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South West Public Health Observatory |
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| The impact of drug misuse on health in the South West, 1996-2001 | ||
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South West and England
Compared to figures for England as a whole, from 1996/97 to 2000/01 the South West had rates of problem drug misuse, drug related deaths, psychiatric admissions for drug abuse, and hospital admissions for narcotics overdoses, in proportion to the region's share of national population (9%–10%). Apart from Bournemouth, Plymouth, Bath and North East Somerset, and Bristol with higher rates of drug related deaths, the remaining areas of the South West have average or below average rates of such deaths. Caution is required in the interpretation of the differences in death rates between areas, because of the small numbers involved. Further comparisons of the South West with England, with regard to infectious diseases, show lower rates of HIV/AIDS cases, but higher than average rates of hepatitis B and in particular, hepatitis C. The region also showed patterns of increase in problem drug misuse and drug related deaths similar to those for the rest of the country, notwithstanding marked regional, urban and rural variation. The South West, in comparison with the rest of the country, would appear to have a high rate of accident fatalities with traces of multiple drug use.
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Incidence and prevalence
Notifications to the RDMD between 1996/97 and 2000/01 demonstrated a substantial increase in the rates of new and repeat cases, which appeared to more than double across the five years. How much of these increases are a reflection of a true rate of growth of problem drug misuse in the region is unclear. Drug misuse services both nationally and for the region have expanded during this time so may be able to assist more clients. The criminal justice system has also focussed more on treatment for offenders, thus bringing to the attention of the RDMD, people who would have otherwise not been notified. The marked increase in rates for areas in the South West for the year 2000/01 are also biased because of the inclusion of higher numbers of people with alcohol problems, and those for whom there was no information about their drug habits.
Balanced against these factors is the likelihood of considerable under-reporting of cases from many of the agencies and DAT areas. For example, it seems highly unlikely that Bournemouth and Poole have such low numbers of problem drug misusers as have been notified, particularly in the light of the rates in Dorset HA for drug related deaths or methadone prescriptions. It could also be argued that more people with less severe problems have been notified. Nevertheless the age of notification has not lowered, the numbers of injecting drug users have increased substantially, as have the numbers of drug related deaths.
It is difficult to estimate a growth rate from the national drug database reports because their figures include people who have been notified repeatedly, such that their numbers are cumulative. Hence we examined rates for new cases; persons not previously notified. The mean annual incidence rate of 2 per 1,000 for new cases notified to the Regional Drug Misuse Database is likely to be an underestimate of agency cases owing to the inconsistent patterns of notification. The mean rate of 3.1 per 1000 for 2000/01 may be an inflated estimate, but a current annual incidence rate around 3 per 1000 is probably realistic. This means up to 6,000 new cases of problem drug misuse per annum for South West residents aged 15–44 years. This figure should also be increased by about 10% to allow for new cases coming into the region from elsewhere. It is not known how many South West residents with problem drug misuse are treated outside the region.
The prevalence estimate of 40,000 to 48,000 for the region is for numbers of people experiencing problem drug misuse, not the greater numbers of drug users per se . This report assumes there is widespread drug use in the 15–44 year age group, judging from local and national surveys of young people. There is though a recent report suggesting a decrease in drug taking amongst 15–16 year-olds in 1999 compared to 1995. 37
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Quality of information
Unfortunately the poor quality and incompleteness of the information provided to the RDMD makes it difficult to draw inferences about a range of demographic factors, notably housing, employment, children and ethnicity. The paucity of information about area of residence precludes any worthwhile analysis of the links with social deprivation.
In order to achieve an accurate picture of links with social deprivation, the RDMD notification forms need to be completed more reliably. There are concerns about risking a breach of confidentiality by including address information that could identify individuals. However clear protocols should be established so that electoral ward information is acquired whilst preserving client anonymity.
Clear audit standards about the responsibilities of agencies with regard to notification practice would seem to be required.
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Age and help-seeking
The mean age of new cases known to drug agencies, either for males or females increased across the period 1996/97 to 2000/01. On average, people aged 28 at first notification reported first using drugs at 15 years of age, and reported first having problems with drugs at 19 years of age. By the time of first contact with services a majority were already injecting and many had exposed themselves to the risk of infection, by sharing injecting equipment. The lag period between age of first use and first problems, and the age of first problems and time of notification requires further investigation. It would appear that with the benefit of hindsight, drug misusers are able to see they had problems long before they acted on them, or until they offended and the criminal justice system notified them. Finding ways to assist people to recognise, and seek help for, their problems sooner would seem to be a priority. To reduce the lag times would seem to be a measurable objective. There need to be some endeavours to reduce the likelihood of injecting, sharing injecting equipment and the length of time spent injecting, to reduce the risks of infection and overdose.
Currently drug services seem to be geared to the more severe end of the drug-taking spectrum, after crises have occurred, either with health, family and social problems, or the criminal justice system. Although there has been an increase in numbers of under 19 year-olds referred, these were a constant proportion of agency notifications across the five years. Although fewer of them inject than their older counterparts, many of these youths (over 20%) have already risked infection by sharing. There have been relatively more under 16 year-olds notified though the numbers overall are small.
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Migration and local area variation
The results show over 10% of problem drug users notified to the South West RDMD came from outside the region, but it is not known if this is typical for other regions. There are a high number of private residential rehabilitation facilities in the South West, particularly around the Weston-Super-Mare area, Plymouth, Bristol, and Bournemouth. These areas also have a high number of secondary care facilities, providing sheltered housing after treatment. As well as providing services to local residents, they offer help to all parts of the country, particularly Wales. It is very common for drug users to be in treatment away from their local community as they are often considered to be in greater danger of relapse in their home area. For this reason also they are commonly resettled away from home.
Numbers in treatment or sheltered accommodation probably explains the consistently high numbers of problem drug users notified from North Somerset. Bournemouth in contrast notified very few people to the database, despite the expectation of high numbers because of the treatment facilities in the area.
Discrepancies in notification practice are in part due to people in treatment or secondary care being considered drug free, and therefore not needing to be notified. Despite the rising number of notifications from community agencies, those from the treatment and sheltered housing sector decreased by over 40% during the five years. This may well be associated with the withdrawal of the statutory obligation to notify addicts in 1997. Unfortunately significant numbers of people leaving treatment, or secondary care, relapse. People who relapse may well then drift to areas of greater supply, adding to the numbers of indigenous problem drug misusers.
Approximately half the numbers of problem drug users in the region live in the hitherto Avon conurbation, most in the Bristol DAT area and probably in districts of high social deprivation. Well-established drug services in the Bristol DAT area also saw over 4,000 residents from adjacent areas. Some of these figures are inflated by notifications from prisons but cross-border flow between DAT areas is common and generally people from more rural areas use services in urban areas. The differences shown between the DAT areas of residence and DAT areas of notifications demonstrate this flow.