Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Antidote [DP080]

1. Antidote is a service providing drug and alcohol support specifically to lesbian, gay, bisexual and transgender (LGBT) people in London. A literature review conducted by the UK Drug Policy Commission (UKDPC) in 2010 on behalf of the Home Office found consistently higher levels of substance misuse within LGBT-identified communities than in society as a whole.1 Since April 2011 Antidote has been provided as a service of London Friend, a registered charity working with LGBT people since 1972. Previously Antidote was a sub-service of a central London substance misuse agency provided by Turning Point. It is unique in being a service targeted at members of these communities. As such it is able to identify trends in drug use within these groups. The written evidence submitted below specifically addresses issues from an LGBT perspective. The evidence seeks to provide information on the following three areas of the inquiry:

The criteria used by the Government to measure the efficacy of its drug policies.

The extent to which public health considerations should play a leading role in developing drugs policy.

The availability of “legal highs” and the challenges associated with adapting the legal framework to deal with new substances.

The criteria used by the Government to measure the efficacy of its drug policies

2. This response relates to the efficacy of treatment in relation to diversity. Although the National Treatment Agency for Substance Misuse requests providers to collect data on service users’ sexual orientation the quality of this data is poor. No data is centrally collected on transgender status. Poor data on sexual orientation and none on trans identity makes it impossible to disaggregate by these two protected equality characteristics and analyse whether LGB or T people are accessing services; have successful treatment outcomes; are more or less likely to be using particular drugs; or are disadvantaged by strategy, policy and methods of service delivery. The UKDPC’s report The Impact Of Drugs on Minority Groups: A Review of the UK Literature (Part 2 LGBT)2 found that despite experiencing higher levels of drug misuse LGBT people often felt treatment services would not understand their needs or were not targeted towards them. Despite mention in the Drugs Strategy 2010 of the need for services to be responsive to the needs of specific groups such as LGBT users, and the need to comply with the Public Sector Equality Duties of the Equality Act, few providers explicitly target LGBT users; there is little evidence of services specifically commissioned for LGBT people; and there are no central support mechanisms to support commissioners and providers, such as guidance from the National Treatment Agency. Neither providers nor commissioners are specifically evaluated on how they meet the needs of these groups. Antidote is provided via a modest grant from the Big Lottery Fund; as such it is not within the pooled treatment budget arrangements and is not required to submit data to the National Drug Treatment Monitoring System (NDTMS). As a result, evidence of need within this community is being missed by the Government’s data collection and high-risk groups are not being adequately commissioned for.

3. Over the past three years, as a targeted service, Antidote was able to identify a new and distinct pattern of drug use by predominantly gay and bisexual men. Service users reported a sharp upturn in the use of crystal methamphetamine (including administration via injecting) and GBL (including physically dependent use at up to hourly dosage, which at that time was a new development with this drug), both very heavily associated with use in sexualised situations. Neither of these drugs has seen significant prevalence in mainstream treatment agencies or outside the LGBT community (predominantly used by gay and bisexual men); in fact early requests to local drug services often resulted in services such as detoxification for GBL use being declined as this wasn’t a drug they provided such modalities for. Such lack of awareness of emerging trends may have been missed had the critical mass of users via one LGBT targeted agency not highlighted this. Poor sexual orientation monitoring would have not allowed for identification as a trend predominantly amongst LGB people. Such trends have been confirmed in emerging data from the pilot Club Drug Clinic (CDC) at the Chelsea & Westminster Hospital, which Antidote provides work in partnership with. Approximately 80% of the CDC’s clients identify as LGBT (mainly gay or bisexual men), with high prevalence of crystal methamphetamine and GBL. This data is now being collated by NDTMS but as yet Antidote’s wider data is not included (although we are working to make this data NDTMS compatible for further discussion with the NTA). The success of Antidote and the CDC at attracting LGBT people into services suggests that when services are specifically marketed at LGBT people this perceived ‘hard-to-reach’ group are willing to engage.

