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Heroin Assisted Treatment (Hat) Pilot Evaluation Report

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Heroin Assisted Treatment (Hat) Pilot Evaluation Report HEROIN ASSISTED TREATMENT (HAT) PILOT EVALUATION REPORT End of year 1: October 2019-October 2020 JANUARY 22, 2021 HANNAH POULTER, ROB CROW, DR HELEN MOORE Contents Infographic Section 3 Executive Summary 6 Introduction 7 Method 10 Results 11 1. Engagement and retention 12 2. Street drug usage 14 3. Psychosocial outcomes 20 4. Criminal behaviour and associated costs 25 5. The impact of COVID-19 pandemic on the pilot 28 Discussion 30 2 Infographics 3 Infographics 4 Infographics The Ministry of Justice data set references, and includes, costs to the police, criminal justice system, victims – including victims services, property stolen/ damaged, and lost output 5 Executive Summary The UK has the largest reported opioid-using Valley CRC and HMPPS) and South Tees Public population in Europe¹. Opiate Dependency Health to drive forward the agenda and (OD) is a complex, multi-faceted, public became the first area in the country to obtain health and social issue. This problem results Home Office licenses and deliver the service. in significant harm to the individual, their families and wider society, in addition to high associated costs to the public purse. This HAT project contributes to the evidence In the past 12 years, the number of opiate base for public health approaches to users over the age of 40 years presenting crime and situating this intervention in to treatment services has tripled². The Middlesbrough which suffers significant current treatment model in the UK for OD deprivation and high levels of crime⁶ will is oral Opiate Substitute Treatment (OST), provide rich learning for crime prevention or Methadone, which is effective for the with national impact. This evaluation majority of individuals³. However, for 5-10% provides a snapshot of health, psychosocial of people who present to treatment services and offending behaviour of the first HAT with OD, OST is ineffective⁴. pilot cohort in the UK. Data from a variety of sources were aggregated to build a picture of participant’s behaviour – all of which are important indicators of recovery Heroin Assisted Treatment (HAT) addresses and stabilisation of this population. Where the treatment gap for individuals who have appropriate and possible, a public health failed to benefit from the standard treatment approach to analysis has been adopted. offer. HAT involves offering synthetic heroin (diacetylmorphine) twice daily, under the Encouraging positive changes were observed supervision of medical staff to inject the within the HAT pilot population during year 1 drugs in a controlled and safe environment; of its operation including: it is also referred to as supervised injectable heroin (SIH). The supervised nature of • increased engagement with this treatment is important as it ensures psychosocial interventions, monitoring, compliance, safety and • reductions in consumption of regulation so that none of the prescribed street heroin, substance can enter the illicit market⁵. • reduction of risky injecting practices, • improvements in physical and In October 2019, after a number of years psychological health, developing a HAT pilot offer, a steering group • improvements in secure housing, was established between Foundations, the • and reductions in the volume and Office of the Police and Crime Commissioner cost of criminal behaviour. for Cleveland, Probation (Durham Tees 6 Early indications suggest that the longer someone engages with HAT, the more benefits are reported in terms of physical health, quality of life, wellbeing and engagement with psychosocial Executiveinterventions. Further analysis willSummary be possible as the project is rolled out and participant numbers increase. The context of the global pandemic presented unique challenges to the pilot in terms of the reduction of availability of some support services and changes to the illicit drug landscape across Cleveland which may have impacted engagement outcomes. Introduction The UK has the largest reported opioid-using However, for 5-10% of people who present to population in Europe¹. Opiate Dependency treatment services with OD, OST is ineffective. (OD) is a complex, multi-faceted, public This population is typically chaotic and are health and social issue. This problem results characterised by chronic and long-term in significant harm to the individual, their entrenched OD; meaning they are subject to a families and wider society, in addition to number of biopsychosocial problems including high associated costs to the public purse. poor health, significant offending behaviour In the past 12 years, the number of opiate and homelessness. users aged over 40 years presenting to treatment services has tripled². The aging Despite