Norfolk, Focus Group, Questionnaire survey, drug treatment, Home Office, crack cocaine, data sources, estimates, Office for National Statistics, drug misuse, Financial support, Successful treatment, prison, drug problems, Focus groups, social support, crack addiction, heroin addiction, Health Policy, Urine drug screen, needs assessment, Norfolk Drug Action Team, Survey results, treatment agencies, total population, drug dependence, estimate, University of East Anglia, School of Medicine
School of Medicine, Health Policy & Practice A CrackCocaine Needs Assessment for Norfolk Richard Holland Vivienne Maskrey Julie Sadler Roberto Vivancos Ian Harvey September 2003
Contents 1. Executive Summary ................................................................................................3 2. Glossary..................................................................................................................4 Drug treatment agencies involved in this needs assessment........................................................................4 Technical terms ....................................................................................................................................................4 3. Project team............................................................................................................5 4. Acknowledgements .................................................................................................6 5. Introduction and background to crack and cocaine ................................................7 6. Project aims and objectives...................................................................................13 7. Methods ................................................................................................................14 Urine screen data...............................................................................................................................................14 Capture Re -capture............................................................................................................................................14 Questionnaire survey community sample: treatment & voluntary agencies........................................20 Questionnaire Survey Norwich Prison.......................................................................................................21 Focus Groups......................................................................................................................................................22 8. Analysis ................................................................................................................26 Capture-re-capture .............................................................................................................................................26 Questionnaire survey - sample size ................................................................................................................28 Questionnaire survey analysis .........................................................................................................................28 9. Results ..................................................................................................................31 Norfolk & Norwich Urine test results............................................................................................................31 Background data (1/4/02 30/9/03)...............................................................................................................33 Questionnaire survey results community sample .....................................................................................43 Prisoner survey results......................................................................................................................................53 Results of Focus Groups for Crack Users .....................................................................................................62 Comments from survey respondents ..............................................................................................................66 Results of Prison Focus Groups......................................................................................................................67 Results of the Treatment Professionals Focus Group & Questionnaires .................................................70 Report from the Police Focus Group .............................................................................................................73 10. Discussion and project limitations.....................................................................76 Urine drug screen data......................................................................................................................................76 Capture-re-capture analysis .............................................................................................................................76 Questionnaire survey community sample ..................................................................................................77 Prisoner Survey..................................................................................................................................................79 Focus groups limitations ..................................................................................................................................80 11. Conclusions:.....................................................................................................82 Capture re-capture data ..................................................................................................................................82 Community Survey results...............................................................................................................................82 Focus Group conclusions.................................................................................................................................83 Reference List...............................................................................................................85 Appendices ...................................................................................................................87 Appendix 1a Drug Questionnaire for New Clients ..................................................................................88 Appendix 1b Drug Questionnaire for Existing Clients............................................................................90 Appendix 2 Drug Questionnaire for Prison Inmates................................................................................91 Appendix 3a Focus Group Topic Guide for Crack Users .......................................................................92 Appendix 3b Focus Group Topic Guide for Treatment Professionals..................................................95 Appendix 3c Focus Group Topic Guide for Police Officers ..................................................................97 Appendix 3d Focus Group Topic Guide for Prisoners with history of crack use...............................99 Appendix 4 Focus Group Consent Form.................................................................................................100 Appendix 5 - Extracts from focus group discussions, community sample ............................................101 Appendix 6 - Detailed Prison Focus Group Report with extracts from the group discussions..........119 Appendix 7 Comments from survey respondents (community sample).............................................124 Appendix 8 - Professionals' questionnaire detailed responses ................................................................129 2
1. Executive Summary This needs assessment was commissioned by Norfolk Drug Action Team (DAT) to elucidate the extent of crackcocaine use within Norfolk, and the needs of this group of individuals. It is intended that the results of this work will assist the DAT in the commissioning of services for crack-cocaine users in the near future. This project used three key techniques. Capture-re-capture methods were used to assess the numbers of problem drug users present within Norfolk. Survey methods in both a community and prison sample were used to assess the proportion of problem drug users severely dependent on crack-cocaine. Finally, focus groups were conducted with crack users (in community & prison), police and treatment professionals to gain varied perspectives on the needs of this group. The key findings from this work were as follows: Capture re-capture data · 2,063 individuals were in contact with one or more of the following Norfolk agencies in the six-month period 1/4/02 to 30/9/02: drug treatment agencies, police (charged with drug-related offences), probation, and the arrest referral service. · 2.2% of the 1,271 in contact with treatment agencies were reported as having crack/cocaine as their main drug, this contrasted with 5.5% of those in contact with the arrest referral service. · Capture-re-capture methods were used and provided an overall estimate for Norfolk's problem substance misuse population as being approximately 8,200 (i.e. 2.0% of Norfolk's population aged 15-54). Community Survey results · Approximately 12% (95% Confidence interval [C.I.] 7% to 16%) of problem drug users in Norfolk are using crack/cocaine in a way that suggests severe dependence. · A further 19% (95% C.I. 14% to 24%) reported using crack/cocaine in a way that suggests some dep endence. · These figures equate to an estimate of 1000 individuals severely dependent on crack/cocaine in Norfolk, with a further 1500 with some dependence on this drug. · Crack/cocaine use is strongly associated with multiple other drug use (on average four other drugs used). · Crack/cocaine use is also associated with being a sex worker Prison Survey results · 77% of respondents had used drugs before prison (95% C.I. 70% - 82%). · The pattern of drug use appeared different amongst prisoners to those in our community sample fewer drug using prisoners were severely dependent on heroin, instead crack/cocaine dependence was much more prominent. · Amongst prisoners who had used drugs 32% (95% C.I. 25% to 39%) indicated severe dependence on crack/cocaine. Many of these were at the extreme end of the dependence scale used. · A further 16% (95% C.I. 11% to 22%) indicated some dependence on crack/cocaine. · Just as in the community sample, prisoners severely dependent on crack/cocaine used significantly more drugs than those not dependent on crack/cocaine (on average 4 other drugs used). Focus Group results The focus groups provided rich data to enhance our understanding of crack/cocaine use in Norfolk. · There was a very strong inter-relationship between crack use and heroin use · Crack lifestyle led to a strong need for involvement in crime or prostitution to fund this habit · Users almost universally believed that there was no treatment for crack use and that services were almost exclusively orientated toward opiates · Successful treatment programmes were characterised by strong personal relationships between clients and professional drug treatment workers · Successful treatment programmes should incorporate a wide range of activities and initiatives to provide structure to a client's daily life · For prisoners there appeared a clear need to focus efforts on supportive discharge arrangements to prevent a return to previous lifestyle/behaviour. · The benefits of learning from ex-users were perceived as an important component in treatment · Lack of accurate information around crack and its effects on health & lifestyle were perceived as gaps in current preventative services. Messages should be targeted at a young audience. 3
Drug treatment agencies involved in this needs assessment
Arrest Referral (CATCH) Bure Centre & Colegate Centre CADS Contact NR5 MAP MATRIX project Matthew Project NORCAS Gt. Yarmouth Tier 3 WSDAS
Organised by the Matthew Project this is a service to detainees in police custody and Group 4 court cells. Assesses drug & alcohol users and refers for treatment. Norwich based clinical drug treatment service Community Alcohol & Drug Service (providing a clinical drug treatment service to West Norfolk) Clinical drug treatment service based in Earlham, Larkman and Marlpit in Norwich Mancroft Advice Project (Norwich) an advice service for young people (aged 11-25) Outreach project for sex workers in Norwich Adult counselling and support service for drug users Gt. Yarmouth based clinical drug treatment service A clinical drug treatment service for young people West Suffolk Drug Advisory Service (Thetford)
Technical terms C.I. Capture-recapture Snow-balling D dataset A&D dataset
Confidence interval the true value of a parameter for a population has a 95% probability of lying within this interval. A technique to measure the size of hidden populations. A technique to contact individuals from hard-to-reach groups. This is a dataset of individuals in contact with one or more of the following in the period 1/4/02 to 30/9/02: police drug-related offences; Norfolk probation; Norfolk arrest referral service; Norfolk drug treatment agencies. This dataset is the same as the D-dataset with the addition of individuals in contact with the police due to acquisitive crime offences.
3. Project team Principal investigator: Dr Richard Holland: MRC Fellow & Lecturer in Public Health Medicine, School of Medicine, Health Policy and Practice, University of East Anglia Project research co-ordinator: Ms Vivienne Maskrey, Research Associate, School of Medicine, Health Policy and Practice, University of East Anglia Statistical support: Ms Julie Sadler, Research Associate, School of Medicine, Health Policy and Practice, University of East Anglia Dr Roberto Vivancos, Specialist Registrar Public Health Medicine Ian Harvey, Professor of Epidemiology & Public Health, School of Medicine, Health Policy and Practice, University of East Anglia Steering Group (in addition to the above): · Clive Rennie: Substance Misuse Manager, Norwich Primary Care Trust · Dr Daphne Rumball: Consultant Psychiatrist, the Bure Centre, Norwich · Chief Superintendent John Bainbridge: Area Commander, Norfolk Constabulary · Mr Malcolm Leader: Head of Drug Strategy, HMP/YOI Norwich · Xany Oliver: Strategic Manager, Norfolk DAT 5
4. Acknowledgements This needs assessment has involved the collaboration of a wide variety of agencies throughout Norfolk, including Norfolk Constabulary, Norfolk Probation, Voluntary agencies working in substance misuse and the NHS drug treatment services. Many individuals in these orga nisations have committed their valuable time to help complete this work and we are enormously grateful for all the kind assistance that we have received. Particular thanks should go to all members of our steering group and the following people for their support and assistance: Mark in Norwich Rick Andrews, Tier 3, Norwich Sharon Matthews, Paul Brierley, Christine Skinn, Zoe Baines & Daphne Smith, Bure & Colegate Centres, Norwich Mark Adeney & team, Community Alcohol & Drug Service (CADS), King's Lynn Des Main, CADS, Kings Lynn Anne Kavanagh, Contact NR5, Norwich Teresa Cumbers, The Magdalene Group Linda Street, Mancroft Advice Project, Norwich Debbie Chedgey, Liz Benns and Wendy Matthews, MATRIX Project, Norwich Andrew Barwick & Julian Bryant, The Matthew Project, Norwich Sonia Farrell & Andrew Cleveland, NORCAS, Great Yarmouth Dan Mobbs, NORCAS - Homeless and Vulnerably Housed Penny McVeigh, NORCAS, Norwich Mike Sowerby, Victoria Alcohol Service, Norwich Simon Aalders, Liz White & Marion Martin, WSDAS, Thetford Dr Chris Dawson, Consultant Chemical Pathologist, Norfolk & Norwich University Hospital John Fairey and Martin Dransfield, Corporate Data Unit, Norfolk Constabulary Lesley McConville, Drug Treatment Testing Order team Nicola Reed, Information Unit, National Probation Service Norfolk Area Mrs J. Hopkins for her work transcribing all focus group data Finally, this report would not have been possible without the very hard work and dedication of Laura Neave, the project secretary, who worked tirelessly throughout this project. Richard Holland Vivienne Maskrey 6
5. Introduction and background to crack and cocaine a) Cocaine Cocaine (cocaine hydrochloride) is an alkaloid derived from a shrub (Erythroxylon coca) grown in the foothills of the Andes.1 Peruvian Indians have chewed this shrub's leaves for centuries, valuing its properties of mood elevation and stimulation. The practical benefits of coca leaf use include improved oxygen absorption and reduced hunger, thus improving ability to function and survive in the environment in which it originates. The leaves were introduced to Europe by returning Spanish conquistadors. Pure cocaine, first isolated in Europe by Niemannn in 1860, was sold over-the-counter until 1916, and formed an important ingredient in the original Coca-Cola. However, it was realised that cocaine was powerfully addictive and dangerous, which led to its re-classification as an illegal drug. Cocaine's major routes of administration are sniffing it intra-nasally or injecting it intra- venously. The latter route gives the user a more rapid and powerful "high" but is associated with increased risk of bloodborne viral infection. b) Crack Cocaine hydrochloride decomposes before vaporising and thus cannot be effectively smoked and inhaled. However, when combined to form its free-base, it is readily smoked. This form is generally produced by combining cocaine with sodium bicarbonate or ammonia. The resulting, hard rocks make a cracking noise when heated, hence the name. In this form extremely high doses of cocaine reach the brain very rapidly. Crack is said to deliver an intensity of pleasure completely outside the normal range of human experience.2 c) Physical effects Cocaine blocks re-uptake of amines, particularly dopamine, noradrenaline and adrenaline. This results in its central nervous system and peripheral effects. Physical effects include: · Increased heart rate and raised blood pressure
· Vasoconstriction · Raised body temperature · Bronchodilation Use of crack or cocaine can lead to heart attack, stroke, fits and sudden death due to cardiac arrythmias. In pregnancy its use increases the incidence of still births, miscarriage and premature birth. Babies born to crack addicted mothers are irritable, have poorly controlled temperature and blood sugar, and are at increased risk of seizures. 7
Cocaine and alcohol are combined by the liver to form cocaethylene. Those who combine use of crack and alcohol experience an intensification of crack's euphoric effect. Combination use may increase risk of sudden death.3 d) Psychological effects Crack's ability to produce a potent "high" or euphoria leads to its highly addictive nature. Some users appear addicted after their first experience. Low and moderate doses cause euphoria, feeling of enhanced physical strength and mental ability, reduced sense of fatigue and decreased appetite. Higher doses may result in repetitive, stereotyped behaviour, tactile hallucinations (e.g. formication - the feeling of insects crawling under the skin), decreased concentration, insomnia, tremor, irritability and paranoia. A form of paranoid psychosis can also occur with delusions of persecution, emotional lability, hallucinations, and aggressiveness. Withdrawal leads to: · Lethargy, hunger, nausea, irritability and restlessness · Depression, often suicidal in nature · Paranoia · Intense drug craving Crack users need to support their drug use. This leads to involvement in acquisitive crime and exchanging sex for money.4 The latter puts them at high risk of acquiring HIV and other sexually transmitted infections.5 e) US experience Cocaine use peaked in USA in the mid-1980s at 5.7 million users (3% of population). Crack cocaine emerged in the late 1980s and its rapid rise in popularity and misuse has been described as an epidemic. However, during crack's emergence overall cocaine use in USA stabilised at 1.5 million users (just under 1% of the population). Crack use is highest amongst young adults 18-25 years old, particularly men. Its use is most prevalent in lower socio-economic classes and those of Hispanic, and particularly black ethnic backgrounds. f) UK experience Nationally drug use estimates are produced by a variety of sources. The British Crime survey (BCS) is a large national survey of adults who live in a representative cross-section of private households in England and Wales. In addition to asking respondents about their experiences of crime, the BCS enquires about a number of other crime-related topics. Since 1994 it has included questions on drug misuse. Findings suggest that the use of cocaine has risen in respondents aged 16-29 from 1% in 1996 to 3% in 1998, and 4.9% in 2000. Crack use has as yet not been reported to exceed 1% in any age group according to this survey.6 8
Total numbers of deaths in England and Wales related to drugs for the period 19931999 have risen each year from 2252 deaths in 1993 to 2943 deaths in 1999 (approximately 0.5% of all deaths). These figures include deaths related to paracetamol, aspirin, benzodiazepines, anti-depressants and illegal drugs. In this period deaths attributable to heroin (+/- other drugs) have risen from 187 (8% of drug deaths) in 1993 to 754 in 1999 (26% of drug deaths). Cocaine-related deaths (which also includes deaths related to crack use) have risen from 12 deaths in 1993 (0.5% of drug deaths) to 87 death in 1999 (3% of drug deaths).7 g) Definition of problem drug use It is important to distinguish recreational and problem drug use. The British Crime survey reports all drug use, irrespective of how this effects respondents. Therefore, this includes occasional users and those who may be drug dependent (either physical or psychological). Equally, it does not distinguish those with no apparent social problems associated with their drug use. This needs assessment is primarily interested in those with problem drug use. For the purposes of this project, problem drug use is defined as: "any person who experiences or causes social, psychological, physical or legal problems relating to their self-administration of a drug, including any form of drug use that involves injecting." h) National prevalence of problem drug use The number of known problem drug users reported by drug treatment agencies has steadily risen over the last decade from 16,810 for the six- month period ending 30th September 1993 to 33,093 for the six- month period ending in 30 September 2000. Heroin is the most frequent reported main drug (64%) followed by methadone (10%), with cocaine reported as the main drug by 6% of those entering treatment.7 Figures which base the national prevalence of problem drug use solely on those entering treatment seriously underestimate the prevalence of this condition. Instead, prevalence has been estimated by applying a multiplier to numbers entering treatment of between 2.5 and 5. The multiple indicator method The multiple indicator method estimates the number of problem drug users in the population by combining information on prevalence that is only available in a few areas (so-called calibration samples or anchor points) with "indicators" or "predictors" of drug use that are available in all areas (e.g. mortality data, clients in treatment etc.). For example, research may yield the proportion of all users in a given area who are accessing treatment. This proportion can then be combined with national numbers in treatment. Estimates derived in this way give UK prevalence as being between 160,000 and 250,000 (i.e. up to 0.8% of the UK population aged 1564). 9
i) Norfolk Numbers entering drug treatment services Data from the Drug treatment monitoring service indicate growing numbers of clients entering drug treatment services across Norfolk.8 9 Numbers have risen from 389 clients in treatment in 1993/4 to 1085 in 2001/2. This equates to 0.13% of the population. Using a multiplier value of 5- fold would suggest a problem drug misuse population of approximately 5,400 (0.68% of Norfolk's population).
Local prevalence of crack use There has been a significant increase in both the absolute numbers, and the proportion of clients attending treatment services who indicate that cocaine/crack is their main problem drug (rising from 1.6 % in 1999 to 7% in 2002, chi-squared test for trend: p<0.001),8 as shown in table 1, below.9
Table 1 The main drug for new clients entering treatment in Norfolk
1999/00* (n=676) 2000/01* (n=835)
10 (1.6%) 11 (1.1%)
24 (2.8%) 22 (2.5%)
22 (3.7%) 24 (3.4%)
*crack not separately classified
Drug treatment monitoring data also record other drug usage. This is only completed in approximately half of individual client reports. In the Eastern Region crack/cocaine was reported as the main drug in 5% of cases (in line with Norfolk data). However, a further 5% of users reported crack/cocaine amongst the secondary drugs that they use. Table 2 below appear to show a rising trend of borderline statistical significance (chi-squared test for trend p=0.08) in the reporting of crack/ cocaine use as a secondary drug.