4. Recommendations

That the Government, through the NTA and subsequently Public Health England:

(i)explores options for commissioning for LGBT-specific treatment services;

(ii)utilises knowledge and evidence from these services to continually improve policy and strategy in relation to LGBT users;

(iii)provides guidance for services on how to commission and provide for the needs of LGBT users as a higher-prevalence group of substance users;

(iv)ensures providers are required to demonstrate how they will target and deliver positive treatment outcomes for LGBT users via performance monitoring; and

(v)improves data collection around the existing requested NDTMS field for sexual orientation of people in treatment via performance monitoring of local partnerships, and explores options for improved data on gender identity of people in treatment.

The extent to which public health considerations should play a leading role in developing drugs policy

5. This response seeks to highlight the overlap in several public health fields. With the change in patterns of drug use by gay and bisexual men as highlighted above Antidote has seen an increase in referrals to our service via sexual health (GUM) clinics. Having taken sexual risks whilst using drugs users seek first sexual health intervention at which problematic drug use is identified. This provides an ideal opportunity for joint intervention, and is one which Antidote provides in partnership with 56 Dean Street, a leading London GUM clinic with a large LGBT patient base. This has been a noticeable change in route of presentation to services by this community and highlights the need for consideration of a range of support to be integrated at either commissioning level, or at provider level via partnership working alongside substance misuse interventions. The Government’s new arrangements for public health integration at local authority level provide opportunity for this.

6. However, the push for localism in commissioning (eg in London at borough level) does not always meet the needs of geographically diverse communities of interest such as LGBT people. Low levels of need per borough combine to much higher level of need at a pan-London or multi-borough level. The recent development of the London Health Improvement Board, a collaboration between the GLA and local authorities to address certain public health needs at a regional level, may offer solutions to commissioning for communities of interest such as LGBT people. Models such as the Pan-London HIV Prevention Partnership may also be appropriate. It is vital that the needs of LGBT substance users are assessed in Joint Strategic Needs Assessments (JSNA).

7. Recommendations

That the Government, through the NTA and subsequently Public Health England:

(i)explores options for greater collaborative commissioning and provision of substance misuse and other interventions such as sexual health and HIV prevention that deliver positive public health outcomes for LGBT people; and

(ii)requires local partnerships to assess need based on equality characteristics that specifically include sexual orientation and gender reassignment via robust JSNAs.

The availability of “legal highs” and the challenges associated with adapting the legal framework to deal with new substances

8. This response offers anecdotal evidence based on information from our service users. The two former ‘legal highs’ most used by our service users are GBL and mephedrone. Whilst mephedrone appears to be used by a diverse range of people, early evidence from our partnership with the Club Drug Clinic suggests that problematic GBL use is more focussed within LGBT groups, predominantly gay and bisexual men. Neither drug appears to have seen a reduction in use since being classified under the Misuse of Drugs Act.

9. Based again on the experiences of our services users it appears to be the case that the transfer of users to the then still legal high GBL following the classification of GHB resulted in unintended consequences of a more severe nature. Many users switched to this drug, seemingly encouraged by its then easy availability (legality being of seemingly inconsequential value). In its consideration of evidence on GBL in 2008 the Advisory Council on the Misuse of Drugs (ACMD) reported that GBL had a faster onset and lower equivalent doses to GHB.3 This links to the sharp increase Antidote has seen of users presenting with dependent use; common experience has been to use for longer periods over weekends, increasing the dose slightly as a sleeping aid at the end of a period of using (typically two to three days). This typically has resulted in users experiencing some mild form of withdrawal, leading them to re-dose to stave off physical withdrawal symptoms, which has ultimately resulted in daily, dependent use, with users typically doing every two hours. This has resulted in users requiring a medically assisted detoxification, on an in- or out-patient basis. It is Antidote’s view that such change to dependence was, at least in part, an unintended consequence of users shifting to GBL following regulation of GHB.

10. Recommendations

That the Government, via the ACMD:

(i)Considers the impact of any speedy decisions to regulate new ‘legal highs’ including careful consideration of the harms associated with unintended shifts to replacements.

January 2012

1 http://www.ukdpc.org.uk/resources/LGBT_groups.pdf

2 http://www.ukdpc.org.uk/resources/LGBT_groups.pdf

3 http://www.homeoffice.gov.uk/publications/alcohol-drugs/drugs/acmd1/report-on-gbl1?view=Binary

Prepared 8th December 2012