What do we do with a drunken country?

A recent Assembly committee inquiry provided a stark reminder
of the devastating impact drink and narcotics have on society.
(Pic : Wales Online)

Three major stories out of the National Assembly during the current summer recess were all related to public health.

Firstly, a report from the cross-party group on eating disorders, which you can read here (pdf).

Secondly, Public Health England's report into e-cigarettes which contradicts current proposals in the Public Health Bill (Tattoos, Bans & Bogs). I hope to return to that later this autumn.

Returning to the subject of today's post, the Assembly's Health and Social Care Committee reported back on a major inquiry into alcohol and substance abuse (pdf). Regular readers will know I covered drugs in spring 2014 (Wales on Drugs), while I looked at alcohol policy in some detail in February 2015 :

• ViceNation : Alcohol I - Our Drinking Culture
• Vice Nation : Alcohol II - Costs & Benefits
• Vice Nation : Alcohol III - Booze & Independence

The Committee made no fewer than 21 recommendations, summarised as :

• The Welsh Government should set out how it intends to take the report's findings into account in the next Substance Abuse Delivery Plan (2016-2018), including specific focus on image enhancing drugs like steroids.
• There should be a review of GP training on substance abuse and more encouragement for GPs to specialise in treating alcohol and substance abuse. This should include training to reduce bover-prescribing and properly diagnose patients with alcohol-induced dementia.
• The Welsh Government should do more to promote substance abuse services, making them more accessible to those who need them or are vulnerable – in particular the homeless and recently-released prisoners.
• The Welsh Government should ensure appropriate information on alcohol and substance abuse is provided to schoolchildren, university students and other young people.
• The Welsh Government should ensure the forthcoming Wales Bill includes measures to help tackle alcohol misuse, while they should also work with the UK Government to determine what information should be put on alcohol products.

The Assembly's Communications team have started to use Adobe Slate to help make committee reports more accessible. They include video clips, put faces to quotes and includes a summary of the report's contents. You don't have to download anything to view them and it's particularly useful if you're on a tablet. You can view the slate for this report here; mae'r fersiwn Cymraeg ar gael yma.

The Scale of the Problem

Increasing abuse of anabolic steroids is cited as a worrying trend.
(Pic : ITV Wales)

This inquiry follows on from a previous inquiry into new psychoactive substances (aka. "legal highs" – see Legally High).

A lot of the evidence the Committee received this time related to on alcohol abuse. Figures consistently show that referral rate for alcohol abuse treatment (54% of all referrals) are consistently higher than that for illegal narcotics such as heroin (15%) and cannabis (9%); it's generally a problem amongst men too – both points I made previously.

One emerging problem is people are becoming increasingly dependent on prescription and over-the-counter medicines, while abuse of so-called "image enhancing drugs" – like steroids – is also increasing amongst young people. The latter is a trend the Deputy Health Minister, Vaughan Gething (Lab, Cardiff S. & Penarth), said is hard to monitor as current evidence and statistics collection is poor.

The Welsh Government have a ten-year substance abuse strategy running from 2008-2018, built around harm reduction and recovery. This received a £47.8million boost in March 2015, with £5million of that going towards residential treatment centres. The Deputy Minister said this funding would continue for the next two years "subject to negotiations with other parties and partners".

Witnesses, and others involved in the inquiry, were broadly supportive of the strategy but were concerned about patchy implementation.

Intervention

The role of GPs in identifying and properly assessing substance abuse
problems was underlined as important - but not without serious issues.
(Pic : UK Government)

There was criticism of the role GPs play, with little advice given on substance abuse or too few referrals to appropriate services. The Deputy Minister acknowledged weaknesses, but these were being worked on, with a specialist certificate in substance abuse backed by the Royal College of General Practitioners (RCGP) available. The problem is not all GPs will want to specialise in the field, and there were frank admissions that some GPs may be prejudiced against those suffering from alcohol and drug issues.

A more common issue, which applies to everyone, is lack of access to GP appointments because of strict booking criteria (i.e making appointments before a certain time). Some patients were also put off seeking help because they believed they "needed to be clean" before accessing services, made worse by a stigma surrounding drug and alcohol treatment programmes.

On alcohol, the BMA have encouraged what's known as an "alcohol brief intervention" (ABI), where those with problems are encouraged through structured conversation to reconsider their habits and seek help. 8,000 people have been trained to deliver ABI, with the Deputy Minister saying there was "good evidence of its effectiveness". However, there were no targets for training.

An emerging problem is addiction to prescribed medicines, particularly in situations where patients have been prescribed powerful medicines over a long period of time. Some prescription drugs have even made their way onto the open market, while expert witnesses said patients on powerful prescription drugs – like methadone – need to have "exit plans" to come off them gradually.