Table 2 Secondary cocaine or crack use reported in the Eastern Region
46 (2.2%) 58 (2.8%)
*crack not separately classified There are three other sources of estimates of crack/cocaine use, a report from the St Martin's Housing Trust, the NORCAS Homeless Outreach Team report and the Health Initiative with Prostitutes report. These reports clearly refer only to a subset of Norfolk's problem drug users. St Martin's Housing Trust In their annual report
2001/2002 this trust, which is based in Norwich, saw 140 drug users. This trust provided a substance misuse service specifically to the homeless. Their report indicates that just over 10% of individuals reported that they had regularly used crack or cocaine.10 NORCAS Homeless Outreach team report In late 2002 NORCAS Homeless Outreach team took over providing a service for this client group. Their initial three- month report stated that 25% of the heroin users seen also used crack, and that a small proportion reported it as their primary problem. Only one individual used crack without also using heroin.11 The HIP (Health Initiative with Prostitutes) Project Survey Report In their report to the Norfolk Drug Action Team of a survey (n=53) carried out between August and October 2002 the HIP project reported that half of their respondents (n=27) used crack and heroin, and that two respondents used crack alone. They highlighted the links between the crack use and the sex industry, and the consequent increased risk taking behaviour of these clients. Overall, robust prevalence data for Norfolk crack/cocaine use is not currently available, hence the need to undertake this research project. j) Treatment for crack/cocaine dependency Shortly after starting this work national guidance for the treatment of cocaine/crack dependency was published by the national treatment
Agency for Substance misuse12. Given this recent National Review
it was decided that this project should not repeat this work. Instead, efforts have been focused on determining the prevalence and needs of crack cocaine users in Norfolk. A brief summary
of the guidance is as follows: · cocaine misuse is treatable using approaches already familiar to drug services · prompting initial contact with services remains problematic. Once contact is made, being seen quickly, reminders and practical help with attendance is helpful · the relationship with drug workers and their involvement with their clients' problems, is a crucial factor in motivation and retention 11
· drug- free psychosocial interventions such as counselling are effective. In the USA cognitive-behavioural therapy has been found to be useful · clients with multiple needs benefit from residential rehabilitation · currently there is no recognised pharmacotherapy for cocaine dependence (Disulfiram may be of use where alcohol dependence co-exists with cocaine use) k) Government Strategy In December 2002 the government published The National Drugs Strategy which set out the areas for action. This strategy was followed later in the month by "Tackling Crack - a National Plan".13 Conducting a detailed local needs assessment forms part of the recommendations of this National Plan. 12
6. Project aims and objectives Aim To perform a needs assessment of crack cocaine users in Norfolk combining epidemiological, corporate and if possible comparative approaches. Project Objectives 1. To perform a literature review of the epidemiology of crack cocaine use in the UK 2. To investigate management of crack cocaine and cocaine users by reviewing the effectiveness literature and visiting one identified centre of good practice. [Please note that due to publication of the National Guidance for crack/cocaine treatment it was considered that this objective duplicated this national review. Therefore this objective was omitted.] 3. To determine the extent of problem drug use in Norfolk using capture-recapture techniques 4. To determine the proportion of problem drug users whose main drug is crack cocaine or cocaine, by using data collected anonymously from each specialist treatment service and data from a survey of Norwich Prisoners. 5. To determine the proportion of problem drug users whose main drug is heroin but who also have important crack cocaine or cocaine addiction, by using data from the specialist treatment services and from a survey of Norwich Prisoners. 6. To investigate current service provision for crack/cocaine from the viewpoints of both providers and users, by the use of focus groups. 13
7. Methods The four key sub-studies have been as follows: · Collecting urine screen data · Undertaking a capture-re-capture analysis of routine data · Performing a questionnaire survey amongst clients of both statutory and non- statutory treatment services (i.e. a community-based sample) and within Norwich Prison. · Conducting focus groups with users and professionals This section describes the methods used to undertake these four elements. Urine screen data Anonymous urine screening data from 1997 to 2002 were sought from the Pathology Unit of the Norfolk & Norwich Hospital. Two key aspects of these data have been described: · the change in proportion of crack/cocaine positive urine tests over time · amongst clients with crack/cocaine positive tests, describing the other drugs found in their urine samples Current urine testing methods for crack/cocaine involve the use of antibody screening for the metabolite benzoyl ecgonine. Positive results are confirmed by capillary gas chromatography. Urine must contain at least 300microgrammes/litre to be considered positive. Urine is likely to remain positive for between two and four days after ingestion/use depending on the quantity used, the period over which it was used and the fluid intake prior to the urine sample being produced. Capture Re-capture This needs assessment provides an estimate of the numbers of problem users of crack cocaine by first estimating numbers of problem drug users in Norfolk. This estimate has been derived from the following separate sources of data. In each case all individuals in contact with these agencies at any time in the 6-month period between 1st April 2002 and 30th September 2002 were included. Agencies providing data: 1) Individuals known to any specialist drug service in Norfolk. The drug services included were as follows: a. The Bure Centre, Norwich b. NR5, Norwich c. Tier 3, Norwich d. West Suffolk Drug & Alcohol Service, Thetford e. NORCAS, Great Yarmouth 14
f. Community Alcohol & Drug Service, King's Lynn 2) Individuals charged with drug-related offences by Norfolk Constabulary 3) Individuals charged with acquisitive crime offences by Norfolk Constabulary 4) Individuals in contact with Norfolk Probation with known drug problems 5) Individuals in contact with the Arrest Referral Scheme operated by the Matthew Project Two further sources of data were collected. Firstly, those believed to have acquired HIV through drug use, and secondly those admitted to hospital secondary to drug use. Both these data sources proved very small and thus were likely to lead to inaccurate estimation if used within the capture-re-capture analysis. It had been the intention of the project to gather data from Accident and Emergency departments throughout Norfolk. This proved impractical as A&E units (with the exception of the N&N hospital) do not collect data on cause of poisoning. This meant it was impossible to distinguish drug- misuse related overdoses from those secondary to drugs such as paracetamol. The following basic dataset was collected from each source: · Initial of first name (one digit) · Surname - soundex coded for anonymity14 · Sex (one digit) · Date of birth (six digits) · Three/four digit post code (i.e. NR3 or NR13) Box 1 Soundex coding: Soundex coding is a procedure that converts all surnames into a letter plus a three-digit code. The soundex code is a coded surname index based on the way a surname sounds rather than the way it is spelled. Soundexed codes are not unique - thus it is impossible to re-generate a surname from any given soundex code. In this way surnames are "anonymised". For instance "Smith" and "Smyth" code to S530, whilst "Holland" and "Hollander" both code to H453. 15
Original Data Table 3 and 4 show the numbers of records received from each agency and the following steps undertaken to ensure there were no duplicate records within a dataset before datasets were compared for matches. a) Stage 1 Duplicate records were removed from each set where exact matches were found for Soundex Code, Initials, Date of Birth, Sex and Postcode. b) Stage 2 Duplicate records were removed from each set where exact matches were found for Soundex Code, Initials, Date of Birth, and Sex c) Stage 3 ("fuzzy matching") Close inspection of the data revealed a number of individuals who appeared to be matches within sets with the exception of possible data entry errors. To allow for the possibility of these errors the following rules were applied to remove duplicate records (so-called "fuzzy matching"): 1. Matched on first name initial, soundex code, sex. Allowing for an error in one of the units of the day, month or year of the date of birth or transposition of the days and months (i.e. these rules considered 12/03/64 and 13/03/64 to be a match, equally 02/03/65 and 03/02/65 were considered to be a match). 2. Matched on first name initial, soundex code, date of birth but allowing sex to be different. 3. Matched on soundex code, date of birth, sex and allowing first name initial to be different (this accommodates for errors introduced if Bill short for William is entered by one agency as "B" and "W" by another agency). 4. Matched on first name initial, date of birth, sex, last name initial but allowing the soundex code to be different. Combination errors, (e.g. apparently similar individuals with identical first initials and soundex code but different sex and slight error in the date of birth) were not considered to be matches. 16
d) The Two Final Data Sets The above data cleaning yielded two final datasets on which capture-re-capture analyses were performed:
D Set: A & D Set:
containing individual records from the Arrest Referral Service, Treatment Agencies, Probation Service & Police D (i.e. solely drugrelated offenders) containing individual records from the Arrest Referral Service, Treatment Agencies, Probation Service & Police A & D (acquisitive crime and drug related offences)
Table 3 Records received from each treatment agency
Treatment agency Bure/Colegate King's Lynn Gt. Yarmouth Contact NR5 Thetford (WSDAS) Tier 3 Total
Number of records 740 258 191 81 40 23 1333
Table 4 Data cleaning of records supplied by the Arrest Referral Service, Norfolk Probation, and Norfolk Constabulary
Arrest referral service
Police A set (acquisitive crime)
Police D set (drugrelated offences) 483
Stage 1 Duplicates with exact
matches for Soundex code,
date of birth, initial, sex and
Stage 2 Duplicates with exact
matches for Soundex code,
date of birth, initial, & sex
Stage 3 Duplicates removed with a
"fuzzy match" (see
description above of fuzzy
Total records minus duplicates
e) Matching rules for comparing individuals in final datasets
Individuals were initially matched on the basis of two sets of rules, described in the table 5, below. The tight match technique, which depended on finding an exact match on postcodes as well as the other variables, drastically reduced matches to approximately one third of the numbers found through the medium match technique. Part of this problem related to the fact that postcode data was absent from between 1% and 50% of records, varying by the different data sources (Table 5a) and these records could not be matched. Equally, this population has frequent changes of address (i.e. appear quite "nomadic"). Thus, it was decided to use the medium match data and then to search to find possible one unit errors (so-called "fuzzy matching", described in detail on page 16, above).
Table 5 Rules applied to match individuals across datasets
First name Last name Soundex
[Fuzzy matching involved matching individuals on four out of the following five variables: first name initial, last name initial, soundex code, date of birth or sex. The fuzzy matching process allowed one variable to differ between data sources by one unit, as described on page 15. This was simply to allow for data entry errors.]
Final results are presented for capture-re-capture results using fuzzy matched data as this was considered to be the most accurate form of matching.
f) Non-Norfolk postcodes As described above, many records in individual datasets either contained no postcode, or contained a non-Norfolk postcode (table 5a). For simplicity all records containing no postcode were presumed to be Norfolk residents. Those records with non-Norfo lk postcodes allowed us to consider datasets in the following three ways: (1) Data from individuals with Norfolk postcodes or no postcode (2) Data from individuals with Norfolk postcodes, no postcode or those individuals whose despite having one non-Norfolk postcode matched an individual with a Norfolk postcode. (3) All data irrespective of postcode
These three ways of considering the datasets yielded different overall estimates. Results are presented considering the second method (i.e. individuals with Norfolk postcodes, those with no postcode and those with a match to an individual with a Norfolk postcode). The effects of either including all data (as in 3) or being more restrictive (as in 1) were considered as part of a sensitivity analysis, described in the results section.
Table 5a Number of records with missing postcodes and non-Norfolk postcodes by dataset
Police D 445
Police A 2412
Number with no postcode (%) Total with Norfolk postcode Total with non-Norfolk postcode
*** Breakdown of records with postcodes**
1246 (99.8%) 233 (92%)
1338 (55%) 930 (87%) 144 (13%)
Questionnaire survey community sample: treatment & voluntary agencies Data from the regional drug misuse database is inadequate at revealing data beyond main drug used. Therefore, a survey (Appendix 1a & 1b) was conducted of clients visiting each of the following treatment services: a. The Bure Centre, Norwich b. NR5, Norwich c. Tier 3, Norwich d. West Suffolk Drug & Alcohol Service, Thetford e. NORCAS, Great Yarmouth f. Community Alcohol & Drug Service, King's Lynn In addition, the survey was conducted in the following voluntary services: a. The Matthew Project b. Mancroft Advice Project c. MATRIX project In order to maximise the numbers completing these surveys, new and current clients were encouraged to participate. Wherever possible, the numbers completing and refusing to participate were recorded so that the representativeness of this survey would be known. The self-complete client questionnaire yields a great deal of valuable information about clients using these treatment or support services. In particular, the questionnaire provides data on the probable level of dependence to all drugs taken on a scale of no, moderate and severe dependence. The drug dependency questions were based on those used by the Office for National Statistics (ONS). These questions have been shown to provide data in good agreement with more detailed clinical assessments (Schedule for clinical assessment in psychiatry - SCAN), kappa = 0.64.15 Furthermore, it provides data on alcohol dependence by using the three AUDIT-C questions (extracted from the Alcohol Use Disorders Identification Test by Bush et al).16 17 18 In order to minimise the impact on service providers, the survey was carried out over a 2-week period in each agency. Distribution and completion of the survey was slow in a number of agencies and repeated efforts were made by the project team to improve response in these locations. In these locations the survey period was extended after consultation with agency staff. 20
Questionnaire Survey Norwich Prison A survey was also carried out in Norwich Prison to determine prisoners' previous drug use prior to entering prison. Prisoners were not pre-selected on the basis of prior residence, but replies distinguished between residents of Norfolk, Suffolk, Cambridgeshire and Essex, and other areas (appendix 2). The questionnaire was very similar to the questionnaire used with treatment agency clients in order to provide data on the extent of drug and alcohol dependence in these respondents. The questionnaire included additional questions investigating the adequacy of detoxification services at the prison. The questionnaire was piloted on a small group of prisoners to recheck its readability and to help publicise this survey amongst prisoners. As a result of piloting a small number of additional questions were included and certain wording was amended. To maximise the response rate we used prisoner landing representatives and "listeners" to distribute all questionnaires. These representatives also helped those prisoners who had difficulty understanding the questions being asked.* Where prisoners had assistance in completing the questionnaire this was indicated in a box provided, thus allowing us an opportunity to make an estimate of any bias that this may have introduced into the results. One week in advance of the survey posters were placed throughout the prison advertising the purpose of the forthcoming survey. Simultaneously, all prisoners received a short letter explaining the survey's purpose. Landing representatives/listeners received sealed envelopes for the appropriate number of prisoners on their landing. Each envelope contained the following: · The questionnaire · An envelope for the questionnaires to be sealed in · A black biro The cross-sectional survey took place over a designated weekend, all prisoners present in the remand wing (A wing) and the young offenders' institution received the questionnaire. Prisoners from the adult training prison were not included as these prisoners tend to be from a much wider catchment area and to have been in prison for longer periods of time. Completion of the questionnaire was completely voluntary. Completed questionnaires were collected in sealed boxes by landing representatives and returned to the UEA researchers. * The proportion of prisoners with literacy problems is unknown. Estimates vary from 20-40%.26 However, few prisoners (<10%) are unable to understand yes/no questions.27 21
Focus Groups Focus groups are a useful method of investigating and exploring the range and diversity of views of groups of people. The group interaction is employed to stimulate discussion and detailed examination across the issues of interest. Six focus groups for crack users were held in Norwich, and one in Great Yarmouth. Groups involved participation of both current and ex-crack users to elucidate the views of ex, current and potential service users. The key aim of these groups was to explore what users believed was needed in terms of service provision for problem crack/cocaine use. One focus group was held with police representatives from Norfolk and one with treatment professionals from Norfolk. Two further groups were held in HMP/YOI Norwich with male young offenders (aged 15-21) and male adult inmates (over age 21). A survey form was also distributed to all treatment agencies to enable those who had a specia l interest in the management of clients with crack cocaine problems to put their views across if they were unable to attend the treatment professional focus group. Results from this survey are reported alongside the results of the treatment professionals' focus group. Recruitment of crack users Participants were recruited from those who responded to posters and information leaflets. These were displayed or distributed at the following places: · Treatment clinic waiting rooms (Bure Centre, Colegate, Contact NR5 and NORCAS Great Yarmouth), · Homeless hostels, one in Norwich and one in Great Yarmouth, · Youth Services (Tier 3 and Mancroft Advice Project), · Voluntary projects (Magdalene Group and Matthew Project) · GP Surgeries in Great Yarmouth · The Alcoholics Ano nymous meeting place
in Great Yarmouth. "Snowballing techniques" were used to endeavour to include individuals both in contact with treatment services and those unknown to these services. This involved asking individuals identified from the initial adverts to generate other subjects. This "snowballing technique" has been found to be successful for accessing subjects in hard to reach populations19 and has enabled groups to include individuals not currently in contact with services. In Norwich one service user who had become enthused with the objectives of this project acted as a `key contact' and encouraged a large number of crack users not otherwise likely to hear about the project to participate. Within services in Norwich and Great Yarmouth some treatment professionals also actively passed on information about the groups to clients who they thought might be interested in participating. 22
Individuals who responded to the advertisements phoned a number at the University of East Anglia. The project was explained to them by the project co-ordinator or project secretary. If interested, they were asked if they wished to disclose their first name, age and whether they were a current or ex-crack user. This information allowed them to be allocated to the appropriate group and details of the date, time and venue were then given over the phone. If the individual decided to disclose their address a printed information sheet and directions were sent via the post. Individuals were also asked if they could leave their telephone/mobile phone number. All information was held securely in confidence, available only to the project secretary and project coordinator. To maximize numbers participating, those who had left telephone numbers were phoned on the day to remind them of the group's time and place. a) Topic Guides Individual topic guides were developed for each of the following groups (Appendix 3a, 3b, 3c & 3d): · Crack Users (community sample) · Treatment Professionals · Police · Crack users (prisoners) Topic guides were developed in consultation with the commissioners of this study and through a process of brain storming relevant ideas with representatives of Treatment Services, Police, Drug Services in Prison, and the research team. Draft topic guides were produced which were amended and approved by the Study Steering Group. The topic guide for drug users covered issues of motivations to enter treatment for crack problems, how information about crack cocaine and specific treatment for crack problems are accessed, and any barriers to treatment experienced. People were asked to explore their previous positive and negative experiences of treatment, and to explore other issues that they might be seeking help with. Participants were asked to describe the key attributes of a crack service. The topic guides were not exhaustive and any topics that appeared relevant when raised within the groups were also explored. The focus group for treatment professionals covered similar ground from the perspective of service provision and training. This is reflected in the topic guide. The topic guide for the police focus group covered issues concerning their perception of the impact of crack on crime in Norfolk. Participants were asked to make a comparison between Norwich, Great Yarmouth and other areas in the county. Their views about links between crack use and specific groups such as young people, different ethnic groups
, and sex workers were explored. Participants were asked their views on the relationship of crack to gang culture, access to firearms, crack houses and violence. The effects of crack use on the behaviour of people in custody were also explored. Opinions were sought on what characteristics participants felt a crack/cocaine treatment service should encompass and what services they considered to be effective. 23
b) The Crack User Groups Individual groups were held in Norwich for younger (25 and under) current and excrack users, and older current and ex-crack users. One women only group was also held for sex workers. One group was held in Great Yarmouth. Groups consisted of between 2 and 11 members. For ethical reasons it was decided not to mix current crack users with ex-crack users. Where this could not be avoided it was made clear to the ex-crack users that current users may be in the group. c) The Premises In both Norwich and Great Yarmouth the groups were held in neutral premises central to the city or town, away from the location of treatment services (NHS clinics). Rooms were furnished with comfortable chairs and a central table for the tape recorders. Tea, coffee and cold drinks were available for participants. d) Equipment and data security Recordings were made with a main tape recorder with a separate microphone (Panasonic Slim Line RQ-2102), and a back up recording was made using an additional recorder (Sanyo TALK-BOOK VAS). Each tape recorder was tested prior to the session. Tapes were stored securely in a locked cabinet at the School of Medicine, Health Policy and Practice at the University of East Anglia prior to transcription. e) Focus Group Facilitation Facilitation of groups was shared between Vivienne Maskrey, Project Co-ordinator and Richard Holland. Vivienne Maskrey was assisted on two occasions by Annie Blyth, Research Associate, UEA, on one occasion by Roberto Vivancos, and on one occasion by Laura Neave, Project Secretary. Richard Holland was assisted twice by Vivienne Maskrey and once by Roberto Vivancos. f) The Groups On arrival the participants were introduced to the facilitators and invited to spend some time reading the information sheet about the group. After a suitable wait for late comers the groups commenced. The facilitator explained the purpose of the group, who it was funded by, and some ground rules (e.g. speaking clearly, and not interrupting or speaking over other participants). The facilitator sought consent from participants to tape record the session. Participants were asked to treat all that was said in the group as confidential, and were assured that individuals would not be identified in the report in any way. However, it was made clear that participants' comments may be quoted in a non- identifying way. All were informed that the tapes, once transcribed, would be destroyed. After a pause for any questions the tape recorders were switched on. Themes in the topic guide were explored, and individuals were asked to expand on any points they raised where this was thought relevant. The discussion was stopped when saturation in the topics was achieved and no new themes or issues seemed to appear. The focus groups lasted between 90 and 110 minutes with a break for participants halfway through. 24