this population being the minority, opiate dependent population has been linked the impact of not having an appropriate to the substantial increase in drug related treatment offer in place is likely significant⁵, deaths (DRD’s) in the UK⁷. The North-East especially considering they may account has significantly higher rates of DRDs than for such a high proportion of associated all other English regions⁷. Many reasons negative outcomes such as offending. This likely account for this, such as high levels of lack of treatment offer is not only ethically deprivation, a large population of people who questionable but does not represent good inject drugs (PWID) and the aging population value for money. Public money is being of opiate users. In Middlesbrough, OD is a distributed into funding OST for up to 10% chronic and pervasive health inequality; the of the OD population in the UK which is largest proportion of drug related deaths in ineffective⁴. Combined with other associated the North-East being attributed to men who public costs of OD: the cost of acquisition are misusing opiates⁷. related crime, impacts on the social care budget, emergency hospital admissions etc, The current treatment model in the UK for the economic drive to progress different OD is oral Opiate Substitute Treatment (OST), treatment regimens for OD in the UK is clear or Methadone, which is effective for the and resounding. majority of individuals³. 7 What is Heroin Assisted Treatment? Heroin Assisted Treatment (HAT) addresses Since 2010, UK drugs policy has veered away the treatment gap for individuals who have from harm reduction approach towards failed to benefit from the standard treatment an abstinence focused approach; a transition offer. HAT involves offering synthetic heroin which has been criticised for increasing (diacetylmorphine) twice daily, under the DRDs¹². Adding to this, the current metrics of supervision of medical staff to inject the success within treatment services in the UK drugs in a controlled and safe environment; are based on 'individuals leaving treatment it is also referred to as supervised injectable and not returning within 6 months'. Some heroin (SIH). The supervised nature of experts identify these metrics as creating this treatment is important as it ensures shame and stigma for people who use drugs monitoring, compliance, safety and (PWUD), failing to account for the long- regulation so that none of the prescribed term nature of recovery¹³. In practice, HAT substance can enter the illicit market⁵. is recommended to combine both harm reduction and psychosocial stabilisation and should be offered in a context of HAT is a routine treatment in many shared decision making, and meeting countries for OD, pioneered in Switzerland patients’ own expectations for treatment, in the 1990’s. Internationally, the evidence following evidence-based guidance for base for HAT is convincing⁸ and shown to implementation¹³. improve many health and social outcomes compared to standard OST. The World Health Organisation and NICE advocate HAT for OD⁹ In the UK, HAT was again recommended in as a treatment of choice for this population. the most recent update of the UK guidelines HAT has already been tested within the UK on clinical management in 2017¹⁴, however by a national RCT in the UK; The Randomised a significant lag is observed in terms of Injectable Opiate Treatment Trial (RIOTT) offering this treatment in clinical practice. tested the efficacy of HAT in the UK and The reasons for this are many and varied; found significant benefits when compared to clearly this topic raises political and public OST¹⁰. A subsequent international systematic attention due to the very nature of providing review concluded that HAT is an effective an addictive substance as a ‘medicine’ for method of treating OD for populations which the very same addiction¹⁵. Adding to its are unresponsive to OST¹¹. political salience, often patients, providers and policy makers have different ideas about retention and success in HAT¹³. Considering The scientific evidence for HAT is substantial, these debates, the impetus for generating yet in the UK there has been hesitation at a an evidence base for HAT within the UK is policy level implementing this treatment. strong. 8 HAT pilot in Middlesbrough In October 2019, after a number of years with the steering group to successfully developing a HAT pilot offer, a steering group leverage in funding from National Institute of was established between Foundations, the Health Research, Applied Research Council Office of the Police and Crime Commissioner in the North East and North Cumbria (NIHR- for Cleveland, Probation (Durham Tees Valley ARC NENC) to conduct important qualitative CRC and HMPPS), and South Tees Public research into this pilot during 2021 and 2022. Health to drive forward the agenda and
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