You can't discuss substance abuse without exploring mental health, with a reported three in four substance abusers also having a mental health condition. It can destroy families and can lead to suicides, alcohol-related brain damage, overdoses or fatal diseases like cirrhosis.

Having an underlying mental illness is said to make treating substance abuse more difficult, and one witness said it results in a "chicken-and-egg situation" where you can't tell which comes first.

Treatment

The wealthy can afford the best care when it comes to addiction, but despite the
best efforts of charities and the NHS, those at the bottom of society are left wanting.
(Pic : houstonpress.com)

Witnesses said substance abuse treatment should be seen as "everyone's business" as it crosses many areas of the health service. Public Health Wales called for "clear treatment pathways" from the earliest point of contact. However, the RCGP argued for a single service, while homeless charity The Wallich said there needed to be just as much focus on the person as the drug problem.

In terms of targeted services, witnesses believed there was too much focus on youngsters binge-drinking while older people are much more likely to be over-prescribed medicines or have a serious alcohol addiction, with the average age of referrals for alcohol abuse being 41 compared to 31 for narcotics.

There were additional concerns about an inconsistent approach to residential treatment, with Wales' sole women-only facility being based in Cardiff. Plus, the Committee were worried about gaps between a former peer-mentoring scheme (which ended in 2014) and its replacement, which the Committee said should "be put in place as soon as possible".

Other vulnerable groups include the homeless – who often have a physical or mental health problem as well as material concerns on housing – as well as recently-released prisoners, who might develop a drug habit whilst inside. Although some treatment programmes in Welsh prisons were praised, there were concerns about resettlement and aftercare. Ex-prisoners are "effectively homeless", or may be released on licence with requirements they be resettled in a particular type of accommodation.

Prevention

As was recommended in the inquiry on legal highs, the Committee said there was a need to make public information more relevant to audiences – something the Welsh Government said they're working on.

Not unsurprisingly, there was a return to the role of schools. The Donaldson Review recommendations (Detention for Donaldson?) included references to creating "ethical, informed citizens" who "understand the consequences of their actions". In the present, there's a programme of school visits from police officers and targeted help towards "the disengaged".

Some witnesses believed the police might not be the best people to deliver the lessons because some young people may not have a good relationship with them; they instead called for the focus to be on harm, not legality.

The issue of alcohol labelling also cropped up, with witnesses saying the use of "units" (10ml of pure alcohol) was unhelpful, suggesting instead that each drink be assigned a percentage of the weekly/daily recommended intake.

The Law & Devolution

Witnesses supported a lower drink-drive limit - in line with Scotland -
as well as tougher licensing rules, but it's unlikely to happen in Wales.
(Pic : Press Association via BBC Wales)

Alcohol Concern Cymru (ACC) said the "big levers" on alcohol policy are price and availability, as well as specifics like a lower drink-drive limit. ACC were worried alcohol was becoming increasingly cheaper, and strongly support a minimum price per unit – backed by some local health boards.

The drinks industry (unsurprisingly) opposed the move, believing a minimum price was targeting them disproportionately. Nevertheless, the Welsh Government recently published a draft Minimum Price Bill, which will presumably be introduced in the Fifth Assembly.

Other witnesses called for limits on alcohol sales similar to cigarettes, as drinks are often on promotion or easy to buy, making life harder for recovering alcoholics. ACC go so far as suggesting "the protection of public health" should become a key consideration in awarding alcohol licences.

However, licensing and sale of alcohol is an exception in Schedule 7 of the Government of Wales Act 2006 and, therefore, non-devolved; similarly drink-drive limits, of which there was support from witnesses for lowering it in line with Scotland.

Alcohol powers weren't included as part of the St Davids Day agreement and are likely to be retained by Westminster – a decision the Deputy Minister described as "disappointing".

Conclusions

We're all going to have our own ideas on what's causing these problems and how to deal with it; I'm not going to go over what I've said previously on either narcotics or alcohol, while there's nothing to really disagree with in terms of the report's recommendations.

William Graham AM (Con, South Wales East) outlined his own "Three R's" for tackling alcohol-related crime – Respect (for people and property), Refuse (to serve), Review (alcohol licensing) – a few weeks ago. I don't know if he was speaking on behalf of the Welsh Conservatives or himself, but you can read more here.

However, it's not just a problem for sink estates and people thrown on society's scrapheap. Substance abuse - though alcohol abuse in particular - is just as much a middle class problem. The statistics speak for themselves.

How many upstanding white collar folk reading this have come home from work and polished off a bottle of prosecco? How's that any different to an 18 year old drinking a litre of Diamond White on a park bench?