g) Transcription Tapes were transcribed either at the University of East Anglia by secretarial staff within the Populatio n Health Group or externally by a professional transcriber. In this case an appropriate confidentiality agreement was drawn up h) Safety Issues It was planned that substance misusers who appeared to be demonstrably under the influence of a substance on arrival at the group would be asked not to attend. This did not occur. Participants were asked not to smoke on the premises, and a break half way through allowed smokers to smoke outside. Two facilitators ran all the groups, and phoned to UEA to report the successful and safe completion of each group. i) Honorarium In Norwich each participant was given an honorarium of 20 x Ј1 TESCO vouchers and in Great Yarmouth a Ј20 ASDA voucher in recognition of the time given up to take part. The stores were chosen for the ir ease of access from the city/town centre by participants and in consultation with service providers. The policy governing the use of the vouchers in each store ensured that they could not be exchanged for cash. A consent form (Appendix 4) for participation in the group also acted as the receipt for the vouchers. Participants were advised that, for confidentiality reasons, signing their first name and detailing their age and sex were perfectly sufficient, and were assured that these forms would be destroyed on completion of the study. 25
8. Analysis Capture - re-capture Capture-recapture techniques were applied to the data sources to estimate the total population with problem drug use in Norfolk.18 First lists were combined in pairs using the Chapman estimator, to estimate the total number of cases (N). The total number of cases is calculated from two sources, according to the formula: - N = (n1 + 1). (n2 + 1) - 1 (n12 + 1) Where n1 is the number of cases identified by a source, n2 is the number of cases identified by another source; and n12 is the number of cases identified by both the sources. The variance can be estimated using a formula derived by Seber: Var (N) = (n1+ 1)*(n2 + 1) *(n1 n12)*(n2 n12) ( n12 + 1) 2( n12 + 2) Subsequently, the 95% confidence interval can then be calculated as: N ± 1.96 Var (N) Two sample estimators must satisfy two key assumptions: · The data sources are independent · For a given source each case is equally likely to be listed by that source The first assumption is almost never appropriate within epidemiological studies estimating disease prevalence
in human populations. Frequently patients appearing in one source are likely to then appear in another source. This positive dependence leads to an under-estimate of the total population. Equally, in some cases appearance in one source makes it less likely for a person to appear in another source. Where there is negative dependence this will lead to an over-estimate of the total population. The second assumption requires that each individual has the same probability of appearing in all sources. However, frequently this varies by age and sex and possibly by other covariates. To adjust the biased estimates obtained by the simple two-sample estimation technique described, Poisson regression modelling (in STATA version 8.0) was used. This gives estimates of the total number of missing cases, i.e. those cases not appearing on any of the four lists for both sets of data. The most parsimonious models that fitted the data well were used, with these decisions based on the deviance statistic and the Akaike Information Criteria, according to the number of degrees of 26
freedom in the relevant models. To overcome the problem of possible over- or underestimation, from positive and negative dependency of the data sources, two and three way interaction terms were included in the model. Box 2 Statistical note on log-linear modelling for capture-recapture Two approaches were considered once the models had been fitted to assess the number of missing cases. Firstly, the constant (corner) parameter term was exponentiated to give an estimate, and the 95% confidence interval obtained directly by exponentiating terms from the model. Secondly, an odds ratio approach was used whereby the estimated number of missing cases can be derived from the expected values given by the model, thus: - Z0000 = Z1000 Z0100 Z0010 Z0001 Z1110 Z1101 Z1011 Z0111 Z1111 Z1100 Z1010 Z1001Z0011 Z0101 Z0110 The expected values for Z1000, Z0100 etc are obtained from the appropriate model with a combination of the following terms: Log E (Zijkl) = u + u1 (i=1) + u2(j=1) + u3(k=1) + u4(i=1) + u12 (i=j=1)+ u13(i=k=1) + u14(i=l=1) + u23(j=k=1) + u24(j=l=1) + u34 (k=l=1) + u123 (i=j=k=1) + u134 (i=k=l=1) + u124 (i=j=l=1) + u234(j=k=l=1) In this model there is assumed to be no 4-way interaction, i.e. u1234 = 0. Finally, the estimates for the total number can be obtained by the following: - N = n + Z0000 Where n is the number of cases identified and Z0000 the estimated number of missing cases. Having estimated the number of problem drug users for Norfolk, estimates of the proportion of those dependent on crack/cocaine have been applied so as to estimate the size of the crack/cocaine using population in Norfolk. 27
Questionnaire survey - sample size The population of Norfolk is 796,733. National estimates suggest that 0.5% of the population are problem drugs users (i.e. approximately 4,000). If the estimated proportion of problem drug users whose main drug is crack is 6% (Drug treatment monitoring unit estimate), then to estimate this proportion within +/- 2% needed a minimum sample size of 480 completed questionnaires. It is probable that the prevalence of crack/cocaine use amongst the prison population is higher than in drug users attending the treatment services, however this is not known with any certainty. The remand (i.e. unconvicted) population and young offenders will have been in prison for a relatively short period of time (under 6months). Surveying this population is thus likely to provide an upper estimate for the prevalence of crack /cocaine use amongst problem drug users in Norfolk. Questionnaire survey analysis a) Assessment of drug dependence To determine the proportion of respondents dependent on a given drug, the questionnaire included five screening questions developed by the Office for National Statistics (ONS). Box 3 below describes this technique. Box 3 Office for National Statistics (ONS) drug dependence questions Each question refers to the last month (for those in treatment we asked them to record their behaviour before they entered treatment): (a) Did you use the drug every day for 2 weeks or more? (b) Did you feel you needed or were dependent on this drug? (You felt you couldn't get by without it?) (c) Did you try to cut down but found you couldn't? (d) Did you find you couldn't get high on the amount you used to use? (e) Did you have withdrawal symptoms such as feeling sick because you stopped or cut down? Those who answered "YES" to one or more questions were considered to have some/moderate level of drug dependence (two or more for cannabis). Those who answered "YES" to three or more of these questions were considered to have severe drug dependence. (These cut-offs had been defined by the ONS). 28
b) Assessment of alcohol dependence The questionnaire also included the three questions from the brief-AUDIT (Alcohol Use Disorders Identification Test) screening tool. Box 4 describes this tool. Box 4 Brief AUDIT questionnaire (to assess alcohol dependence) 1. How often do you have a drink containing alcohol Options: never (0), monthly or less (1) 2-4 times per month (2), 2-3 times per week (3), 4 or more times per week (4) 2. How many drinks containing alcohol do you have on a typical day when you are drinking? Options: 1 or 2 (0), 3 or 4 (1), 5 or 6 (2), 7 to 9 (3), 10 or more (4) 3. How often do you have six or more drinks on one occasion? Options: Never (0), less than monthly (1), monthly (2), weekly (3), daily or almost daily (4) Scoring: 0-4 = normal, 5+ = problem drinking c) Primary analyses conducted The following primary analyses were undertaken on survey data: · Proportion of respondents reporting moderate or severe dependence on any drug · Proportion of respondents reporting problem drinking · The proportion of respondents reporting moderate or severe crack/cocaine dependence according to: Ш nearest town Ш whether they are a new or current client Ш whether they are a client of a clinical treatment agency able to prescribe medication. (For the purposes of the latter comparison the following were considered as a treatment agency: the Bure Centre, NR5, Tier 3, WSDAS Thetford, CADS King's Lynn and NORCAS Gt. Yarmouth). · An analysis of possible risk factor
s associated with severe crack/cocaine dependence was conducted. The following risk factors were considered: Ш Age Ш Sex Ш Nearest town Ш Lives in own home Ш Ethnic minority 29
Ш Employed Ш Registration with a GP Ш Prostitution (sex for money, drugs or favours) Ш Injecting drug use and sharing injecting equipment Ш Numbers of drugs used · A multi-variate analysis was then conducted entering those factors identified in the above univariate analysis to determine which factors are independently predictive of severe crack/cocaine use after adjustment for other factors. A similar analysis was undertaken for results from the prisoner survey. However, certain risk factors collected from the community sample were not collected from prisoners (e.g. prostitution and registration with a GP). Furthermore, certain data were collected in a different format: prisoners were asked whether they were homeless (rather than detailing the type of accommodation) and prisoners were also simply asked to identify their county of origin, not their town (to maintain anonymity). 30
Norfolk & Norwich Urine test results Figure 1 below shows the number of urine tests conducted by the Norfolk and Norwich Hospital Biochemistry laboratory over the last five years and the proportio n of these urine samples that are found to contain cocaine metabolites. The vast majority (over 90%) of these tests are samples from clients of the Bure Centre in Norwich. It is clear that there has been a substantial growth (threefold increase) in numbers of urine tests conducted in this time period. This almost certainly reflects changes in professional practice and a growth in the client numbers attending the Bure Centre. However, the proportion found to contain cocaine metabolites has increased markedly in this period (from 2% to over 15%). Interpretation of these data alone is difficult as they refer to urine specimens not individuals. Thus, it is possible that those individuals who use crack or cocaine are tested more frequently than non-crack users. Nonetheless these data suggest a marked growth in crack/cocaine use amongst Bure Centre clients.
Number of urine tests performed
Figure 1 Graph showing number of urine screens performed at N&N biochemistry laboratory and number (and proportion, as bars) found to be positive for crack/cocaine
% urine tests positive for crack/cocaine
25 20 15 10 5 0 2002-03
% cocaine positive Total cocaine positive Total drug screens
Dr Chris Dawson (Consultant Biochemist) conducted a review of all urine results from those individuals found to have one or more cocaine positive urine tests. This reviewed data for the 12- month period 1/12/01 to 31/11/02. 30% of those found to have cocaine positive urines were female. These individuals' concomitant drug use is shown in figure 2, and indicates that not only did 90% have opiate positive urines, but many other drugs were also used. In particular, benzodiazepines and cannabis were used by 75% of these individuals. 64% were taking methadone, and 3% buprenorphine. On average, these individuals used 4.4 different drugs (range 1-7).
% Other drugs present in urine from cocaine positive clients
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
amphetamine Drug type
Background data (1/4/02 30/9/03) Data were successfully collected from police, probation, the arrest-referral scheme and specialist drug treatment services. The age and sex characteristics of each of these datasets is described in table 6 below, and the overall age distribution of the combined drug-related data is shown in figure 3 (this figure excludes police data relating to acquisitive crime which includes individuals who may or may not be a problem drug user). Table 6 Age/sex distribution of all individuals in each dataset (including those with non-Norfolk postcodes)
Drug agency clients
Number in dataset 1271
Mean age (median) 31.8 (31.2)
Police drug related offences
Police acquisitive crime offences
Probation known drug problems
Arrest referral drug problems
Age / sex characteristics of individuals identified from the datasets above (excluding police acquisitive crime) after all duplicates had been removed.
Figure 3 Age distribution of known problem drug users in Norfolk 200
50 0 14 18 22 26 30 34 38 42 46 50 54 58 62 66 Age
Prevalence estimates are shown in table 7 below. The estimates are based solely on known problem drug users (i.e. users in contact with any of the four types of agencies described above) and exclude duplicate records.
Table 7 Table showing age/sex distribution and prevalence of all known problem drug users in Norfolk for 6-month period 1/4/02-30/9/02
Age group 10-14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 +
female unknown Grand Total Norfolk male Norfolk
b) Treatment drug services and Arrest Referral Services record of main drug used: Each treatment service and the Arrest Referral Service (ARS) indicated in their data a main drug for each individual. Data refer to the period 1/4/02 to 30/9/02, as it does for the capture-recapture analysis. Figure 4 below shows that heroin/opiate drugs are very clearly the main focus for treatment agencies. Treatment services reported that for 1077 clients (84%) the main drug was heroin or other opiates. Crack/cocaine was only reported as the main drug for 26 (2.2%) of clients. The pattern of main drug use for the Arrest Referral Service (ARS) appeared to be different to that reported by treatment agencies. For the ARS heroin or opiates was reported as the main drug in 117 of their 235 clients (50%), whilst alcohol was also important, recorded as the main drug for 48 (20%) of clients. Crack/cocaine was identified as the main drug for 13 clients (5.5%). The difference of 3.3% in the proportion of crack/cocaine users identified by the treatment services as compared to the ARS is statistically significantly different (95% Confidence Interval from 1% to 7%).
Proportion of clients
Main drug as reported by clinical treatment services and the Arrest Referral Service
Alcohol Amphetamine* Benzodiazepine Cannabis Crack/cocaine Heroin and
Clincial treatment services Arrest referral service
a) Finding informative duplicate records within the capture-recapture datasets
As described in the methods, duplicate records were sought within two final datasets. The first (D-Set) consisted of police drug-related crime data plus treatment agency, arrest referral and probation data. The second (A&D set) consisted of police drugrelated and acquisitive crime data, plus treatment agency, arrest referral and probation data. Duplicate records were sought using the criteria described in the Methods sections. The numbers of duplicates found is shown in table 8 below, and a breakdown of one unit data errors contributing to matches is given in table 9.
Table 8 Duplicate records found in datasets used for the capture -recapture analyses
D-set (i.e. police drug-related crime, treatment agency, arrest referral, probation )
A&D set (i.e. police drug-related crime, treatment agency, arrest referral, probation)
(first initial, soundex coded surname, date of birth, sex)
Fuzzy match (allowing one unit data errors)
(where more than two records appeared duplicate and
both medium and fuzzy matches were involved)
Table 9 Probable one unit data entry errors in D-dataset and A&D datasets Norfolk-plus
No. probable one unit errors in D-dataset
No. probable one unit errors in A&D-dataset
Date of birth (e.g. 14/05/68 and 16/05/68 or transposition 07/05/72 and 05/07/72) [note: data otherwise identical for first initial, soundex code and sex]
Sex errors [note: data otherwise identical for first initia l, soundex code & date of birth]
First initial errors [note: data otherwise identical for soundex code, date of birth and sex]
Soundex numerical errors [note: data identical for first initial, surname initial, date of birth & sex]
Total probable errors
*NB: totals not equivalent to sum of rows as some records (1 in D set & 4 in A&D set) involved in multiple exact/fuzzy matches.
Capture-re-capture matches: Table 10 Individuals matched across the four different datasets:
Total matches in D-set using medium matching criteria and allowing for one unit data entry errors
Total matches in A&D set using medium matching criteria & allowing for one unit data entry errors
Police Agency Probation ARS
Police Agency Probation
Police Agency ARS
Police Probation ARS
Agency Probation ARS
Problem drug users unknown to all agencies
*for these individuals no duplicates were found ** with postcode adjustment described in Box 5 below *** with postcode adjustment and adjustment for proportion of acquisitive crime that is not drug-related.
(This box can be ignored without loss of continuity)
Box 5 Derivation of values to enter into cell 15 i.e. unmatched police records
Cell 15 needed two forms of adjustment: (1) adjustment for non-Norfolk postcodes (this affects both D set and A&D sets). (2) in the case of the A&D set adjustment was also needed for acquisitive crimes that were not drug-related.
1) Postcode adjustment As noted in table 5a (page 19) over 50% of records in the police datasets lacked postcodes. Of those with postcodes, 14% of individuals identified on police records appeared to live outside Norfolk. Thus, it was decided to adjust cell 15 (unmatched police records) to take account of possible non-Norfolk individuals with no postcode:
a) Total number of police individuals in D dataset with no postcode ? Assume 14% of these live outside Norfolk
= 223 = 223 x 0.14 = 31
b) Total number of police individuals in A&D dataset with no postcode ? Assume that 14% of these live outside Norfolk
= 1516 = 1516 x 0.14 = 212
(In all other datasets less than 5% of individual records lacked postcodes so no adjustments were made).
2) Acquisitive crime adjustment Only a proportion of acquisitive crime is related to drug dependence. National estimates vary by area from 36% to 66%.20 Advice from Police colleagues suggested we should assume that between 40% and 60% of acquisitive crime in Norfolk is related to drug dependence.
a) Total number of individuals in Acquisitive crime dataset with Norfolk postcode no postcode, or matching an individual with a Norfolk postcode 40% of figure A
= 2275 (figure A) = 910 (figure B)
b) Total number of individuals in Acquisitive crime dataset with a match (i.e. very likely to be drug-related crimes)
= 481 (figure C)
c) Number of unmatched individuals in Acquisitive crime set likely to be drug dependent
= 910 481 = 429 (figure D)
ALSO note number of unmatched individuals in police drug-related crime set
= 292 (figure E)
3) Calculation of Cell 15
a) For D-dataset only the adjustment for postcode is needed: Cell 15 = E X = 292 31 = 261
b) For A&D dataset need to make thepostcode adjustment and non-drug-related acquisitive crime adjustment:
= unmatched individuals in D-set (E) + unmatched individuals in A set adjusted for non-drug related Acquisitive crime (D) - police data with no postcode assumed to be living outside Norfolk (Y).
? Cell 15
= figure E + figure D figure Y = 292 + 429 212 = 509 (assuming 40% of acquisitive crime is drug-related)
If 60% of crime is drug related cell 15 = figure E + 0.6 x figure A figure C figure Y = 292 + [(0.6 x 2275) -481] 212 = 965
b) Chapman estimates
Chapman estimates were calculated according to the formula given in the methods section, page 26. The results are given in Table 11 for the D-dataset matched according to the medium criteria allowing for one unit errors ("fuzzy matched") and making the postcode adjustment described in Box 5, above. Results are also given for the A& D dataset following similar rules and assuming 40% of acquisitive crime is drug related. These Chapman estimates lie between 1,500 and 7,000. The mean of these estimates is 3732. If no adjustment is made for records with no postcode which may represent individuals living outside Norfolk the mean Chapman estimate increases to 3873.
As described in the methods these calculations assume that each dataset is independent of another (e.g. Police and Probation). In this case there are likely to be reasons for individuals appearing in more than one set i.e. the sets are not independent. Hence the need for further statistical modelling described below.
Table 11 Chapman estimates from both datasets
Source Police / Agency Police / Probation Police / ARS Probation / Agency Probation / ARS Agency / ARS
Estimate from D-dataset using medium matching & allowing one unit errors 7043 3270 2025 3636 4950 4989
Estimate from A&D dataset using medium matching & allowing for one unit errors 4899 1815 1535 3712 1810 5096
c) Results of statistical modelling The research team considered the data provided by the medium match, allowing for one unit data errors (so-called "fuzzy matching") to most accurately represent numbers of individuals found in one or more agency set. The most conservative estimate is then provided by adjusting for postcodes (as described in Box 2) and using the D-dataset. The model based on this is described below: Log E (Zijkl) = 8.74 3.17 (police = 1) 1.79 (agencies = 1) 3.33 (probation = 1) 3.94 (ars = 1) + 0.83 (police = 1 & probation = 1) +1.45 (police = 1 & ars = 1) +1.11 (probation = 1 & agencies = 1) +1.69 (probation = 1 & ars = 1)
This yielded a missing cell estimate of 6,266, 95% C.I. (4728 to 8304)
The model included four 2-way interactions, all indicating positive dependence as follows:
· police and probation · police and Arrest Referral · probation and treatment agencies · Probation and Arrest Referral
Note: positive dependence implies that individuals appearing in one agency are more likely to also appear in the other agency (e.g. police and probation). Negative dependence implies that individuals appearing in one agency are less likely to also appear in the other agency (in this case no such negative dependence was found).
This model appears to fit the data reasonably well. Table 12 shows the observed values and the apparent values from the fitted model. The two sets of va lues appear very consistent; suggesting the estimated value for the unknown cell is reasonably accurate.
Table 12 Comparison of duplicates found within D-dataset medium matching & allowing for one unit errors and values generated by the final model
Cell no. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Records matching across the following agencies Police Agency Probation ARS Police Agency Probation Police Agency ARS Police Probation ARS Agency Probation ARS Police Agency Police ARS Police Probation Agency Probation Probation ARS Agency ARS Agency Probation ARS Police Unknown
Count (Observed Values) 5 17 5 8 21 41 26 19 105 24 29 1045 227 119 261 ? ?
Fitted Values (from statistical model) 7 11 5 10 18 44 22 22 112 23 30 1041 223 123 262 6266 8218
Total number of problem drug users in Norfolk is therefore estimated as: =Total in unknown cell + all known problem drug users = 6266 + 1952 = 8,218 (95% C.I. from 6,680 to 10,256)
· Norfolk prevalence between ages 15-54 = 8,218/ 404371 = 2.02% (1.65% to 2.53%)
d) Sensitivity analysis A sensitivity analysis was undertaken to assess the variation in the estimate of the unknown cell (i.e. cell 16 of table 12). This is the number of problem drug users unknown to treatment agencies, probation, arrest referral or police.
The following were assessed:
D-set (1) (2) (3) (4) (5)
D-set results with postcode adjustment D-set results without postcode adjustment D-set results with no fuzzy matching D-set results only using individuals with Norfolk postcodes D-set results using all data (irrespective of postcode)
A&D set assuming 40% acquisitive crime is drug related
A&D-set results with postcode adjustment
A&D-set results without postcode adjustment
A&D-set results with no fuzzy matching
A&D-set results only using individuals with Norfolk postcodes
A&D-set results using all data (irrespective of postcode)
A&D set assuming 60% acquisitive crime is drug related
A&D-set results with postcode adjustment
A&D-set results without postcode adjustment
A&D-set results with no fuzzy matching
A&D-set results only using individuals with Norfolk postcodes
A&D-set results using all data (irrespective of postcode)
Table 12a below describes the results of these sensitivity analyses. These results demonstrate that estimates provided by the combined acquisitive crime and drug dataset are considerably larger than those estimated solely using police drug dependent data. However, it should be noted that the estimate made assuming that 40% of acquisitive crime is drug related and adjusting for non-Norfolk postcodes yielded a missing cell value of 11,583. Though, higher than estimates based on the Dset, the 95% confidence interval overlapped the confidence intervals around many of the D-set estimates.
