominantly from the charitable sector, have acted quickly to ensure that people on methadone and buprenorphine are moved from daily supervised consumption to prescriptions that allow them to collect their medication, or to nominate family and friends to do so. Government guidance published on April 15th has now caught up with these actions, stating that ‘Services should be transferring most, if not all, patients from supervised consumption to take-home doses’[11].  Overall, initial reports from service users and staff of drug treatment, have been overwhelmingly positive about this change which sees people on opioid substitution treatment reporting greater control over their own treatment and greater engagement with services. Fears of overdose and diversion due to larger quantities of take-home medication being dispensed have largely not been realised.

The process of moving people onto less restrictive prescribing practices has been a herculean task for the providers, who have taken extraordinary measures in a very short time. They have also been working tirelessly supporting their clients who are alcohol dependent and those who are dependent on other non-opiate drugs. But more needs to be done to support them in this work. The current level of funding for drug treatment services is wholly inadequate, even before the additional burden created by COVID-19.  Guidance issued by PHE on “COVID-19 for hostel or day centre providers of services for people experiencing rough sleeping”[12] advised on the need for service providers to ensure “sufficient treatment capacity is available if people look for withdrawal support or substitute prescribing alternative to using illicit drugs”[13]. There is simply not enough money within the drug treatment sector to ensure that all those who need access to services will get support. It is undoubtedly the case there will be greater demand on services; there have already been reports of high rates of relapse during lockdown, and as we experience the impact of the economic crisis, with people losing their jobs and homes, it is also likely we will see an increased use of illicit drugs.

As stated, these services, many of whom are charities, need additional financial support - this sector has already suffered significant cuts as highlighted above. However, there are serious concerns about the damage done to local authority budgets as a result of COVID19. The BBC reported this week that 39 local authorities could cut local services due to a funding shortfall fall of £2.5billion.[14] This could be devastating for drug treatment services, who are funded through local public health budgets and whose funding is not protected. We would recommend that the Government not only ‘ring fence’ drug treatment funding, but that funding is significantly increased to address the challenges detailed above, and that drug treatment is mandated through legislation in the same way sexual health services are.

A particular group who have suffered due to cuts are women, as specific services to meet their needs are now rarely provided. This is especially important for those who are fleeing domestic violence (DV), who will have difficulty engaging in mixed gender services. There are real concerns of increased incidences of DV during a time where women are forced to remain at home with abusive partners – anecdotally, advocates in some areas of the country have already seen an increase in applications for Domestic Violence Protection Orders. The Home Secretary stated on the 11th April 2020 that there had been a 120% rise in the number of calls to the National Domestic Abuse Helpline in a 24 hour period. Refuge, who run this helpline, state further that visits to their website surged 700%. Women who use drugs are at particular risk of exploitation and coercion, and if the predicted increase in DV occurs, the need for women-specific drug services will be even greater.

The £750 million package of extra funding for charities on the front line is welcome and much needed. To protect the vital services used by those dependent on drugs we would like to see a dedicated funding stream for civil society organisations and charities providing drug treatment. The knock on effect of a lack of funding to these critical services would be catastrophic to some of the most vulnerable in our society. As explored above, drug market disruption and dwindling income sources will continue to drive increases in high risk behaviours, overdose, poisonings and involuntary withdrawal. Drug treatment services will have to deal with increased demands from existing clients, as well as tens of thousands of new clients. There simply are not the resources to do this effectively, and without the necessary funding., We would therefore ask the Committee to make a specific recommendation that funding for frontline drug treatment services  is increased dramatically, and ringfenced, or large numbers of vulnerable people will be put at risk of infection, drug related harm, illness and death - further straining an already critically overloaded NHS.


3. Housing provision for those who are street homeless, and access to drug treatment services.

We applaud Local Authorities’ rapid action in requisitioning hotels and other accommodation for people who were homeless during the first months of the COVID-19 crisis. The ‘Everyone In’ programme, while not perfect, was a huge success given the challenges involved, with the Government suggesting 14,500 people were helped. In the process, this programme proved that the UK does not have to have a street homelessness problem. If we do return to large scale homelessness, then that will be the direct result of policy choices.

So we call for the political will shown in the early stages of the COVID-19 crisis to be maintained, by continuing to help the homeless, including providing the resources required to seize this opportunity. It may require ingenuity, with further use of temporary accommodation while permanent accommodation is identified or built  (for example some areas are exploring utilizing blocks of student accommodation empty because overseas or other students are deferring or not attending universities this autumn) but this goal is achievable.