Table 12a Sensitivity analysis on estimate of problem drug users unknown to services and overall total
Estimate of number of problem drug users unknown to services
95% C.I. for estimate
Overall total problem drug users in Norfolk
1) BASELINE ESTIMATE (includes postcode adjustment)
2) without postcode adjustment 3) with no fuzzy matching 4) only using individuals with Norfolk postcodes or no postcode 5) results using all data (irrespective of postcode) 6) postcode adjustment
6,879 8,119 6,847 7,949 11,583
5,207 9,088 6,268 10,516 5,168 9,072 6,005 10,521 7,464 17,973
8862 10,175 8,820 10,002 13,7 99
A&D assuming 40% acquisitive crime is drugrelated
7) without postcode adjustment 8) with no fuzzy matching 9) only using individuals with Norfolk postcodes or no postcodes 10) using all data (irrespective of postcode)
11) with postcode adjustment
A&D assuming 60% acquisitive crime is drugrelated
12) without postcode adjustment 13) with no fuzzy matching 14) only using individuals with Norfolk postcodes or no postcode 15) using all data (irrespective of postcode)
* calculations yet to be performed
14,754 * * * 19,460 22,937 * * *
9,461 23,009 * * * 12,466 30,376 14,686 35,823 * * *
17,182 * * * 22,132 25,821 * * *
Questionnaire survey results community sample
a) response rates
Table 13 reports the response rates from different sources. Response rates are reported in two ways. Firstly, response rate as reported by each agency (i.e. proportion of clients asked to complete survey who returned a completed survey). Secondly, the response rate is reported in terms of returned completed questionnaires as a proportion of the number of questionnaires distributed to each agency. Table 13 Questionnaire response rates from different agencies
Site Clinical Services Bure/Colegate Norwich Contact NR5 CADS Kings Lynn NORCAS Gt. Yarmouth Thetford Tier 3 Voluntary Sector Mancroft Advice Project Arrest Referral Scheme Matthew Project MATRIX Project
Survey time period (weeks)
Response rate Via Agency report
Response rate Via Returned Supplies
Not available Not available
Not available Not available
100% 86% 100% 100%
100% Not available Not available 100%
b) Background demography of respondents: -community sample
Table 14 below shows the demography of survey respondents. The majority (77%) of respondents lived close to either Norwich or Great Yarmouth, 73% were male and their mean age was 29.3 years. Almost all respondents were white, with only 6% from other ethnic groups. This is a greater proportion than expected for Norfolk, where only 1.5% of the population is from ethnic minorities.21
Table 14 Background demography of survey respondents
All respondents (n=306) NB proportions are of those responding to each question
Mean Age (median) Age range (Interquartile range) Standard deviation
29.9 (29) 15 55 (24-35) 8.0
White 94% Black 1% Mixed 4% Other 1%
% registered with GP Home address Nearest town (Note proportions of responses do not relate to overall proportion of drug use by town. Instead it reflects extent of survey activity in each treatment centre. In particular extra survey work was performed in Gt. Yarmouth as part of a Gt. Yarmouth drug needs assessment).
Night Shelter 1%
No fixed address 12%
Great Yarmouth 43%
King's Lynn 9%
Table 15 below describes the demography of respondents from different sources. Due to the small numbers of respondents from certain sources, no formal analysis of differences has been undertaken. However, it is interesting to note the variation in proportion living in own home (from 33% to 91%) with highest proportions for treatment agency clients in Norwich and King's Lynn. In contrast, low rates of own home occupancy were found in clients of voluntary agencies, and clients from Great Yarmouth and Thetford. Unemployment was very prevalent (mean %employed was 10%) and the worst affected were clients in Great Yarmouth and Thetford.
Table 15 Demography of respondents with each treatment agency
Total Mean age % male responses
%living in %GP
employed own home registered
80% Not asked
c) Main drug reported
This question was omitted by 98 (32%) of respondents. Table 16 belo w shows the responses of those who completed this question. (Note: 23 respondents gave two main drugs, and one respondent three main drugs). Heroin was clearly the most commonly used main drug, reported by 84% of respondents. Crack/cocaine was reported as main drug by 17 (8%) of respondents to this question. It should be noted that 10 of these 17 respondents reported this in combination with heroin.
Table 16 Main drug as recorded by respondents
Heroin Cannabis Crack/cocaine Methadone Speed/amphetamines Benzodiazepines Dihydrocodeine Diconal Alcohol
Main drug / drugs (n=178) 174 (84%) 18 (9%) 17 (8%) 4 (2%) 4 (2%) 3 (1%) 2 (1%) 1 (0.5%) 8 (4%)
d) Number of drugs used Figure 5 below show the number of drugs used by respondents over the last month (if yet to start treatment) or reported use by current clients before they entered treatment. The median number of drugs used was three (mean = 3.8).
Figure 5 Number of drugs used before entering treatment
Number of drugs used*
*For new clients this referred to use in previous month, for current clients this referred to use prior to treatment
e) All drugs used Figure 6 shows the different drugs used by respondents. It is clear that whilst heroin is the most commonly used drug (almost 90% of respondents used this drug before treatment or currently), crack or cocaine has been used by over 60% of respondents (95% confidence interval 57%-68%). Cannabis (71%) and benzodiazepines (54%) are also frequently used. Figure 6 % respondents using drug before treatment or currently
f) Drug dependence The pattern of respondents' dependence on drugs is of far greater importance than the data on the pattern of use of drugs alone. Figure 7 below shows the proportion of clients moderately or severely dependent on different drugs according to their responses to the five screening questions described in the methods section. This reveals that heroin is again the major drug of dependence in those presenting to the agencies surveyed (moderate or severe dependence in 80% of respondents). However, some crack/cocaine dependence was evident in 31% of respondents (95% C.I. 26%-37%), and this was severe in 12% (95% C.I. 9% to 17%). Figure 7
%respondents moderately or severely dependent on different drugs
50 severe dependence 40 moderate dependence 30
The numbers of individuals with one or more positive responses to the five questions concerning crack/cocaine use are shown in figure 8. Figure 8
Respondents crack/cocaine dependence scores no dependence 70
Crack/cocaine dependence score
Whilst the majority of those dependent on crack/cocaine used crack, some also reported use of cocaine. The overlap between severe dependence on crack and cocaine is indicated in figure 9 below:
Figure 9 Venn diagram of individuals severely addicted to either crack or cocaine or both
g) Demographic data on survey respondents who indicated moderate or severe dependence on crack/cocaine.
Table 17 shows the numbers of individuals severely or moderately dependent on crack by closest town. Estimates for Swaffham and Cromer are based on very small numbers and should be treated with caution (this is reflected in their very wide confidence intervals). However, elsewhere the proportion severely dependent varies between 7% and 16%, with the greatest proportion for Norwich. Moderate dependence varied between 13% and 22%, again being greatest for Norwich.
Table 17 Proportion of crack/cocaine dependent individuals amongst respondents grouped by their closest town
Norwich (n=120) Great Yarmouth (n=100) King's Lynn (n=27) Thetford (n=15) Swaffham (n=7) Cromer (n=2)
Number (%) severely
2 (7%) 1 (7%)
5 (19%) 2 (13%)
Proportion moderately or severely dependent on crack/cocaine (95% confidence interval) 38% (29% to 47%) 27% (20% to 36%) 26% (11% to 46%) 20% (4% to 48%) 43% (10% to 82%) 50% (1% to 99%)
Table 18 shows very little difference between the crack use of new or current clients. In both cases approximately 12% appear to be severely dependent on crack/cocaine and a further 16-21% moderately dependent.
Table 18 Proportion of crack/cocaine dependent individuals amongst new and current clients
New patients (n=96) Current patients (n=177)
Number (%) severely
Proportion moderately or severely dependent on crack/cocaine (95% confidence interval) 28% (20% to 38%)
33% (26% to 40%)
Table 19 similarly shows that the proportion of crack dependent clients does not vary between those attending clinical treatment services (able to prescribe drugs) and those attending other agencies:
Table 19 Proportion of crack/cocaine dependent individuals amongst clinical treatment service clients vs. other agencies
Clinical treatment services (n=249) Other agencies (n=56)
Number (%) severely
Proportion moderately or severely dependent on crack/cocaine (95% confidence interval) 32% (26% to 38%)
29% (17% to 42%)
h) Use of other drugs by those severely dependent on crack/cocaine
Those severely dependent on crack/cocaine use a mean of five drugs, as compared to those not severely dependent who use a mean of 3.5 drugs (p<0.001, using the Mann Whitney test). Figure 10 explores the use of other drugs by those severely dependent on crack/cocaine and shows that 90% of these clients are also severely dependent on heroin and 48% are severely dependent on benzodiazepines.
%those severely dependent on crack/cocaine
Other drug use in those severely dependent on crack/cocaine
100 90 80 70 60 50 40 30 20 10 0 cannabis
severe dependence moderate dependence
i) Association between crack/cocaine dependence and other survey data Table 20 examines the relationship between severe crack/cocaine dependence and a variety of possible risk factors. Whereas 40% of those severely dependent on crack cocaine were female, only 26% of all other respondents were female. Those severely dependent on crack/cocaine appeared marginally younger, and were more often unemployed. However, none of these differences between those severely dependent on crack cocaine and all other respondents were statistically significant. Whilst a higher proportion of those severely dependent on crack lived in Norwich, it should be noted that in our sample 14 (42%) of those severely dependent on crack/cocaine lived outside Norwich, particularly in Great Yarmouth (where nine lived). Those severely dependent on crack were statistically more likely to be from an ethnic minority, not to live in their own home, to have exchanged sex for money, drugs or favours, or to be severely addicted to heroin, speed, benzodiazepines and cannabis when compared to all other respondents. As noted in section (h) above, these clients also use more drugs (a mean of 5 drugs versus a mean of 3.5 drugs). j) Multivariate analysis A multivariate analysis was conducted using logistic regression (STATA Version 8.0). Variables identified as being significant (p<0.05) during the above univariate analysis were entered into a model. The final model suggested the following variables were independently associated with severe crack/cocaine dependence: · High number (greater than four drugs used) compared to low number (two or less) of drugs used (odds ratio = 7.9, 95% C.I. 2.2 to 28.7, p<0.002) · Prostitution (odds ratio = 2.8, 95% C.I. 1.2 to 6.7, p=0.019) · Ethnic minority (odds ratio = 5.3, 95% C.I. 1.6 to 18.0, p=0.007) 51
Table 20 Demographic, behavioural and drug associations of those severely dependent on crack/cocaine in the community sample
Severe dependence on crack/cocaine (n=38, though this may be less in certain rows due to respondents omitting certain question s)
Not severely dependent on crack/cocaine i.e. all other respondents (n=267)
p-value comparing severe crack/cocaine dependent users with all other respondents (chi-squared test, except where indicated)
Mean age= 28.4
p=0.21 using t-test
% female = 36%
%female = 27%
Treatment agency respondent
Living in own home
Not registered with a GP
Sex for money, drugs or favours
Injected drugs in last month
Shared injecting equipment
Severely dependent on heroin
Severely dependent on methadone
Severely dependent on speed etc
Severely dependent on benzo's
Severely dependent on cannabis
Severely dependent on solvents
Number of drugs
Mean= 3.6 (median=3)
p<0.001 (Mann Whitney test)
Prisoner survey results a) Response rates There was an overall response rate to the survey of 61% (n=232) of an average prison occupancy of 380 men. The response rate in the Adult Wing was 61.4% (n=143) and the Young Offenders Institution 60.8% (n=89). Overall 11 respondents (5%) indicated that they had had help to complete the questionnaire, 3 (3%) from the YOI and 8 (6%) from the A Wing.
b) Background demography of prison survey respondents (table 21)
Of the 232 respondents, 66% of respondents were convicted, 34% were on remand. Three quarters came from East Anglia, with 41% (n=94) from Norfolk. The majority of respondents had been in Norwich prison for less than 3 months and were generally young (almost 70% were under 30 years). Only 77% were white very different from the proportion in the Eastern region where 96.5% are white. 43% were either employed or self-employed, which is considerably higher than the proportion employed/self employed amongst drug treatment agency respondents (13%). The proportion homeless (17%), was similar to the proportion amongst drug agency respondents (13%).
Table 21 Background demography of prison survey respondents
All respondents, n =232
Length of time in prison (not recorded =11) Age ranges of respondents (not recorded = 1) Ethnic Group (not recorded = 4) Employment (not recorded = 7)
0 to 3 months 3 to 6 months 6 to 12 months Over a year 18 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 and over White Black Asian Mixed Other Employed Self employed Student Retired Unemployed
112 (51%) 57 (26%) 25 (11%) 27 (12%) 42 (18%) 69 (30%) 46 (20%) 32 (14%) 20 (9%) 22 (10%) 175 (77%) 21 (9%) 12 (5%) 12 (5%) 8 (4%) 55 (24%) 42 (19%) 7 (3%) 6 (3%) 115 (51%)
Homeless before coming to prison (not recorded = 11)
Number of respondents
80 70 60 50 40 30 20 10 0 18 to 19
Age distribution of respondents to prison survey n=232
20 to 24
25 to 29
30 to 34 Age groups
35 to 39
40 and over
Demographic characteristics such as ethnicity, employment, length of time in prison, were similar across the respondents from the Adult wing and Young Offenders' Institution. Though more of the young offenders had been convicted 78% (n=69) compared to 55% (n=79) of the adults, and more of the adults were homeless before coming to prison 20% (n=29) compared to 9% (n=8) of the young offenders. Respondents from Norfolk were predominantly white (95%) in line with the results of the survey conducted with treatment/voluntary agency clients. Homelessness and unemployment both appeared more common amongst inmates from East Anglia (table 22) than amongst those from outside the region.
Table 22 Background demography: Norfolk residents compared to non-Norfolk residents
Other East Anglia 78
% convicted 64% 59% 67%
%white 95% 82% 33%
% unemployed 55% 54% 33%
% homeless 17% 19% 10%
c) Drug Use
77% of respondents had used drugs either outside or inside prison (95% CI 71%82%). Previous drug use was more common amongst young offenders (89%) compared to adults (70%). Overall the proportion of respondents who had used drugs was high in all groups under the age of 40, particularly in the group 20 to 24 years where 93% had used drugs. In contrast, in those aged 40 and over only 23% had used drugs.
Table 23 Proportion of respondents in each age group who have used drugs
18 to 19 20 to 24 25 to 29 30 to 34 35 to 39 40 and over
n (%) 35 (83%) 64 (93%) 35 (78%) 25 (78%) 13 (65%) 5 (23%)
d) Main drug reported
Of those that reported drug use, 67% of respondents omitted this item. The responses of the 59 (33%) who did complete this are reported below (note 12 respondents gave two main drugs and 7 gave three). Table 24 Main drug as recorded by respondents
Cannabis Cocaine Crack Ecstasy Heroin Opiates Speed/amphetamines Benzodiazepines Alcohol
Main drug/drugs n= 85 25% 6% 22% 7% 25% 1% 1% 2% 9%
e) Number of drugs used
The chart below shows the number of drugs used by respondents in the last month before coming into prison. The median number of drugs used was 4 (mean 4.1)
Number of different drugs used in the month before entering prison 18%
Number of drugs used
f) All drugs used Cannabis was the most commonly used drug by respondents in the month before entering prison 91% (n=155), followed by crack 60% (103), heroin 53% (n=91), cocaine 52% (n=98) and Benzodiazepines 50% (n=85). Overall crack/cocaine was used by 69% (n=122) in the month before entering prison. Figure 12
% respondents using drug before entering prison
Crack or Cocaine
g) Drug dependence
The drugs that most respondents indicated a moderate or severe dependence on were: crack /cocaine 49% (n=87, 95% C.I. 41% to 56%)), cannabis 48% (n=85) and heroin 46% (n=82). Figure 13 % respondents moderatly or severely dependent on different drugs n=178 60%
50% 40% 30% 20%
Severe dependence Moderate dependence
The number of individuals with one or more positive responses to the five questions concerning crack/cocaine use, is shown in the figure 14, below. This shows that of those that did have a dependency to crack/cocaine their dependency was more likely to be at the severe end of the dependency scale.
0% No dependency
Respondents crack/cocaine dependency scores n=178
Table 25 tabulates the data from the previous figure (fig. 14) and compares past drug using prisoners with results from the community sample. This emphasises the difference observed between figure 14 and figure 8 (page 48). Whilst the majority of the community sample were not dependent on crack/cocaine almost half of previous drug using prisoners indicated some dependence. Furthermore, amongst these prisoners over four times the proportion observed in the community indicated the severest level of dependence to crack/cocaine (i.e. a score of 5 on the dependence scale).
Table 25 Crack/cocaine dependence scores in the community sample of treatment/voluntary agency clients compared to prisoners with a past history of drug use
Community sample of treatment/voluntary agency clients (n=305)
Prisoners with a past history of drug use (n=178)
0 no dependence
1 some dependence
2 some dependence
3 severe dependence 4 severe dependence
13 (4%) 16 (5%)
16 (9%) 17 (10%)
5 severe dependence
The considerable overlap between severe dependence on crack cocaine and cocaine observed in the community survey (figure 9, p48), was also observed amongst prisoners, see figure 15 below. Figure 15 Venn diagram of individuals severely addicted to either crack or cocaine or both
h) Demographic date on prison survey respondents who indicated moderate or severe dependence on crack cocaine Table 26 shows a comparison of the number of individuals severely or moderately dependent on crack/cocaine, in Norfolk, other East Anglian Counties (Cambridgeshire, Essex and Suffolk) and elsewhere. This shows little variation between the various areas, particularly in proportion severely dependent on crack/cocaine (30-35%).
Table 26 Proportion of crack/cocaine dependent individuals amongst respondents grouped by their county of residence
Number (%) severely dependent on crack/cocaine 29 (35%)
Number (%) moderately dependent on crack/cocaine
% moderately or severely dependent on crack/cocaine (95% confidence interval)
Other East Anglia (n=58) Other (n=33)
18 (31%) 10 (30%)
7 (12%) 7 (21%)
43% (30%-57%) 52% (35%-67%)
i) Use of other drugs by those severely dependent on crack cocaine Those severely dependent on crack/cocaine used a mean of 5.6 drugs compared to those not severely dependent on crack/cocaine who used a mean of 3.4 drugs. Of those severely dependent on crack/cocaine, 59% were also severely dependent on cannabis, 53% severely dependent on heroin and 46% severely dependent on benzodiazepines. In comparison to the community sample (figure 10, page 50) a smaller proportion was severely dependent on heroin, but severe dependence on benzodiazepines was similar between the groups. Figure 16
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cannabis
Other drug use in those severely dependent on crack/cocaine n=178
Severe dependence Moderate dependence 59
j) Association between crack/cocaine dependence and other prison survey data Table 27 examines the relationship between severe crack/cocaine dependence and a variety of possible risk factors. This univariate analysis revealed that those severely dependent on crack/cocaine were less likely to be young offenders, but were more likely to have received treatment, help or advice for their drug problem before prison , to have injected in the month before prison and to have shared injecting equipment. Those severely dependent on crack/cocaine were also more likely to have been severely dependent on heroin, methadone, benzodiazepines, solvents or other drugs. As found in the treatment/agency clients those severely dependent on crack/cocaine used more drugs than those not severely dependent (5.6 vs. 3.4 mean drugs, p<0.001) A multi- variate analysis was conducted entering the variables found to be significant in the univariate analysis above. This revealed that the key factors independently associated amongst prisoners with severe crack/cocaine use were: · High number (greater than four drugs used) compared to low number (two or less) (odds ratio = 4.4, 95% C.I. 1.1 to 27.2) · Severe dependence on heroin (odds ratio = 8.4, 95% C.I. 3.4 to 20.9) · Severe dependence on other drugs (odds ratio = 3.6, 95% C.I. 1.4 to 9.5) 60
Demographic, behavioural and drug associations of prisoners with severe crack cocaine dependency
Severe dependence on crack/cocaine n=57
Not severely dependent on crack/cocaine n=121
p value comparing severe crack/cocaine dependent users with all other drug using respondents
Ethnic minority Norfolk residents
Employed In treatment before prison
17 (33%) 25 (45%)
52 (43%) 25 (23%)
Homeless Injecting month before prison Shared injecting equipment Severely dependent on cannabis
13 (23%) 43 (75%) 22 (42%) 22 (39%)
19 (17%) 32 (28%) 13 (22%) 34 (28%)
0.33 <0.001 0.02 0.16
Severely dependent on heroin Severely dependent on methadone Severely dependent on speed etc Severely dependent on benzo's Severe dependence on solvents Severe dependence on other drugs
45 (79%) 13 (23%) 8 (14%) 25 (44%) 2 (4%) 1 9 (33%)
28 (23%) 3 (2%) 8 (7%) 15 (12%) 0 (0% ) 16 (13%)
<0.001 <0.001 0.11 <0.001 0.04 0.002
Number of drugs
Results of Focus Groups for Crack Users There were seven focus groups, six in Norwich and one in Great Yarmouth conducted amongst crack users outside prison (i.e. living in the community). In Norwich groups were divided into younger (under 25's) and older, ex and current crack users. For reasons of timing one younger person in each of the ex and current user category chose to attend a group with older participants. A women only group was also held for sex workers in Norwich. In Great Yarmouth seven of the eight participants of the group identified themselves as ex users.
Table 28 Focus Group Participants, age and sex
Mean age (years)
Focus Group 1
Focus Group 2
Focus Group 3
Older Ex- users
Focus Group 4
Focus Group 5
Focus Group 6
Focus Group 7
Range (years) 20 - 24 21 - 53 21 - 48 22 - 25 24 - 39 30 - 39 20 - 53
Most participants had had some experience of contact with local services. These services included the Bure Centre, the Colegate Centre, the Matthew Project, the Mancroft Advice Project, NORCAS (Homeless Outreach Team and NORCAS Great Yarmouth), the Arrest Referral Scheme, CADS, the Probation Service, DTTO (Drug Treatment and Testing Order), Ferry Cross, Victoria Street, inpatient services at Hellesdon Hospital, drug-related services in Prison, social services
, and General Practitioners. Some participants also mentioned services that they had been involved with when living in London or other parts of the country. These included advice services, drug clinics, day programmes, residential rehabilitation programmes and therapeutic communities. Within the groups dynamics were good with most participants contributing freely to the discussions. Discussions were stopped when saturation in the topics was achieved and no new themes or issues seemed to appear. Similar themes emerged in all of the groups. a) Drug use Participants spoke of being introduced to crack cocaine through their other drug use, describing a drug ladder from cannabis, through drugs such as amphetamines, ecstasy, powder cocaine, to heroin and crack. They made it clear that their crack use and heroin use were entwined, crack was available from the same dealers who provided them with heroin, and they used heroin to help them manage the `come down' they experienced from crack Within the women only group it was explained that crack use and prostitution were linked. A dealer might introduce a young woman to crack by posing as her boy- friend. Once dependent, he would want payment for the drug and threaten the woman for it. Street prostitution was used to make money to fund continued drug use and to `keep the dealers off their backs'. Participants described a twenty-four hour, seven-day-a-week `crack- life' revolving around drug use, crime or prostitution. Crack was felt to be `worse' than heroin as the effects of the drug were more likely to lead to risky or extreme behaviour. They identified crack as being different to heroin in that the dependence was psychological rather than physical. Participants identified physical, mental and social problems related to their crack use, and described factors that motivated them to stop using. Having decided they wanted to stop using, participants had difficulty identifying places in Norfolk where they could access help for their crack problems and many believed that there was no help currently available for crack dependence. 63
b) Experience of Services Participant's experience of seeking help from General Practitioners varied. Those with positive experiences had accessed clinical services more speedily via their GP or had received short-term assistance in the form of Benzodiazepine prescriptions to help with cravings for crack. Negative experiences predominated, with participants feeling that they had experienced prejudice from their GPs when they had revealed that they were seeking help for drug problems, particularly if they mentioned that they used crack. They felt they were stereotyped as `crack heads'. Participants felt that the clinical treatment services were able to deal with their heroin problem but currently had little to offer them for their crack problem. They were critical of the length of the waiting time to access clinical services and the lack of flexibility of these services to take into account their crack problem, whilst assisting them with withdrawal from heroin. Some participants described how they had had help for their drug problems, which had been made available to them through being in prison or on probation (e.g. Drug Treatment and Testing Orders). Without support and follow up after time in prison, it was felt easy to return to a previous life of drug use. Participants spoke of the attributes that they valued in the services that they had experienced. The relationship with their key worker or counsellor was important, having someone to talk to, someone who took an interest, who empathised and offered support. It was also of significance to them that this was a continuing relationship. They valued services that could facilitate their involvement in activities, training or offer help with practical problems such as housing, benefit advice and personal or family issues. People were overwhelmingly positive about the accessibility and usefulness of the needle exchange scheme. When asked about negative attributes of treatment services a number of issues were identified. Problems included long waiting times for appointments, feelings of exclusion from decisions about their care and some participants found the experience of mixing with other users in the waiting room problematic when they were no longer using drugs. There were strong feelings expressed around experiences of having a `script' stopped as a result of providing a `dirty' urine sample, especially when crack was involved, as they felt there was no help offered for their crack problem other than advice not to use it. Some felt that having treatment removed left them in a worse position than they had been in before starting. Whilst many participants complained that counselling services were not sufficiently available, others felt that counselling which involved examination of the ir family history and reasons for drug use had been a negative experience. People felt that the key worker scheme should be more flexible, with options to change where this important relationship was not working. 64
It was felt that there was insufficient communication between agencies such as the treatment services, social services, housing and probation. c) Gaps in Services Participants described what they perceived to be gaps in the services, together with attributes of services that they thought would be helpful for crack users. A recurring theme in all the groups was the lack of a substitute drug for crack, or one that would block the cravings or the effects of crack. It was felt that research should be focussed on this area. People desired an accessible service, such as a drop in or a twenty- four hour service of some kind, either someone to contact or somewhere people could go when they had had enough. Home visits or someone to take them to their appointments were also suggested as potentially helpful. A theme that emerged very strongly in all of the groups was the value placed on exdrug users being involved in the care and support of those attempting to come off drugs. This, it was felt, could either be in a voluntary capacity or that more ex-drug users should be employed as professional drug workers. People felt that counselling services should be more readily available, together with social and personal skills training, including anger management. People suggested there was a need for residential rehabilitation for crack users, along the lines of that available for heroin users. The importance of providing something to do was emphasised repeatedly and a comprehensive programme was suggested that should include activities, education or training followed by assistance into employment. This, it was proposed, should also include help into housing, advice on money management and a substantial commitment to supportive after care and relapse-prevention. Those with families identified the need for help and advice with relationships and legal advice where parents were trying to re-establish contact with children. Women with children needed somewhere to go where they could engage in activities with all the family, they also required help with childcare to attend appointments. For the future, prevention was considered important with greater availability of information about crack and its effects. This required a comprehensive programme of realistic information to young people in schools. Appendix 5 includes detailed quotes from the transcripts of the focus groups contributing to the above results. 65
Comments from survey respondents Individuals who filled in the drug questionnaire were asked to comment if they wished about the services that they had experienced for their drug problems. All clients attending clinical services had been invited to fill out these questionnaires so responses are not specifically crack related (Full text of the responses in Appendix 6). More than half of all the respondents recorded their comments. These fell into three main categories; those who were satisfied with the services they had received, those who were critical, and those who expressed a specific need that they felt the services were not meeting. Ш Good things about the services Help for drug problems was `life saving', `life changing' Helpful relationships with staff members at the agencies Maintenance script helpful Counselling helpful Where liaison with GP's worked this was helpful Valued help with other issues Ш Problems with services Long wait for appointments Stigma of drug use leads to GP's discriminating against drug users Problem of having a script stopped - puts people in a worse situation Agencies focal point for dealers Difficult to get help for complex problems Staff knowledge inadequate Ш Other comments Stated preferences for different drugs for opiate detox / maintenance Need for self-motivation to be successful in treatment Ш Needs More accessible support 24/7 Need for flexibility in appointment/ pick up times to help those in work Need for more support for those coming out of rehab or prison 66
Results of Prison Focus Groups Two focus groups were conducted in Norwich Prison, one in the Adult Wing and one in the Young Offenders Institution. There were four men in each group. These groups were held in private rooms within the prisons and no prison staff members were present during the discussions. Dynamics in both the groups were good, with discussion flowing freely, discussions were stopped when saturation in the topics of discussion was achieved and no new themes or issues seemed to appear. The groups were obviously different in terms of age, but also in the participants' experience of drug use, experience of services and interest in accessing services for drug problems. In the young men's group all participants identified themselves as drug users with experience of using crack cocaine. None of them had had any treatment from clinical drug services, though one participant said that he had received some counselling around alcohol and drugs from a drug worker at a hostel. Two participants had lived in social care for significant parts of their childhood. They all expressed a desire to move away from a drug using lifestyle, though not all were confident of their abilities to do so. In the older men's group all participants had had experience of contact with services for opiate use, both inside and outside prison. One had participated in a specific residential rehabilitation programme for crack users outside prison. For these participants drug use was a long-standing part of their lives, and problems with different drugs had predominated at different times (opiates, crack or other stimulants). Throughout the group it was clear they were nostalgic for their drug use, and at times it was difficult to draw the focus back to discussing the topic in hand. Not all planned to be drug-free on release; their considerable experience they felt, would lead them to choose which drugs they were going to continue to use and remain out of trouble. The young men said that having heard about crack, they wanted to try it for themselves. After using cannabis and ecstasy one said he and his friends wanted to try something with a `better buzz'. Drug use was described as `something to do' in places where there was nothing to do, and other activities were too expensive. Having parents who were drug users was also a factor in being introduced to drugs. One of the young men, who had been in residential care as a child, described how for him his drug use (cannabis at that time) was the only stable and predictable thing in a life full of moves and changes. Crack use they felt led to a range of problems, weight loss (money goes on crack not food), debt, mood and anger problems, crime to fund the drug use, which leads to arrest and prison. The young men said that a reputation as a `crack head' could `spoil your whole life'; this could lead to being labelled as a `smack head' (perceived as even more pejorative) even though they were not using heroin. This they felt was the `punishment' for using crack. 67
A young man from Norwich identified Mancroft Advice Project as a potential source of information and help about drugs. The others whilst being unable to think of anywhere where they might access help for crack problems, felt they could approach their Doctor/Probation Officer/Social worker/mum about where they might access help for drug problems generally. From the older men the feeling was that there was no help for crack users in prison, some felt that there was none on the outside either, especially as there was no `blocker' or substitute drug. They identified crack as different from other drugs especially heroin in terms of the considerable amount of money that could be spent on it in, and the psychological rather than physical addiction. One participant felt that trying to provide treatment for crack addiction was `flogging a dead horse' the only way to stop crack use was to remove crack from the market. The young men were aware of the possibility of approaching the doctor within the prison for help with drug problems, but felt that this help was predominantly for those with heroin addiction. They were also aware of the existence of the CARAT team for help with drug and alcohol problems. They felt that the numbers of people waiting to see them was a problem - one young man had been waiting six weeks so far, though he said his cousin had managed to see them. The older men had mixed feeling about their treatment experiences. Positive ones included residential rehabilitation as particularly useful for getting away from the drug- using environment (this included the crack specific programme one participant had experienced). The 12-step programme was felt to be helpful for some but was too much like `brain washing' for others. They were critical of the long waits for appointments at drug clinics for those referred to the DTTO scheme. Within the prison they felt that responses to positive drug tests on the drug free wing or prior to entry to the wing should be flexible enough to take into account drug use just before going to the wing. Detox within the prison was described as a bad experience. Any treatment that focused on exploring a participant's reasons for using drugs in the first place was thought to have very limited relevance to the older drug user and that a focus on help with current behaviour would be much more helpful. Some liked the idea of groups, others preferred one to one. The young men felt there were some helpful aspects to having been in prison. Those that had become drug free with no treatment felt very positive about the fact that they had done it on their own, `being drug free clears the mind'. They were aware that drugs were available in prison if sought. Participation in Foundation Training Corporation courses in prison were deemed to be useful for developing skills to be used on the outside. The older men also acknowledged that prison could offer an opportunity to change their pattern of drug use - one participant said he had only stopped using crack because he had come to prison. All were wary of the time of release from prison as they said it was hard not to go back to the same people and places. They were also acutely aware of their `street reputation' i.e. being kno wn within their area as a drug user, this issue generated a very animated discussion and opinions differed as to the possibility of moving away 68
from drug use and still being accepted. This was a double-edged issue, you could move away from drug use, but yo ur reputation means the police still see you as a user, but as you no longer use the `gang' wouldn't accept you any more, the consequences of which could include violence. The older men felt the same that many of the problems that drug users had before coming into prison would just be perpetuated on their return to the outside, as they were going back to the same environment The young men also saw real problems in the immediate period leaving prison for those that did not have family to go to. As they perceived it the system released them with insufficient money to survive until they were able to negotiate themselves through the complicated, time consuming and bureaucratic process of travel to their hometown, probation appointments, hostel placement, hous ing benefit application and job-seekers allowance application etc. This they felt put people at risk of being hungry and on the streets, and thus sucked back into drug use and crime. The young men felt that real help for crack problems would include counselling, anger management courses, organized activities (that could engage younger crack users and give them a chance do things that they enjoyed away from drug use), safe places to go and rehabilitation schemes. The older men thought that drug users should be admitted to a system in the last 3 months of their sentence to prepare them for the outside, this would include residential rehabilitation and housing attached to the prison. Appendix 7 includes detailed quotes from the transcripts of the prison focus groups contributing to the above results. 69
Results of the Treatment Professionals Focus Group & Questionnaires There were 11 participants in the group, 4 male and 7 females, plus 6 respondents to the questionnaires. They represented the various agencies and organisations from both from the voluntary and statutory sectors in Norfolk. Agencies Represented · Arrest Referral Scheme · Bure Centre / Colegate · CADS Kings Lynn · Contact NR5 · NORCAS Norwich · NORCAS Great Yarmouth · Mancroft Advice Project · Matthew Project · WSDAS Thetford The focus group was generally less interactive than the user groups. Discussion needed to be prompted with direct questioning. There was a lot of head nodding on most topics. Drug Use It was felt that crack/cocaine use was increasing as an `add-on' problem to heroin use, and that crack was currently the second `drug of choice' for agency clients. Whilst many used the drug, only a small percentage presented to agencies with a primary crack problem, though this was increasing. There was a perceived increase in crime related activity with increased availability of crack/cocaine. Amongst young people attending advice services crack was reported to be easily available e.g. parties/recreational use. An increase in both physical & mental illness related to crack use had been observed at the treatment agencies, higher levels of addiction were being seen with crack/cocaine than with other drugs. At some agencies crack use tended to be a `hidden problem'- where patients would hide their use of crack to avoid losing their script, this also created problems around urine testing. Crack use in the city was associated with prostitution, an increased risk of sexually transmitted diseases. It was noted that locating the new Sexually Transmitted Disease clinic out of city (i.e. at new Norfolk & Norwich University Hospital) would cause access problems. Crack use had been seen to lead to a more chaotic lifestyle, increase involvement in crime, violence (prostitution, pimping, personal), and potential of violence towards staff. Users described their fear of dealers - dealers were perceived as a very violent group 70
Service Issues Problems were identified in access to services, with long waiting lists to enter treatment. The current system was perceived as unable to cope with `chaos & crisis', which are common in crack users. The chaotic lifestyle, paranoia and psychosis have an adverse effect on clients' abilities to access services. Existing services were perceived as `heroin' oriented. Staff identified a lack of knowledge of how to deal with crack users, and the need for training and increased awareness of crack related issues. Though when pressed there was an acknowledgement that many staff already possessed many of the skills and techniques required to treat crack users and that some of the issues were around confidence in applying these skills to this group. In terms of service structure it was felt that a service with quicker access was required i.e. 24 hour access & support. There should be guided access to treatment - by assessment. It was felt that a range of psychological therapeutic interventions would be effective, including more motivational work (more than with opiates), and that finding ways of addressing the `boredom' issue were important. The possibility of incorporating alternative therapies into the range of therapeutic interventions available was also suggested as important, as some clients may find these attractive. Increased support for patients was thought to be important, preferably from outside their own circles. It was felt that a commitment to increase links between agencies and increasing joint working and would make the `system' easier to access and use for clients. There was seen to be a need to increase information about the effects of crack and the availability of services for users (as well as for professionals). There was confidence that once a service was perceived to be offering effective intervention for crack/cocaine problems word of mouth would publicise this service. A `geographical cure' i.e. removing the client from their own environment, and linking all aspects of `treatment' (housing, rehab, activities) was also thought to be valuable. 71
Summary There was a perceived increase in crack/cocaine use within the county and an increase in associated illness (mental and physical) and social problems. There was need for flexibility in existing services to cope with the different needs of crack users, especially faster access. There was disagreement with regards to an outreach approach, mainly due to issues of safety. Staff felt a need for training and support to expand their range of therapeutic skills for use with clients with crack/cocaine problems. There was an acknowledged need for support for clients. Involvement of ex-users was perceived as valuable in mentoring / supporting individuals in treatment. Though, this would need to be well-structured to avoid putting vulnerable individuals at risk. Selfhelp groups were also perceived as valuable. There was an increasing need for joint working between all agencies for clients in general, but particularly for clients with crack/cocaine problems. The importance of being able to access a range of assistance for clients, which includes activities/skills development, physical and mental health
care, housing, financial and social welfare issues was emphasised. 72
Report from the Police Focus Group Two police officers participated in this group, one from Norwich and one from County Headquarters. The officer from Norwich had a local perspective and the officer from headquarters was able to provide a strategic perspective on policing issues surrounding crack use in the county. Impact of crack use on crime in Norfolk It was explained that crack use impacts on crime at all three levels · Level 1 volume crime (e.g. burglary, theft, car crime) · Level 2 within Norfolk and cross-border crime · Level 3 national and international Historically intelligence had shown crack was becoming more readily available on the streets from about December 2001. Prior to that Norfolk had had a relatively stable heroin market run by mid- level dealers, without involvement from organized criminal groups. The Police participants told us that they have a "predictive model" for the form of crime which crack may cause in a location. This enabled them to forecast the impact of the introduction of crack into Norwich's drug market. An organized group had targeted central city areas, the sex industry and established heroin dealers to introduce crack to Norwich. This happened very quickly, within about a four- month period. Crack was first introduced at a reduced price. At this time volume crime (robbery, car crime, burglary, etc.) started to increase. Police Intelligence built up a picture of the customer base and distribution system within Norwich. At the conclusion of an operation in August 2002 a number of arrests were made of significant individuals. This was followed up with further arrests of lower level participants who were offered access to treatment and support services with mixed levels of success. Since this operation others have moved in to fill the crack supply void, but on a less organized basis. The size of customer base was reported to be at the same level as last year, though a detailed assessment would be needed to confirm or refute this. The focus group participants felt that at the moment the supply of crack is just to the demand that exists, and if this were allowed to start to seek new markets, then ground would be lost. Overall, the void in crack supply left by the operation last year has been just about filled despite police efforts. Different areas of the county It was explained that at the time of the focus group, police were not seeing crack as a problem in either western or eastern areas of the county, and that crack use appeared to have a central Norfolk base. 73
When asked about specific towns they said that Cromer has a little bit of crack use, and that Kings Lynn and Great Yarmouth drug markets tended to be mainly heroin focused. There was some suggestion of crack problems in Great Yarmouth, but sourced differently to the Norwich crack, from the same dealers that provide their heroin. Crime The crimes that are most associated with crack use are those that can realize money for drug purchase. The rise in violent crimes seen, such as street-robbery, is due to the nature of crack i.e. making people more aggressive. It was also noted that much more money was needed for crack use compared to other drug use. Crack use impacts within specific groups It was felt that due to the drug culture, crack may be more attractive to some, such as young people. Some may view cocaine as "trendy". Whilst, crack inhalation doesn't have the stigma of heroin injection and may thus appeal to people who would not initially consider using heroin. Strong links were also seen between sex work and crack use. It was explained that the infiltration of the Norwich market was facilitated from this base because of the existing link between sex work and heroin use. The officers were not aware of any link between crack use and male prostitution. The Norwich picture Whilst the police officers explained that there was no evidence of gang culture at the moment in Norwich as the Norfolk drug supply market was not organized in that way, they did say that weapons tend to be worn as part of the dealer culture, as a "badge of office". These do not seem to be used, but contribute to threat and intimidating violence used to maintain the market. This intelligence has meant more operations carried out by police firearm teams. Within the crack market crack houses tend to be where users go to buy crack, rather than as `crack dens'. It was estimated that there were 6-10 at any time, of which 6 are active. Crack and heroin use are disproportionately represented in deprived areas, but there was no evidence of links with specifically deprived groups (e.g. ethnic minorities or asylum seekers). Crack use and the behaviour of people in custody/violence towards police It was explained that violence in the custody suite was rare and that no particular increase had been seen with crack use. Many people in custody have been through the procedure before and know what to expect. Any people in custody that are perceived to have medical requirements are seen by medical officer, e.g. some will become agitated because of drug withdrawal. Others once in custody and away from the possibility of getting more crack, will cope calmly with the situation that they find themselves in. 74