However, as things stand, many of the people helped by this programme will, or already are, being evicted back onto the streets. The funding announced to date from the Government to find permanent homes as the hotels and other accommodation close their doors, is largely money from existing budgets being ‘re-announced’. Just £52m of the £433m announced is new money. Of this £160m will be available this year, with the remainder spread over the following 3 years.[15] And while bringing forward this funding for 3,300 new units in the next 12 months is a positive start, given the scale of the problem revealed by the ‘Everyone In’ programme, it is clearly inadequate. The cost of accommodating people will now also be more expensive, because consideration will have to be made for social distancing and support needs will have a new dimension to them. This increased costs will further reduce the ability of current funding to deliver the housing needed. The homeless charity Crisis has estimated it would cost £282m to provide the people in emergency accommodation with permanent housing and support for the next 12 months.[16] Furthermore:

        There is a high level of problematic drug use amongst people who are homeless. In 2018, 40% of deaths amongst people who were homeless were as a result of drug poisoning (this was an increase of 55% on the previous year).[17] [18] So to get people off the streets, there will need to be a very large increase in programmes like the Government backed  ‘Housing First’[19] projects that accept it is necessary to tolerate people continuing to use drugs within their new accommodation, while drug treatment, mental health and other services are brought to bear to help them rebuild their lives. Excluding people from housing because of their drug use means excluding many from the only path that could see them lead healthy and stable lives. The Rough Sleeping Taskforce should take a strong lead to help the homeless with drug dependency issues in this way.

        Already we are seeing people becoming homeless because they have lost their jobs. As unemployment rises in the coming months this problem will, if unchecked, further raise the numbers on the streets.

        Even during the peak of the lockdown, around 1000 prisoners were discharged into homelessness.[20] Specific provision needs to be given to ensuring everyone leaving prison has a home to go to - with particular attention to provision of appropriate support for those with mental health and drug dependency issues.

Relying on Local Authorities to pick up the tab for homelessness simply will not work. Councils of all political hues agree the additional money promised so far to cover costs from COVID-19 is inadequate. Without Central Government showing the political will, and committing additional dedicated funding, we will see a patchwork of different quality responses in different areas, and in all likelihood an overall surge in street homelessness again.  Far from seizing a unique opportunity to end street homelessness, the UK may end up with a worse situation than we had at the start of  this year.

4.     The provision of harm reduction equipment including sterile injecting equipment and access to naloxone.

The scaling up of access to harm reduction equipment to people who inject drugs (PWUD) was largely achieved under the Thatcher government to tackle the HIV/AIDs crisis in the 1980s.   PWUD are at a greater risk of contracting HIV and other Blood Borne Viruses (BBVs), with UNAIDS estimating that the risk is 22 times greater for this group in society than the general population.[21]  One significant concern at the moment is that much of the supply of such equipment is through community pharmacies who are already stretched to capacity, and who might end this provision in the coming days and weeks. This will place people at greater risk from sharing injecting equipment and, in turn an increase in BBVs, including HIV.

We have already witnessed an outbreak of HIV amongst PWUD in Glasgow.[22]  The rate of Hepatitis C amongst people who inject drugs is also extremely high, with over 50 per cent estimated to have the virus.[23]  There has also been a worrying increase in the number of new infections amongst PWID drugs, rising from 45 percent of this population to 55 per cent in 2018, it is thought that one of the drivers of this is inadequate access to harm reduction equipment.[24] Sharing injecting equipment and other drug paraphernalia is also a risk factor for transmission of COVID-19.  As such, we must ensure that there continues to be an adequate and accessible supply of such equipment. There will be a requirement to be flexible and creative in the way it is dispensed to ensure physical distancing rules are observed.  Investing in harm reduction has repeatedly been shown to be cost effective.[25] Short term cuts to harm reduction budgets are a false economy; quite aside from the human cost in lost lives, they incur vastly greater downstream treatment costs in addressing BBV infections and other related illnesses in the medium to long term.

In addition, we need support to ensure a significant supply of naloxone is available for people who use opioids. This is an overdose reversal medication that save lives. The provision of naloxone  is affected by the same issues related to the supply of other harm reduction equipment - if fentanyl does significantly corrupt heroin supply, as has happened in North America, naloxone will be one of the first lines of defence. We are also concerned that there will be increased risk of overdose due to stockpiling of drugs and medications, as well as an increase in adulterated drugs due to decreasing supplies. As we have seen with groceries, where people fear there may be restricted supply in future some will buy excessive amounts now. This will increase the risk that they take too much, either forgetting how much they have already taken, or because they normally restrict their use by buying in smaller quantities to reduce the temptation to increase their intake.  Naloxone should be made available to all emergency responders including the police,  without prescription to PWUD from all pharmacies, free to all PWUD from drug service providers, and mandated for all prisoners with opioid dependencies released from prison.