Services Services that the officers perceived as particularly helpful for crack users were the CARATS team in the prison and the Link workers. The Arrest Referral Scheme they felt might be targeting users at the wrong time, as they had the dual problems of being in custody and of not getting a fix, uppermost in their mind. The officers also expressed concern about lack of support and continuity of care for offenders leaving prison, after receiving support in prison. When asked about what other services they felt should be provided for people with crack problems, they suggested that because of the characteristics of the drug (no specific drug treatment, with psychological addiction rather than physical) that crack needs a social solution more than a medical one. It was felt that there was a need to look at users' social conditions and opportunities to change. They were concerned that if a user went elsewhere to come off the drug and then returned to their same community, maintaining their motivation to be drug free would be difficult. They felt that the other things that are needed are more local analysis (such as this project). This they felt would enable a menu to be devised of tactical options for intervention. Otherwise, it was felt that responses were to the symptoms of the problem. Experience from other cities showed very quickly they could not tackle the problems crack causes, but instead suffered from them. It was emphasised that crack use is different from other drugs. Heroin use has been quite cyclical over the years, steady rises have been experienced, but with crack there has been an explosion in its use. The problem is that people who previously weren't using class A drugs are using crack. This refers back to the user culture around crack. Also crack is not portrayed in the media in the same way that heroin is. The press have focused on the increase in street robberies, but have not emphasised the link with crack. Education is needed to emphasise that crack use can lead people down the same route as heroin use. Education from school age upwards to both young people and society as a whole. Equally, it was felt that the police should invest in tackling organised crime, such as drug distribution, in order to deal with lower level crime (such as burglary and theft). This is worth doing, as once organized crime is embedded in the community it is much harder to remove. 75
10. Discussion and project limitations Urine drug screen data Data were only available from the biochemistry laboratory of the Norfolk & Norwich hospital, thus these only reflect results from the Norwich area. Results clearly implied a substantial growth in crack use with positive tests rising from 2% of all tests to 15% over the last 5-years. These data should be interpreted cautiously as this reflects tests performed, not individuals. However, the trend is strongly suggestive of a growing pattern of crack/cocaine use. Capture-re-capture analysis Estimates provided by this analysis are based on statistical modelling. These estimates depend on accurate assessment of duplicate records. Every effort has been made to detect duplicates and the project team considered that the medium match (described on page 18) with adjustment for one unit data errors was the most appropriate matching technique. However, it is likely that these rules have led to certain individuals being matched who in fact were different people (over- matching). Equally, other duplicate records have almost certainly been missed due to greater than one unit data entry errors (under- matching). Whilst under- matching will have led to an over-estimate, over-matching will have led to an under-estimate of the final total. A large proportion of individuals within both police datasets lacked any postcode information. An adjustment was made for this assuming that the proportion of these who were non-Norfolk residents was similar to the proportion found amongst those individuals with a postcode. It is possible that this was false and that one reason for lacking a postcode was non-Norfolk residence. However, the research team considered that it was more likely to represent persons with temporary accommodation or the homeless. A further issue is the "goodness of fit" of the final statistical model. Whilst, the model included in this report fits the D-set well use of the A&D dataset (i.e. data which includes both acquisitive and drug-related crime) depended on estimating the proportion of acquisitive crime that is related to problem drug use. This extra uncertainty made this second estimation more prone to error. A sensitivity analysis conducted yielded widely varying results depending on the assumptions made. However, results from the D-set were reasonably consistent (total problem drug users in Norfolk between 8,000 and 10,000) and these estimates did overlap with the confidence interval around the most likely A&D set estimate (40% acquisitive crime related to drug use plus postcode adjustment). It should be noted that a small proportion of individuals arrested for drug-related crime may not themselves have a drug dependence problem. This is likely to be a very small proportion and hence is unlikely to have led to an over-estimate. The final estimate suggests a total population of problem drug users in Norfolk of 8,200, or 2.0% of Norfolk's population aged 15-54. This contrasts with national estimates of 0.8% of UK's population aged 15-54 based on the multiple indicator 76
method. However, other estimates of drug misuse populations using capturerecapture techniques have found similar prevalence (see table 29) with estimates varying from 1.8% to 3.6%. In the context of these results, Norfolk's results seem reasonable. Table 29 Estimates of prevalence of problem drug use by capture-recapture studies
Age group prevalence estimate refers to
North West of England (2001)22 Bolton Manchester Liverpool Sefton St. Helens & Knowsley Wirral
Overall prevalence (%) 1.78 3.65 3.45 2.16 2.37 3.29
London (1999)23 Lambeth/Southwark & Lewisham Newham Dundee (1996)24
3.1% 3.6% 2.9%
North East Scotland (2000)25 Aberdeen Fraserburgh
Questionnaire survey community sample The questionnaire survey appeared to have a very good response rate throughout the county though certain areas were poorly represented in particular Cromer and the North Norfolk coast. Those agencies that reported response rates suggested it varied between 83 and 100%. However, no response rate was available for four sites (approximately one third of the survey returns). Agencies were strongly encouraged to survey all possible clients and not to target those with known crack dependence. Thus, it is hoped that the survey reflects average clients presenting to all drug agencies. Survey respondents mean age was 29.9 years, this is slightly below the mean of all clients reported by treatment agencies for the capture-recapture study (mean 31.7 years). Furthermore, whilst 28% of survey respondents were female, 31% of clients within treatment agencies last year were female. However, overall these figures
suggest that survey respondents reasonably reflected treatment agency clients in terms of age and sex. A number of respondents had difficulty completing the key questions concerning drug use. It appeared that some respondents misunderstood that all questions related to previous drug use (i.e. prior to treatment). This led to some respondents completing the table in a way that made interpretation difficult. A common error was difficulty completing boxes vertically beneath each other (i.e. a drug would be identified in section B question 1 and then boxes would be completed under a different drug when answering questions
2-7 [Appendix 1]). All interpretation problems were resolved between Vivienne Maskrey, Richard Holland and the project secretary. The cut-offs used to determine moderate or severe dependence are not perfect. Thus, some clients with dependence will not be recognised through these questions (lack of sensitivity). Equally, some clients without dependence will be wrongly classified as dependent (lack of specificity). Given the problems experienced by certain clients completing this questionnaire it is most likely that this survey has under-estimated dependence, as opposed to over-estimating dependence. Estimates for crack cocaine dependence were remarkably consistent across both types of service (clinical or non-clinical) and by whether clients were new or current patients. In all cases, estimates of around 12% were found. This suggests that those with crack dependency are presenting to all forms of treatment agency. This is an unexpected finding. It had been thought that those with crack dependence were likely to be avoiding clinical treatment services, in view of the lack of a useful/effective substitute drug. In reality, this finding almost certainly reflects the fact that within this population crack use appears to be simply one part of complex poly-drug use. Thus, affected individuals are seeking help from clinical treatment services to assist them with their heroin (and/or benzodiazepine) problems. One further unexpected finding from the survey work was that whilst crack dependence was most prevalent in Norwich (estimate of 16% of problem drug users), severely dependent individuals were found throughout Norfolk. The numbers used to base estimates outside Norwich were small (with the exception of Gt. Yarmouth). However, there was reasonable consistency in results throughout Norfolk, with approximately 20-40% of users indicating some dependence on crack/cocaine. It should be noted that it was not possible to survey clients in such a way that the sample of respondents reflected the true distribution of problem drug users attending drug agencies throughout Norfolk. Instead, the sample frame was a convenience sample of users attending different agencies during generally brief survey periods (an average of 2-weeks) in the early part of 2003. Furthermore, we deliberately oversampled in the Gt. Yarmouth area as part of a concomitant project being undertaken at the same time. As a result 40% of community respondents were from Norwich and 43% Gt. Yarmouth, with a further 9% from King's Lynn and 5% from Thetford. In reality, the majority of Norfolk drug users accessing drug agencies (60-70%) are based around Norwich. The result of our over-sampling in Gt. Yarmouth is likely to have led to a slight under-estimate of the proportion severely dependent on crack/cocaine (as the proportion in Gt. Yarmouth was lower [11%] than that found in Norwich [16%]). 78
Prisoner Survey The prisoner questionnaire was based on that used in the community and suffered similar problems with some respondents having difficulty completing it accurately. Equally, the response rate at first attempt was low (30-40%) leading to the team repeating the process two weeks later. This boosted response to between 50 and 60%. Accurate estimation is difficult as the normal turnover of prisoners meant that some prisoners had left and new prisoners arrived. Nonetheless, a conservative estimate of the response rate was 52% (based on those respondents in the second survey who indicated they were present at the time of the first survey). Basing the response rate on the average number of prisoners present across the survey period yielded a 60% response rate. It should be noted that a small number of respondents required help to complete questionnaires. This precludes the possibility that large numbers respondents would adjust their answers about drug use to fit in with the expectations of the person assisting them. However, this low number requiring help may imply that respondents with literacy problems have been under-represented by this survey. Given the response rate it is important to consider certain results of this survey with caution particularly the proportion of prisoners using drugs before prison. It is possible that those who did not use drugs were put off completing the questionnaire as it was titled "Drug & Alcohol questionnaire". Equally, drug users in prison are suspicious of revealing their current or past drug use for fear of possible reprisals by prison authorities. This may have put certain prisoners off completing the questionnaire despite repeated efforts to ensure they knew that it was anonymous and confidential. However, our estimate of 77% of prisoners having a history of previous drug use is very similar to results of a survey conducted at Norwich Prison in 1999 where 79% of prisoners had previously used drugs (in this case the response rate was close to 70%). Irrespective of the possible bias in the proportion of prisoners who had used drugs, it seems unlikely that there was particular bias amongst different types of drug user. Thus, the estimate of the proportion of users with dependence on crack/cocaine is unlikely to have been biased. Results indicated that 50% of prisoners with a history of drug use had some dependence on crack/cocaine, and in 30% they were severely dependent on crack/cocaine. This was almost three times the proportion found in the community sample. Furthermore, this proportion was highest amongst those respondents from Norfolk. It should also be noted that the prison appeared to contain many individuals with very severe crack/cocaine dependence. Our overall estimate of numbers severely dependent on crack/cocaine clearly depends on which of the community or prison sample better reflects those problem drug users not in contact with agencies. By using the community proportion (12%) we have sought to make a conservative estimate of the possible extent of severely dependent crack/cocaine use. 79
Focus groups limitations a) Crack Users Groups Every effort was made to obtain a cross-section of users and ex-users. The mean age of 30 and the proportion of women attending (38%) are close to the mean age (27.8) and proportion of women (39%) amongst severe dependent crack/cocaine survey respondents. This result occurred by chance as one of the aims of the focus groups was to ensure diversity amongst participants. One group that was poorly represented was teenagers. The groups were stratified (current and ex users, older and younger users, women only group) to ensure that a range of crack user's views would be represented. People with serious problems with crack/cocaine are likely to have chaotic lifestyles, making it difficult for them to be recruited and then participate in focus groups. Within the current users' groups there will have been a bias towards recruitment of those, who whilst still using crack, have more stable lifestyles. The volunteer fee, offered to those who participated to compensate them for their time and trouble, proved to be a valued incentive to the participants, of those who initially expressed an interest in taking part, only a handful did not come to their group. Where recruitment relied on word of mouth it is possible that this resulted in friendship groups being recruited (e.g. women's group). The benefit of this approach was that it enabled us to recruit not only those who were in contact with services, but also those who had fallen out of contact and a few individuals who had never contacted any services. Where this happened, it also had a positive result of more open and fuller discussions in these groups. The reservations around this approach to recruitment include that friendship groups might have very similar views to each other. However we deliberately recruited a number of varied groups i.e. younger users, older users, and geographically separate groups (i.e. Great Yarmouth). The views and issues that were expressed were very similar in all groups. Ultimately the views expressed by the participants of these groups are their views only and must be extrapolated with caution to others. However given that similar themes emerged in all the groups adds weight to their validity and generalisability. b) Prison Focus Groups Whilst these groups were very small and recruitment had to be mediated through prison staff, the privacy of the groups' settings, the willingness of the participants to talk openly and the recurrence of themes similar to those outside prison give weight to the validity of these results. 80
c) Police Focus Group Whilst this group contained only two officers, they were both in a position to give important perspectives on crack use in Norfolk. The officer from headquarters was able to give a strategic perspective that encompassed the whole of Norfolk, and links to national and international issues on crack-related crime, whilst the officer from the city gave a very useful perspective on crack use in Norwich. They were unable to give detailed perspectives on East and West Norfolk. The drug market is constantly changing and any views expressed at the time of the focus group could be quickly out of date, especially where problems may be emerging. d) Professionals Focus Group This group brought together professionals from a range of clinical and voluntary services who may have initially felt inhibited in expressing their views in front of each other as evidenced by the initial lack of free flowing discussion in this group. It is also worth considering that the group contained individuals who came from different theoretical models of care and modes of working, which may have initially inhibited frank exchange within the group. To balance this there seemed to be much consensus on issues discussed as evidenced by considerable head nodding. As this shared concern became clearer the participants contributed much more freely to the discussion. The result of the professional's focus groups was complimented by, which were completed by six staff from agencies questionnaires (results in Appendix XX). Questionnaire responses from respondents who did not subsequently attend the focus groups mirrored the range of the discussion. In summary Similar themes emerged in all groups. Professionals, police and drug users shared similar perceptions of the problem, all be it from different perspectives and shared similar thoughts on the structure of services that could address these problems. 81
11. Conclusions: Key findings from this work are as follows: Capture re-capture data · 2,063 individuals are in contact with one or more of the following agencies in the six- month period 1/4/02 to 30/9/02 (this figure was derived from the D dataset after removal of all duplicate records). · 2.2% of the 1,271 in contact with treatment agencies were reported as having crack/cocaine as their main drug. This contrasted with 5.5% of those in contact with the arrest referral service. This also contrasted with self-report data (from the survey) in which 8% reported crack/cocaine as their main (or one of their main) drugs. · Capture -re-capture methods were used and provided an overall estimate for Norfolk's problem substance misuse population as being approximately 8,200 (i.e. 2.0% of Norfolk's population, aged 15-54). The 95% confidence intervals for this estimate provide a low estimate of 6,700 and a high estimate of 10,300 for the size of this population. Community Survey results · Approximately 12% (95% Confidence interval 7 to 16%) of problem drug users in Norfolk appear to have severe dependence on crack/cocaine. · A further 19% (95% C.I. 14% to 24%) reported using crack/cocaine in a way that suggests moderate dependence. · These figures equate to an estimate of 1000 individuals severely dependent on crack/cocaine in Norfolk, with a further 1500 with some dependence to this drug. (The low estimate for the number severely dependent on crack in Norfolk is 700, and a high estimate of 1,600 assuming there are 8,200 problem drug users in Norfolk). · Crack/cocaine use is strongly associated with multiple other drug use (on average four other drugs used at the same time). It is also associated with being a sex worker Note: this estimate assumes that the use of crack-cocaine amongst users unknown to any agency was most similar to the use amongst users known to drug treatment/voluntary agencies. It is possible that the use of crack/cocaine amongst those not in contact with agencies is in fact closer to that found amongst prisoners. In this case, estimates of the number severely dependent on crack within Norfolk would in fact be over 2,500. Equally, it could be argued that drug use amongst those yet to 82
enter treatment is different from either group surveyed. This clearly makes it hard to be sure of the true extent of crack use. As there is no easy way of systematically surveying those outside treatment (or yet to enter treatment) our best estimate is the lower number (i.e. up to 1000 individuals severely dependent on crack cocaine). Prison Survey results · 77% of respondents had used drugs before prison (95% C.I. 70% - 82%). · The pattern of drug use appeared different amongst prisoners to those in our community sample fewer drug using prisoners were severely dependent on heroin, instead crack/cocaine dependence was much more prominent. · Amongst prisoners who had used drugs 32% (95% C.I. 25% to 39%) indicated severe dependence on crack/cocaine. A further 16% (95% C.I. 11% to 22%) indicated some dependence on crack/cocaine . · Amongst the 57 prison respondents severely dependent on crack/cocaine 24 (42%) appeared to be extremely dependent. This contrasted with the community sample where 9 of 38 (24%) were as severely dependent. · Just as in the community sample, prisoners severely dependent on crack/cocaine used significantly more drugs than those not dependent on crack/cocaine (on average 4 other drugs used). Focus Group conclusions The focus groups provided very rich data to enhance our understanding of crack/cocaine use in Norfolk. Key findings were as follows: Community sample · There was a very strong inter-relationship between crack use and heroin use · Crack lifestyle led to a strong need for involvement in crime or prostitution to fund this habit · Users almost universally believed that there was no treatment for crack use and that services were almost exclusively orientated toward opiates · Successful treatment programmes were characterised by strong personal relationships between clients and professional drug treatment workers · Successful treatment programmes should incorporate a wide range of activities and initiatives to provide structure to a client's daily life 83
· The benefits of learning from ex-users were perceived to be an important component in treatment · Lack of accurate information around crack and its effects on health and lifestyle were perceived as gaps in current preventative services. Messages should be targeted at a young audience. Prison sample · Clear need for support pathways to be accessed immediately on discharge from prison to prevent return to previous drug use. · Prison can be a place to initiate a drug- free lifestyle · Prison drug services need to be more widely accessible to those with varied drug problems Professionals (treatment and police) · Police are actively dealing with crack-related crime of a varied nature mainly focused in Norwich · Need for flexibility in services, especially to allow faster access · Need for training and support to expand the range of skills to cope with these more complex clients · Joint working across all agencies is essential to ensure these clients access a full range of necessary physical, psychological and social support. · Staff, like their clients, acknowledged possible roles for ex-users in support 84
Reference List 1. Calvey, Williams. Pharmacology in Anaesthetics. 2. In Search Of The Big Bang, What is Crack Cocaine? [Web Page]. Available at http://cocaine.org/. (Accessed 30 August 2002). 3. Crack and Cocaine NIDA Infofacts [Web Page]. 5 November 1999; Available at http://www.nida.nih.gov/Infofax/cocaine.htm. (Accessed 30 August 2002). 4. Gossop M, Marsden J, Stewart D, Kidd T. Changes in use of crack cocaine after drug misuse treatment: 4-5 year follow- up results from the National Treatment Outcome Research Study (NTORS). Drug & Alcohol Dependence 2002; 66(1):21-8. 5. Booth RE, Kwiatkowski CF, Chitwood DD. Sex related HIV risk behaviors: differential risks among injection drug users, crack smokers, and injection drug users who smoke crack. Drug & Alcohol Dependence 2000; 58(3):219-26. 6. Aust R, Sharp C, Goulden C. Prevalence of drug use: key findings from the 2001/2002 British Crime Survey. Communication Development Unit, Home Office, 2002. (Findings; vol 182). 7. Aujean S, Murphy R, King L, Jeffery D. Annual report on the UK drug situation 2001. Drugscope. 8. Drug Treatment Monitoring Unit (SE[W] & Eastern). National drug treatment monitoring system (SE[W] and Eastern) Annual report 2001/02 Norfolk. 9. Drug treatment monitoring unit (SE[W] & Eastern). New episodes of recorded problem drug use in Norfolk DAT 2000/01. 10. . Annual report of the St Martin's Housing Trust - 2001/2. 2002. 11. . NORCAS Homeless outreach team report. 2003. 12. . Treating cocaine/crack dependence. National Treatment Agency for Substance Misuse, 2002. 13. . Tackling Crack - A national plan. London: Home Office. 14. Soundex coder [Excel Visua l Basic]. Howell DJ; 2000. 15. Singleton N, Farrell M, Meltzer H. Substance Misuse among prisoners in England and Wales. London: Office for National Statistics. 16. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT 85alcohol consumption
questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care quality improvement
Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998; 158(16):1789-95. 17. Aertgeerts B, Buntinx F, Ansoms S, Fevery J. Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population. Br J Gen Pract 2001; 51(464):206-17. 18. Corrao G BVVGFS. Capture-recapture methods to size alcohol related problems in a population. J Epidemiol Community Health
2000; 54:603-10. 19. Griffiths P, Gossop M, Powis B, Strang J. Reaching hidden populations of drug users by privileged access interviewers: methodological and practical issues. Addiction 1993; 88(12):1617-26. 20. Matrix MHA & NACRO. Evaluation of drug testing in the criminal justice
systme in nine pilot areas. Home Office, 2003. (Findings; vol 180). 21. . The UK Census - 2001. Office for National Statistics. 22. Beynon C, Bellis MA, Millar T, Meier P, Thomson R, Jones KM. Hidden need for drug treatment services: measuring levels of problematic drug use in the North West of England. Journal of Public Health Medicine 2001; 23(4):286-91. 23. Hickman M, Cox S, Harvey J et al. Estimating the prevalence of problem drug use in inner London: a discussion of three capture-recapture studies. Addiction 1999; 94(11):1653-62. 24. Hay G, McKeganey N. Estimating the prevalence of drug misuse in Dundee, Scotland: an application of capture-recapture methods. Journal of Epidemiology & Community Health 1996; 50(4):469-72. 25. Hay G. Capture-recapture estimates of drug misuse in urban and non- urban settings in the north east of Scotland. Addiction 2000; 95(12):1795-803. 26. Davis D, Caddick B, Lyon K, et al. Addressing the literacy needs of offenders under probation supervision. London: Home Office, 1999. (Research & Statistics Directorate Report. 27. Spurr M. Literacy level in Norwich Prison (personal communication). 2000. 86
Appendices 1. Appendix 1a Drug Questionnaire for New Clients Appendix 1b Drug Questionnaire for Existing Clients 2. Appendix 2 Drug Questionnaire for Prison Inmates 3. Appendix 3a Focus Group Topic Guide for Crack Users Appendix 3b Focus Group Topic Guide for Treatment Professionals Appendix 3c Focus Group Topic Guide for Police Officers 4. Appendix 4 Focus Group Consent Form 5. Appendix 5 - Extracts from focus group discussions community sample 6. Appendix 6 - Detailed Prison Focus Group Report with extracts from group discussions 7. Appendix 7 - Comments from survey respondents (community sample) 8. Appendix 8 - Professionals' questionnaire detailed responses 87
Appendix 1a Drug Questionnaire for New Clients 88
Appendix 1b Drug Questionnaire for Existing Clients 90
Appendix 2 Drug Questionnaire for Prison Inmates 91
Appendix 3a Focus Group Topic Guide for Crack Users
Introduce yourself and explain v the purpose of research v who the research is funded by
Introduce the tape recorder ask people to speak one at a time
everything said in the group is in confidence - tape will be destroyed after being typed up, no one will be identified individually in the report.
Set ground rules
everyone's views are valid - it doesn't matter if people disagree - there are no right or wrong answers
Ask if there are any questions
2. Background v First name only v Non threatening warm up back ground info subject 1 e.g. Sport v Non threatening warm up back ground info subject 2 e.g. Music/TV programmes v Indicate briefly if you have ever had any counselling or treatment for drug problems
3. Where would you turn for advice with problems with crack use?
possible lay systems would you go to primary care for advice
4. What services for drug problems are people aware of?
Where in Norwich/Great Yarmouth would you think of going to if you wanted help or advice about problems with crack use?
5. What might be the motivation to enter treatment for crack problems? What are the main reasons that would make people using crack look for treatment? Probe all factors v Money problems v Health problems v Problems coping with dealers v Peer pressures/Other pressures v Criminality problems Would experiencing after effects of crack use make you want to look for treatment? v Looking for medication for come down, psychosis, or rebound agitation 6. What barriers might there be to entering treatment? What sorts of things make it difficult to have treatment for crack use? How available have you found services? Are issues such .......... barriers to entering treatment? v Location v Opening hours v Waiting list v Not being able to cope with the waiting room Is violence an issue? v your own or other peoples Do you think the treatment that you know about is relevant to crack users? (opiate focus & no substitute prescribing) 7. What positive experiences have people had of treatment? What aspects of treatment have you found helpful? Why? What was really relevant to you? 8. What negative experiences have people had of treatment? What aspects of treatment have you found unhelpful? Why? What aspects have been irrelevant to you? 93
9. What help with other issues are people looking for when they attendn treatment services? What sort of help with practical problems would be helpful? v Social (housing, relationship, child welfare) problems v Financial problems debt, benefits v employment problems
What health issues do you think crack users might need help with? v needle exchange v blood borne viruses v sexual health v physical problems e.g. Noses and teeth What help might people need with alcohol problems? 10. If you have received any treatment for crack use has it improved your quality of life? If you have been in prison was any of the help received there? If you previously were offending has the treatment enabled you to stop? 11. What would people be looking for in a crack treatment service? What would encourage you to make use of a service if you are not in one? Some have mentioned needing .... what do you think? v `Somewhere to hide' /safe place/drug free space v Counselling or therapy v Alternative therapies e.g. acupuncture 12. How could it work within the current service structure? Thinking about the services that you are familiar with What else could these services offer to make them more useful for people with crack problems? What aspects of how people use these services could be changed to make them more responsive to people with crack problems? How would you promote services for crack users? 13. Has anyone got anything that they would like to add? 94
Appendix 3b Focus Group Topic Guide for Treatment Professionals
1. Introduction Introduce yourself and explain v the purpose of research v who the research is funded by
Introduce the tape recorder ask people to speak one at a time
Stress confidentiality everything said in the group is in confidence
tape will be destroyed after being typed up, no one
will be identified individually in the report.
Set ground rules
everyone's views are valid, we are exploring
people's opinions and experience
Ask if there are any questions
2. Background v Your Name v The organization you work for/post you hold with in it v General description of your responsibilities v Broad remit of your organization
3. What is your organization's current experience of client's crack problems?
What proportion of your work is with people with primary or secondary crack problems?
4. What barriers might there be to individuals entering treatment?
What sorts of things make it difficult for users to have treatment for crack use? How do you engage crack using clients?
How open are clients about their crack problems when disclosing information about their drug use? - occasional users i.e. when they have enough money - opiate users who develop a crack problem but don't disclose it, as they don't feel there is any help available
How available are services? Are issues such as.......... barriers to entering treatment? v Location/Opening hours/Waiting list/ v Agitation/Not being able to cope with the waiting room What crack related behavioural issues are there? v clients demanding or difficult to cope with? v is violence or intimidation an issue? ( for staff or crack users being afraid of each other) Do you think users think the treatment is relevant to crack users? (opiate focus & no substitute prescribing)
5. What positive experiences have people had of treating crack users? What aspects of treatment did the clients find most helpful? Why? 6. What negative experiences have people had of treating crack users? What were the problems? Why? 7. What help with other issues are people looking for when they attend treatment services? What practical problems are people looking for help with? What health issues do crack users need help with? What help might people need with alcohol problems? 8. What are clients looking for in a crack treatment service? What would encourage them to make use of a service? Some have mentioned needing .... what do you think? v `Somewhere to hide' /safe place/drug free space v Counselling or therapy v Alternative therapies e.g. acupuncture 9. Are your services geared for crack treatment? What are the skills you feel drug treatment professionals need to treat crack users? Are there aspects of their skills you feel drug treatment workers need to develop to treat crack users? 10 How could it work within the current service structure? What else could these services offer to make them more attractive for people with crack problems? Idea of a flexible accessible response - how could this work? How would you promote services for crack users? 11.Has anyone got anything that they would like to add? 96
Appendix 3c Focus Group Topic Guide for Police Officers
Introduce yourself and explain v the purpose of research v who the research is funded by
Introduce the tape recorder ask people to speak one at a time
everything said in the group is in confidence tape will be destroyed after being typed up, no one will be identified individually in the report.
Set ground rules
everyone's views are valid, we are exploring of people's opinions and experience
Ask if there are any questions
2. Background v Name v Organization you work for/title of your post v General description of your responsibilities v Broad remit of your department
3. How do you perceive crack problems impacting on crime in Norfolk?
What about specific areas of the county? Norwich Great Yarmouth Kings Lynn and West Norfolk South Norfolk/Thetford North Norfolk Broadland Breckland
Which crimes? Drug dealing / robbery / violent crimes etc.
4. Can we talk about some sensitive issues? What are your views about how crack use impacts within specific groups or areas? young people different ethnic groups in the county sex workers/prostitution access to firearms relationship to gang culture crack houses violence in general /domestic violence vulnerable adults e.g. mentally ill/exploited 5. How is crack use effecting the behaviour of people in custody? Safety of suspects in custody Management of crack related behaviour in custody suites Safety of custody officers and other prisoners 6. How do you perceive the problem changing? Increasing? Stabilising? Any change after `crack down on crack'? Information area by area 7. What services do you perceive as responsive to people with crack problems? What aspects of these services do you feel help users with their crack problems? 8. What other services do you feel should be provided, given your everyday experience of people with crack problems? What characteristics would these services have? 9.Has anyone got anything that they would like to add? 98
Appendix 3d Focus Group Topic Guide for Prisoners with history of crack use
1. Introduction Introduce yourself and explain v the purpose of research
v who the research is funded by
Introduce the tape recorder ask people to speak one at a time
Stress confidentiality everything said in the group is in confidence - tape will be destroyed after being typed up, no one will be identified individually in the report.
Set ground rules everyone's views are valid & it doesn't matter if people disagree there are no right or wrong answers we won't be discussing individual drug use or why people are in prison Ask if there are any questions
2. Background Ш People introduce them selves, first name only Ш Indicate briefly if people have ever had any treatment from prison services for drugs or from services on the outside.
3. What services for drug problems are people aware of? a) In prison or b) In your home area How did you hear of them? E.g. Have you heard of the DTTO programme
4. What might be the motivation to enter treatment for crack problems? What sort of problems would you think make people look for help with crack cocaine problems?
5. What barriers might there be to entering treatment? What sorts of things make it difficult to enter treatment?
6. What do you think people would be looking for in a crack treatment service?
7. What positive experiences have people had of treatment if any? What aspects of treatment are helpful?
8. What negative experiences have people had of treatment if any? What aspects of treatment are unhelpful? 9. When you were using drugs outside prison what did you need that wasn't there that would have made a real difference to you?
10. What about the transition from prison to home, what is needed?
11. Has anyone anything else to add?
Appendix 4 Focus Group Consent Form DRUG ACTION TE AMS DAT
University of East Anglia Norwich NR4 7TJ CONSENT FORM Crack Users Focus Group
First Name ............ ............... ...
Sex M / F Please tick box
1. I confirm that I have read and understand the information sheet dated 18/12/02 for the above study and have had the opportunity to ask questions.
2. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason
3. I understand the group discussion will be tape recorded so that everyone's views are
accurately recorded and that I will not be individually identified in any way in the report
4. I understand that the group discussion is confidential
5. I agree to take part in the above study
6. I have received a Ј20 Tesco Voucher as a thanks for my participation
Vivienne Maskrey Research Associate /Project Co -ordinator Department of Health Policy and Practice University of East Anglia Norwich NR4 7TJ
____________________ Signature Ms Xany Oliver Norfolk Drug Action Team Phoenix House White Lodge Business Park Hall Road Norwich NR4 6DG
Appendix 5 - Extracts from focus group discussions, community sample a) Introduction to crack Participants described how they were introduced to crack cocaine and described a `drug ladder', their initial introduction to drug use being through cannabis, which in turn introduced them to other drugs. "It starts off in my experience, someone starts smoking cannabis, he will go from cannabis to either LSD or speed, ecstasy and then they go onto hard drugs heroin and crack. Everyone says that is where it starts, cannabis all the time, everyone I know. .......it is because it is you get into that group of people who know where to get other drugs from." Another participant described a situation where cocaine powder was unavailable and they were sold crack instead. "Well the way I tried it was, when I was younger like, snorting it (cocaine) in night clubs and that, but you could not get no powder one night, but we could get crack, so we got crack and we smoked it and it was better. So it was all down hill from there really." For some women, a link with crack use and prostitution. B "The dealers and it is usually black guys not being funny or racists, but they tell you they love you and lead you up the garden path make you ill and then start threatening you when you haven't got the money that they want." C "Yeah you are out on the streets, one to keep your habit going and two to keep them off your back..." b) Crack and Heroin People fo und that, having become dependent, their lives revolved around providing for their drug use. Common to all who spoke in the groups, was that their crack and heroin use were entwined, either they had had a heroin problem and used crack in addition to the heroin, or they had developed a heroin problem from using heroin to manage the come down from crack. Participants also stressed that the same drug dealer sold both heroin and crack to them. "Yeah I have got a heroin addiction ......I used a lot of crack and I used the smack to come down off crack, and ..I became addicted to heroin" 101
"But because there is no treatment for crack that is why I ended up on heroin, because there is no
treatment for crack. So I ended up self medicating myself by using heroin to try and stay away from the
crack and then you have a heroin problem."
B "It was exactly the same I came off crack by using heroin and obviously I am a heroin addict, and my ex partner did exactly the same thing. And I know an awful lot of people who have substituted crack for heroin"
"I love crack personally, but I just can't afford to do it because of my heroin addiction, but I think I need help ...to get both of them ... out of my mind completely, but I don't think I can do that."
"We have all been talking a lot more about heroin, but they go hand in hand.....smack and crack .....your white dealer or your dark dealer, it is hand in hand"
"I used my crack intravenously which is a lot worse. I never really smoked it that much, I would mix it with my heroin in a needle and straight in my arm"
"That is the other thing yeah I have only smoked crack a few times, because all the other times I have always injected it and I thought it was a waste of smoke really."
c) `Crack Life' People described how the ir drug use dominated their lives twenty- four hours a day "I was living on the streets and I was homeless and I had nothing going for me and it was just heroin and crack and that was my life basically" "If you do manage to sleep you get up first thing in the morning, you feel rough as anything you won't be able to move properly, and the first thing you need to do is go out and make the money. However you make the money, whether you shop lift or you are a burglar or a mugger, you do need to you will get the money. You will go and score and you will smoke it and shortly after you finish your last pipe, you will have to go out to earn some more money. So your days just become a blur of earning money scoring doing the stuff." "I have been on sessions and missions that have lasted like four or five weeks non stop, not stopping for nothing, not stopping for sleep not stopping for food. Just continuously going out during the day doing shop lifting, and then during the evening going out and burgling places. And just continuously either committing an offence or smoking".......
d) Crack v Heroin People also described how they felt that crack was `worse' than heroin "But the thing with crack is I think it is more evil ...heroin is the lesser of the two evils. Because you are on heroin ....you are physically ill and you feel so ill you just lay there and hope someone will come around and look after you. But crack you are up, you are raring to do it, but the things I have done in eight years for smack doesn't compare to what I have done in less than eight weeks for crack. Eight year and I have done worse in eight weeks."
"If I want a crack pipe I want it I will kill someone for it, heroin doesn't bother me anymore because there is Subutex the blocker" e) Problems caused by crack use Ш Physical problems Participants identified physical health problems, such as exacerbation of asthma and other lung problems, weight loss due to reduced appetite, poor nutrition and sleep deprivation. "being skeletonised, ....I can't really describe it to you. My mum and dad said they saw me at the top of the garden and I looked like an old woman, I was bent over and skinny dark rings around my eyes didn't sleep properly. Just no energy to do anything, I was too weak to do anything, I could hardly get out of bed and get dressed." "you do tend to get depressed, you get worn out, because you are not getting any sleep ......you have no energy, and slowly you lose weight and you will look like a skeleton" Ш mental health problems
Paranoia, anxiety, agitation and depression. "Mentally I was really as low as I could go and no self confidence, and I was starting to get really paranoid like, the psychological affects of the crack. I didn't like going out especially on my own and I was really antisocial I didn't want to talk to anyone, see anyone even my own family. I was really just sunk into a black hole really, it was like the ground had opened up and had swallowed me up. It was like I didn't exist I was just a sort of shadow wandering the earth." "crack makes you paranoid.... And when you have not got crack, you are depressed and also paranoid......the depression I had to go through was unbelievable, I really felt suicidal" "So paranoid yeah that I use to just hurt people because I thought they were going to hurt me, do you know what I mean and they weren't." "The only time you get anything physical from crack, is when it is in your face and you start getting sweaty palms and ....you start getting clammy and .....fidgety and that is really bad." Ш Social conseque nces These for many have included relationship problems with partners, losses of children to other carers, losses of jobs & money, family and friends. "Well I got locked up in prison seven years, I lost everything my son, my family. Nobody wanted to know me, I had no friends nothing". 103
"when I was on drugs absolutely hated myself and I mean I am only twenty four years old and I have got two kids. And I have got nothing, my four year old is living with my mum and my two year old is dead" "losing your family having no one, ...because ...you borrow money from friends so many times and not pay them back, before long you are going to have no one. You can only nick money out of your mum's purse and your dad's purse so many times and you end up with no one so, you are going to end up on your own". "Crack is a social killer, none of my family want to know me" Ш Crime and Prostitution Involvement with crime or prostitution to fund their drug habit "you get up you rob, you score, you rob again, you score some more" "I worked as a prostitute to fund my habit" `you go into prostitution, you go with you life in your hands all the time. And there is the emotional side of it as well you can't get close to anyone because you always think they just want you for one thing and it is for the money and the sex'. Worry that desire for the drug would lead to engaging in more risky behaviour as a prostitute "the only thing that really would worry me is if I got myself into a situation where I was so desperate for it and I didn't have a condom, that I would do it without. Luckily it didn't happen" f) Motivations to stop using Ш Self recognition People described getting to a stage where they have had enough "When you hit rock bottom" "Something clicks doesn't it, you are just fed up......... until you are actually ready to address or realise you have got a problem, you aren't going to do it aren't you." 104
Ш Low self esteem Participants talked of their low self-esteem related to either engaging in crime, violence or prostitutio n to fund their habit. "I have been robbing people ......I have been doing all manner of shit, stealing fucking things out of cars and stuff like that. And I have come so close to beating somebody up the other day to take what they had, and that is not the sort of person I am yeah. And you know that made me stop and think, what the fucking hell going on here?" "I feel guilty, I really want it and then after I have done it the guilt sets in, and I sit there and I want to cry, because of how much money I have just spent and it has all gone up in smoke. You know, I have just worked like an hour, and I saved myself a Ј100, doing the most obscene things, being a woman I am sitting on a gold mine. ......then in half an hour that Ј100 has gone" "And when you go out working and you try and find money and you are ill and you feel rough and you know you feel rough and they can see that the guys. And that puts your confidence down and they make you feel you are not worth it. That is the cheap price they put on you the sex, so as you can buy the drugs. They will drive around for about an hour and a half and they see you still standing there and they say well we have only got a tener." Ш Lack of money Their money running out "my problem got worse and worse and my credit ran out" C "Being skint all the time, no fags no food nothing." A "No nice clothes,no money in your pocket." C "No gas, no electricity, and that is how it hits you, and when you have got children as well, and you can't do that because you need food for the kids don't you?" 105
Ш Major life events Some major life event can provide motivation, together with new relationships, plans and a changed perspective on the future "Mine was friends and family around me, after my sister had died and I just went worse on drugs, before I got better. But since I got better eight months now, I have got a whole new set of friends, we do a lot and I have got other mates that I go out drinking with and all that. It is changing my friends changing my attitude and doing the best I can." "I mean like to me having the family and settling down is more important than having a good time and going out and getting drunk. And I think that is part of growing up as well, I am only twenty three." "I want to settle down and have kids and stuff, and have a normal life and shit, be like all these other people and have money in the bank and have their own house .....I want to raise kids and give them a life.......... I don't ever want them to go through the shit that I ha ve had to and that is my motivation to get off the drugs." Ш Key people Help and support from key people at the right time "With a lot of help from my family, and worker at ***** and from you (indicates partner in the room) and from people that actually care about you. Luckily, if I think, if I didn't have my family I don't know if I would be in the same position." Ш Moving away Being removed form the triggers A "Yeah it is really important to get out of your surroundings if you can, because you associa te loads of different things, ....that can trigger, you know, to start thinking about the drug or needing the drug. And it is important to, sort of, get away from certain people and certain areas I think." Q "Disassociate?" A "Yeah disassociate yourself from that kind of life, because it is a whole way of life" 106
g) Difficulties accessing help or information for crack problems Most participants were unsure of where they would go to access information and help. "As far as I am aware, there wasn't anywhere, there was only one way you stopped you ran out of money" "The advice places .... in Norwich which deals with crack , you don't hear about it, as well you do not know where to go." "I didn't know myself like there were any services or I don't know where I would try" "Nowhere, there isn't anywhere in Norwich" "Well I mean you have got CADS right, and you have got your doctors right, you have got your friends that you can talk to, and be open and that is about it. I suppose you could go if you were really desperate, and knock on some church. Samaritans, but you are scrapping the barrel there. I mean because none of these people have got any experience at all. You can get sympathy, and if you go to the AA you will get a bit of empathy, but that is about it." Though one couple identified the library as a way to find information on the drug and advice services. h) General Practitioners Participants had experienced a range of responses from General Practitioners when they had approached them for help with their drug problems. Some experienced prejudice and being treated as a `bad person' for being a drug user, treatment was refused and or they were discouraged from staying on the GP's list. If you go and see your local GP or your general GP's they don't want to know" "Yeah, so it is really disheartening because I have always had a bit of a fear of doctors, I never really liked going to the doctors at all if I won't go unless I am like dying basically. So when you actually do pluck up the courage to go and say look doctor I need help, I have got a heroin dependency I have got a crack dependency as well. Then you get that far to perhaps get down to tell them and then they kick you in the teeth and say we can't actually help you because we have got so many of these already and they suggest you try and find a different doctor." "when I came out of prison I went to three doctors and they all turned me away bar the last one. Who took me one because of history or whatever with my drug addiction and I am a recovering addict with this that and the other. All of them have got that face out there and sorry mate we can't take you on we don't want to take you on, we don't want people like you in our surgery." 107
Others accessed service referral via their GP "I got referred through the GP because that was the quickest way of doing it." Some had received benzodiazepines as a short-term aid for crack cravings. "I went to the GP recently yesterday in fact to ask him about it (crack) and also my heroin addiction obviously, and I have to wait for treatment at *****. And he prescribed me diazepam for the craving, he said, to take it away. Then afterwards he said `I don't know the answer." "He said four weeks with the diazepam and no more otherwise I would get addicted to them..." One participant cited not wishing to go to their family doctor for confidentiality reasons "Because I have always worked, I got jobs and I didn't want anyone to find out, you know, I wanted to be very confidential I certainly didn't want to go and tell the family doctor or anything like that." i) Barriers to entering treatment People identified a number of barriers to entering treatment Ш Waiting time The length of time it takes to get an appointment when they have reached a point where they are seeking help. "If someone walks in and wants help off crack they have got to get to them straight away" F ".......how long it takes to get on there as well, you go down there and it is going to be like six, eight weeks ,before you even see anybody, if not mo re. G Yeah and you are past your willingness to try and you are back on the road to ruin again" 108