Funding should be made available to drug treatment providers to ensure they can fund innovative approaches, including peer outreach programmes, mobile services, and exploring the possibility of using existing and new premises to dispense equipment and medication, including opioid MAT (Medication-Assisted Treatment) and naloxone. COVID-19 specific  harm reduction advice and information will not only have to be developed for PWUD but for suppliers of drugs, as drugs are often transported in unhygienic ways including hiding small quantities in bodily orifices.   This work has started but more support would help to expand the reach and targeting of the advice being given.

 


[1] Release is the national centre of expertise on drugs and drugs law. See: https://www.release.org.uk/

[2] Transform is dedicated to reducing the risks associated with drugs, promoting evidence-based policy, and improving the lives of those harmed by ineffective drug laws.Seehttps://transformdrugs.org/

[3] In 2018, there were 4,359 overdose deaths registered in England and Wales. (Source: ONS, 2019)

[4] EMCDDA (2019) Frequently asked questions (FAQ): drug overdose deaths in Europe http://www.emcdda.europa.eu/publications/topic-overviews/content/faq-drug-overdose-deaths-in-europe_en

[5] Crew2000 (2020) COVID-19 and Drug Markets Survey – Week Two Summary https://www.crew.scot/covid-drug-markets-survey-week-two/

[6] Impact of Coronavirus on Drug Purchases Survey (2019)  https://www.release.org.uk/coronavirus-drug-purchases-impact-survey

[7]NHS Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group, (15 June 2020) ‘Surge in number of homeless people engaging in substance misuse services during coronavirus outbreak’  https://bnssgccg.nhs.uk/news/surge-number-homeless-people-engaging-substance-misuse-services-during-coronavirus-outbreak/

[8] National Audit Office (2014) The impact of funding reductions on local authorities, Local government report

by the Comptroller and Auditor General https://www.nao.org.uk/wp-content/uploads/2014/11/Impact-of-funding-reductions-on-local-authorities.pdf

[9]  ACMD (2017) Commissioning impact on drug treatment. https://www.gov.uk/government/publications/commissioning-impact-on-drug-treatment

[10] The Health Foundation (2018) Briefing: Taking our health for granted. https://www.health.org.uk/publications/taking-our-health-for-granted

[11] UK Government (2020) COVID-19: Guidance for Commissioners and providers of services for people who use drugs or alcohol https://www.gov.uk/government/publications/covid-19-guidance-for-commissioners-and-providers-of-services-for-people-who-use-drugs-or-alcohol/covid-19-guidance-for-commissioners-and-providers-of-services-for-people-who-use-drugs-or-alcohol

[12] UK Government (2020) COVID-19: guidance for hostel or day centres for people rough sleeping https://www.gov.uk/government/publications/covid-19-guidance-on-services-for-people-experiencing-rough-sleeping

[13] Ibid

[14]  BBC Coronavirus: England's councils 'face large-scale' cuts to services https://www.bbc.co.uk/news/uk-politics-53066037

 

[15] Rough sleeping cash brought forward in bid to prevent returns to the streets, 26 May 2020 https://www.lgcplus.com/politics/coronavirus/rough-sleeping-cash-brought-forward-in-bid-to-prevent-returns-to-the-streets-26-05-2020/

[16] BBC (4 June 2020) Thousands of homeless 'back on streets by July'Xhttps://www.bbc.co.uk/news/uk-52915913

[17] Office of National Statistics (2018) Deaths of homeless people in England and Wales https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsofhomelesspeopleinenglandandwales/2018

[18] UK Government, (June 2019) Drug-related harms in homeless populations - https://www.gov.uk/government/publications/acmd-report-drug-related-harms-in-homeless-populations

[19] About Housing First https://hfe.homeless.org.uk/about-housing-first

[20] Guardian (15 June 2020 ) Over 1,000 prison leavers left homeless amid pandemic, MoJ figures show, https://www.theguardian.com/society/2020/jun/15/over-1000-prison-leavers-left-homeless-amid-pandemic-moj-figures-show

[21] UNAIDS (2018) MILES TO GO CLOSING GAPS BREAKING BARRIERS RIGHTING INJUSTICES https://www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdf

[22] Public Health England (2018) Shooting Up: Infections amongst people who inject drugs in the UK, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/851815/Shooting_Up_2019_report.pdf  

[23] Public Health England (2020) Hepatitis C in England 2020: Working to eliminate hepatitis C as a major public health threat https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/887802/HCV_in_England_2020_Report_270520.pdf

[24] Ibid

[25] Wilson et al (2015) Commentary: The cost-effectiveness of harm reduction https://doi.org/10.1016/j.drugpo.2014.11.007