Ш `No help for crack' Believing that there is no help for crack problems "I have lived all over the place, they have always got a like treatment for heroin addicts, but there is nothing for crack.....they don't recognise it, I don't know, maybe they just don't bother I don't know" "I have talked to the top doctor at ***** and he doesn't know to help people with crack addictions, so if he doesn't know....." Ш Lack of substitute prescribing "for heroin.... there is subutex the blocker. But for crack there is nothing like that." Ш Opiate focus Services are experienced as opiate focused and lacking in flexibility to help with crack problems as well as opiate problems "And my partner had more of a crack problem but she used hers to come down off like a lot of people do and stuff. They basically stuck her on methadone and valium, and the only problem that they could see she had a heroin problem." "When I went there I had heroin and crack addiction and the key workers ....would try and stop my heroin addiction, but nothing was done about my crack.......I had stopped my main habit of heroin. I was still using crack quite a lot ....but they offered me no help, nothing. All I am getting is that you shouldn't be doing that, we will stop your scripts" Ш Needing to be ready to change Being at the right stage of the cycle of change "in a way you have got to be able to help yourself before anybody else can help you. But if you are not prepared to help yourself, then you can kid yourself for several months if not more" Ш Accessing help through prison and probation Some people spoke of using crime to access help "I think I sort of sent myself to prison in a way, I knew what was going to happen if I didn't stop and I carried on ...I did seven weeks on remand...they put me in the hospital wing for a week....they gave me a detox .....through CARRAT I said I wanted a DTTO......a lot of liaison went on .....I managed to get myself bailed.......they put me in contact with the bureau who run the DTTOs.....through them, via the network, from having nothing to help me I had a network of people that wanted to help......... you have to go to prison and then come out to get the help you need " 109
Or using going to prison as a chance to be away from drugs, to start again "I asked to get me moved out of the Norwich area because I was pretty much fresh out of prison and I was clean and I asked to get moved out of the area so I was put somewhere where I didn't know anybody." Although many said that drugs were as available in prison as out "I was on drugs when I went into prison and I wondered where I was going to get them from, and they were everywhere." Conversely lack of support and after care on leaving prison could lead back to drug use "when I was in prison I got clean and you have fuck all to do in prison anyway. But then when I came out, do you know what I mean, I didn't have nothing. I didn't have anywhere to live so I was back on the street again and what else can you do Apart from turn back to drugs basically. You can't get a job because I didn't have an address and I had just come out of prison and no one was going to give me a job anyway. So I just took the easy option and went back to drugs basically." j) Attributes valued in Drug Services Participants spoke of the attributes that they valued in drug services they had experienced Ш Relationship with treatment professionals Someone to talk to, to be comfortable with, someone who takes an interest, who can empathise, offer support and plug people into structure and activities. "The thing I think was good for me is counsellors ......our counsellor .....says oh don't you look well.......it makes you feel good someone saying that to you. Asking how are you getting on, .......at the end of the day they are not family or someone that is intimate in your life ......and they are pleased that you have done well. And that is the experience I have had of it, being praised for what we have done. And I have done it for myself and each other, but someone on the outside saying it makes you feel good really." "I had a really good social worker, she was a student she had a lot of spare time to spend with me. She actually, by doing silly little things for me she just bought me a little present once, it was only a little make up bag with a few bits in it. But it made feel like I must be someone for the effort of changing and getting clean for, you know. And that really mattered to me I think that that was one of the things that helped me a lot." 110
A .....it is easier to talk about ...problems .....you get a rapport going. ...it's about a one on one, I think for me. B Yeah the rapport... it was a great help when I first started .... and I could talk about anything really and I felt a lot better after talking for an hour and get a lot of stuff off your chest. A You can get very sentimental with them can't you, when I say sentimental you feel a bit tearful but that don't matter. Ш continuity of care "Well I have had the same key worker the whole time I have been going there which is since August last year and she has been brilliant she is like a friend to me, so I tell her everything things that I wouldn't tell my parents I can tell her. And she is kind of like a parent to me like I could go to her with problems" Ш opportunity to do training/be occupied/ provide structure to the day "make sure we keep occupied she would try and find things that we could do, like education and things because a lot of us have too much time" "Yeah you go there and you do things to occupy your time, so when you have got that gap in your life and you need something to do as opposed to thinking of doing jobs and everything. You go there and you do things, you go on the internet you do word processing
on the computer, play games on the computer scan pictures in send them off. Do whatever you want to on the computers there is art and design course that you can do, there is a carpentry course, a cooking course...." "But I was lucky .....I did a three month course I have jus t finished it a month or so ago. I stopped using crack during that time, I had already stopped using heroin anyway, but it is like you said it is the having things to do and keep my time occupied. But if I was bored I would just want any drug no matter wha t" "..a daily routine, they have really put me back in my life" "It can be anything from a support group to an exercise of some sort, at the moment my schedule during the week now is on a Monday I have to go for a support session for an hour where I have to provide a urine analysis during that time. ..... my support worker I let her know what is going on, how I feel and if I have got any problems I can tell her and she will do what she can to help me etc. Then on Tuesdays I do computers down at ***** I am studying for a higher certificate in certain things. That is for a couple of hours and then I do woodwork on a Wednesday .....it is a routine it is doing something during the day. ......... something that is not drug related, it is all healthy good stuff." 111
Ш needle exchange "I think it is quite good the service that they are providing the needle exchange service that is a brilliant idea you know. Because there is no need to share they are so accessible you know and you have always got a friend who has got a bag of new works and there is no need to share." k) Negative attributes of services They spoke of the negative attributes of the services that they had accesses Ш unhelpful help-lines "Well the numbers that they gave me to try weren't of any significance really, I rang them up and ......one was for a counselling group, and it was just over the phone counselling which was not the right thing for me. I needed something different..." Ш Being unable to cope with the waiting room "The only negative thing about ***** is sitting with the other users down in the waiting room......I don't like sitting there associating with people who are still using" Ш No help for crack problems Whilst feeling helped for their heroin problems, those that had confided in the services they had stimulant problems as well, did not feel these were addressed "I have joined ***** for crack and heroin addiction, and I got the help for the heroin addiction with Subtex which is working, it is brilliant and I have been on that for five months. But my crack habit got worse and worse and the only help they could offer was advice." "nothing was done about my crack, ..when I was going in ...even though I had stopped using smack I was still using crack. And they would have a go at me ....and stopped my scrip ts even though .....I had stopped my main habit of heroin. I was still using crack quite a lot and I knew that they were having a go at me, but they offered me no help nothing." "I have got a problem with speed and they just say get a hobby. You know I have been doing speed for ten years I have not got the heart to give it up. I have seen counsellors and bits and pieces but there is no information on speed addiction." "No there is nothing to stop the craving, I mean like fair enough like, things like Benzos help a little bit, diazepam and that, they help a bit, but it still doesn't get rid of the craving " 112
Ш Long wait for counselling "I was crying my eyes out and he (key worker)says I can get you counselling but it is going to take three months.." Ш Negative aspects of counselling Some people had negative experiences of counselling A "I got counselling from *****. But I don't think that counselling helps anyway." B "No I just think they are all nosey bastards, who has just got to know all your fucking business aren't they." "Can I just say something, people might not want to talk to somebody that though, you should be able to get help without having to pour out your life's history. Because I wouldn't be able to talk to somebody ......I would find it very hard" Ш Humiliation of supervised consumption I have go every day and I don't like it. I would rather get me own prescription and do it ..my way ......instead of going there every morning, every day, taking my thing like a peasant in front of them. When you have to take it, it is so humiliating ....I just don't like it, I take my script and I have no choice really ." Ш Not feeling included in decisions about their own care "They listen to you to a certain extent ........Yeah at ***** we can get on Methadone or Subutex, but basically every week they get into a big group and have a conversation about all of us yeah. And basically it is the group's decision and it is not the key workers decision or it is not the doctors decision it is the group's. So I mean we do not get to speak to the group we only get to speak to the doctor or the key worker." Ш Need for flexibility if the key worker relationship isn't working out "And if you don't get on with your key worker then you are fucked aren't you." Ш Lack of continuity and follow up after residential rehabilitation "Also you have got, I find that there a distinct lack of support as well, once you have finished there is not after care there is no follow up. And it is so easy to relapse and go back." 113
l) Gaps in Services Participants identified gaps in the services that they had experienced that they felt would be helpful. Ш Blocker/Substitute for crack Many felt that medication to block the craving for crack would be beneficial and should be the subject of research. "A blocker which means once you have got it, if you take crack ...it would't do anything" A "You can't get a substitute for crack" B "Everyone would want it if there was a substitute" Ш Drop in centres/coffee bars/somewhere accessible 24 hours a day "somewhere like old fashioned coffee bars that we don't have any more" Ш Support "someone to talk to, like me" "Just someone to talk to ...each day or each week, just to keep close" Ш Having ex users to talk to for "someone that can empathise, somebody that's been there someone who has had a crack problem or heroin problem, he has been there, he has been through all the shit" "One of the best people to help would be an ex user .....because they know what you have been through and that, ........because they are ex crack users at the end of the day." "if you talk to a counsellor who is an addict, the counsellor can share his experience and what happened to him and what it was like. So not only you have got the rapport there straight away, because he has already told you his story, he has already confided in you before you have even opened you mouth and told him where you come from. And not only that he can tell you how to recover as well, do you know what I mean, stage by stage day by day all the way up to recovery. Not just talking to somebody step by step in the text book" "A mentor, a friend, someone to say come on come over.." 114
" ..And services I mean the **** ,I mean they need someone who has been there and done it like. Like us lot, but not a whole lot of straight people, a volunteer group" "The worse part is the key workers, they have no actual experience of going through the heroin" "There is definitely a resentment from the people that are trying to recover towards the people that are trying to give them help, because they can't empathise with them, because they are not actual drug users, they are seen as getting their knowledge from a book, text book junkies is the phrase" against D "You see I do know somebody who is an ex user and he is working. E As a counsellor or something like? D Yeah. But all I heard was being slagged off for being in that position, you know junkie criticizing it " Ш Activities, something to help with normality and boredom including goal setting for daily plans/daily routine A "A lot of it is boredom as well isn't it once you stop taking drugs you have got nothing else to do have you." B "Yes you need something else to fill in your time instead of just changing from one drug to another, you need something to occupy your mind and to focus on. And they don't offer any alternative you know help after that no after care, and after care is what they should be looking at more so." "Some of the courses are available you have got what it is like a problem solving
course. You identify the problems and then you identify the aspects that you need to sort that out. All the repercussions looking at it from all the different perspectives. And basically they are giving you the equipment to actually solve problems, and the communications that are needed etc. and an in depth course of twenty-two sessions in that. And most people do learn things and they actually send people from companies to these courses as well it is not just people with drug problems." Ш Anger management training/gym "you get so fucking angry, I have really beat my girlfriend senseless three or four times and it is scandalous I do. But something that will help, you take me down to a room and beat fuck out of a bag once a week until there is someone there to help you talk about it" 115
Ш Housing (more help available for women than men) A "I was in a night shelter for eight months and now I am at ***** and I have been there for about two weeks. I have done the hostel thing where I have been from one hostel to another to another hostel to another hostel and it just gets you...." B "I was in a hostel for a whole year and then I got a two bedroom flat and I have got a two bedroom flat now, but I stuck it out in a hostel and I got my flat a two bedroom flat. But there is more help in women hostels than there is for men in hostels." "I think there is something like a ten year waiting list (for housing) for a single male in Norwich" Ш Financial advice "Financial support, getting your financial things in order" Ш Advice around child care. Family relationships. Social and legal advice for men and women who want to re establish contact with their children. "rights for fathers with children" A "Well that's right my little boy went to live with my mum, and I have been fighting for him for three years now, and the reason my mum keeps throwing it up in my face is, we don't want heroin here and you are on crack.That is what I get. You are a prostitute, you are a dirty whore. How can I trust you because I have never been able to trust you before, because of you being in the drugs scene. Well I am sorry I want my boy back now and I am not into drugs or anything." C "You have to prove yourself." A "Yeah and I have even turned round and said to my mum I have said if you want blood tests to prove that I am not on no drugs you can have them, and she is blah blah blah at me." B "You don't have to have a blood test just a urine test you know." A "Exactly but you have got to build that trust back you have got to build that trust back." C "And that takes a long time." A "Yeah." 116
Ш Residential rehabilitation for crack users A comprehensive programmes to include detox therapy, training housing money management and support and relapse prevention after the residential phase. "I think residential rehab for crack users and kept them there for six months a year and give them support. The same as they have got for smack" "If I was taken to a building off the streets.... that I know I didn't have access to drugs" "There isn't anything .....in between, criminal and mental institutions. Either you get sectioned or you go to jail because there is nothing in-between you know, and that is probably what is needed." Ш More doctors who can prescribe for drug users. More services "you need to have certain doctors in every city...... obviously registered doctors ....so they can prescribe. But they are there to focus on drug addicts with crack addiction and heroin addiction. So as opposed to going to the doctors and him turning you away because you have got an addiction..... These people are there to help you and they can monitor your medication .....and try and help you to get off it, and have counselling and for people who might be interested, and have more kind of leaflets and that. And just more organisations that are to help people with these specific addiction because it is the hardest thing anybody will have to go through the crack addiction or a heroin addiction" Ш Continuous removal of dealers from streets "If you are going to hit them, why not continue hitting the dealers, bust them and bust them, why leave them go" Ш Police to have more knowledge about drugs "More people like, police officers knowing more about of, say like a doctor what it does to you and how it affects you." Ш Better links between agencies "if you have got problems with drugs, more than likely you are going to have problems with your benefits, and your housing and what to do with your time. Now if the council and the DSS linked up with ***** agency and probation and that. Because there is more than likely crime involved as well or there is in a lot of cases. If all these agencies actually link up and help each other, then the person that is receiving the treatment is going to be a lot smoother for them, they are not going to have to do so much running about." 117
m) Prevention Education and prevention with young people was thought to be very important, some participants expressed concerns that progressively younger people were becoming involved in serious drug us e "Well something has got to be done, because the younger generation, my sister eighteen years old and she is snorting coke, she skips hash, she skips trips, she skips speed, she skips E's the whole lot straight on the coke, she has used heroin already " In general it was felt that more realistic information about drugs and their effects was needed for young people. People felt that drug education should start early, at around 10 to 12 years of age. The `just say no' message that some people had experienced during drug education when they were at school was felt not to work. They felt young people in their teens were curious and this sort of message made them likely to want to try drugs, as they know from what their friend have told them that people don't die the first time they take a drug and that there are pleasurable effects. Conversely others felt whatever the message, it wouldn't work, as they had been at a stage where they had wanted to find out things for themselves and drug education however presented would not have made any difference. "To be honest with you when I started smoking puff when I was like a kid, I used to think to myself yeah it is dirty and junkies and that. But it was when I was a bit older I thought to myself how can I have an opinion unless I have tried it, so ...one day ...the first time I ever done it I had a hit, and I thought to myself cor yeah I like that ......I thought yeah I will do that now" People felt that drug users going into schools telling young people about their life revolving around drug use might be helpful, a few people felt so strongly about this that they indicated that they may be willing to do this themselves. It was also felt that information about drug effects and how services could be accessed should be mo re widely available through posters, and leaflets. 118
Appendix 6 - Detailed Prison Focus Group Report with extracts from the group discussions Ш Crack use M1 "To be quite honest I knew people that had done it and that but I really wanted to find out about it myself. M2 It was from a few of my friends because we all because we all use to smoke weed and then we thought we would try something better pills, and we thought we would do a bit of crack and that. Q What do you and your friends mean by being better what does that lead to? M2 It was just a better buzz in due course you know you just get use to the buzz so you try something different. Q What sort of pills were they? M2 Ecstasy." Problems with crack v heroin "you spend so much money, and heroin is how much you can spend in a day, what a fiver a day? With crack you can spend two or three grand and still spend more. Because crack is one of those drugs if you have money in your pocket you are going to spend it, don't get me wrong if you have a thousand pound in your pocket you won't stop until you have smoked that thousand pound. And after you have smoked it you are going to get more money. But with heroin how much can you smoke of heroin a quarter?" Ш Prison Pressures on the service "There is a counsel team that you can see but to be quite honest I donґt know, I have had an application to see him but I havenґt seen him yet." M3 It is stale mate to get to see the CARAT but they haven't been round. My cousin he's actually seen them........ M1 They are a loads of people to see anyway, do you know what I mean." "I have gone through the detox centre, so now I have gone through them in jail. None of them are any good I would never ever go though another RAPT course like I did coming in here this time and I was going through a detox as well. I was having detox in here, and all I wanted to do was get comfortable and die. It isn't going to happen" 119
Prison helps to become drug free "You say prisons is, can't cope, but is has helped me in every way, like before I was out and I was living my life on drugs. And when I get back out it has cleared my mind you know I can think straight because I am not on the drugs" "I didnґt break with the crack, it is just that have come into prison, and if I hadnґt have come into prison I would have just carried on." But drugs are available if sought "When I first came in here `cause I knew people from when I came in last time. I was (age) when I came in last time. And I came in and I was offered it and I have been offered it like crack cannabis or any other stuff, and I have had the chance to get it but I donґt want to do it. One, because it wonґt do me any good in here, two I want to try and sort of myself out anyway." M1 "In jail I think smoking makes your time go a bit better I really do." M2 "If there is more puff in a jail..............." M4 "In this jail yeah." M2 "If there is more pot in the jail there wonґt be so much gear in the jail." Ш Need for support/simplification of processes on discharge from prison "I would like to say yeah he is saying like get all these things and set up for you in here like with probation and that yeah. But when you get out like you have got so much to do to prove like the community and the hostel, and you have to fill out a load of new forms and that yeah. And that is on your first day out and what you really want to do is just be happy and they donґt let you, and it stresses you out yeah. And then when you get to the probation they just nag at you like even if you have done nothing you have just out of prison. And they nag at you, you better not be like this again or whatever and they are to help and that and you just get in the way yeah. And you walk out of there and you feel so relieved to get out then because do you know what I mean. Unless you have got a nice probation officer like because when I get out of jail I have to go to the train station and straight to the probation and it is like about four hours like to get to Norwich. My argument is when you have to go down to the job centre and if you live in a hostel you need to get to the job centre to get housing benefit forms and benefit books and tax books and stuff like that yeah. And that takes ages as well and then you have got wait until they will give you an appointment for your job seekers thing. Then you have to go to that appointment when they are signing on and they will put you on the books on that day but you still have to wait another two or three weeks for your actual dole money to come through. That is three weeks and you have got no money for three weeks and they expect you to be all good and that yeah. Do you know what I mean they expect you to do nothing, especially when you live in a hostel and you have got no food." 120
Difficulty of returning to same environment on discharge from prison "Do you know the problem that is difficult that happens is that you have a certain group of people that you have been hanging about with before you get locked up right. Come in you go to jail you get up to gear when you're in jail you go back out it is the same address the same so called mates and within days you can guarantee you will be back on the gear."
Complexities of street reputation
Drugs are not a good reputation no, see in ****** it is only a little small place and
half of it I would say yeah about half of it and people are doing drugs and they walk
past ****** Court and all that and you know that they are all smack heads and that.
And you see them all and people and they all think, oh yeah this and that yo u do drugs.
But the people that I know they are not small people but they are not big people either.
Do you know what I mean they are like people that you need to know. And you see
them they are all smack heads my friends and look at them and say look at the state of
them do you know what I mean. They walk out the door scruffy and you can clock
them straight away they are going shop lifting there do you know what I mean. It is not
a reputation to be a druggie it is a reputation just to be normal.
M2 Yeah I know but once you are in that crime you try and get out of it again and sort yourself out, you have always got that one thing that you never got caught for. And you are going to get dragged back into it.
M3 That is what has happened to me I sorted my life out and I went to court and then I was put back in here. But at the end of the day I know that they are not going to keep me in here forever and when I get out of here I am not going to drink or anything. I am going to get out and I am going to get a job and I am going to sort my life out. I have got to look after my little brothers and sisters do you know what I mean, so I am going to have to do that. And that is going to be me sorted no drink no drugs no nothing, so in a way prison has helped in a way. But in an other way if you come out of here and you go back with your old friends who are doing the drugs, you are going to think oh I will just try it I will just try a little bit. Like smoking you go back to smoking and that happens and you think oh I will not get addicted again. You try it once and you think oh and you try it again and the next thing you know you are back.. You are doing your robberies and that.
Family when available support can be crucial "Well I am lucky enough I have always got my mum to fall back on, but she is not going to be here for ever and I have got to sort myself out."
Ш What users would like in a service Residential rehabilitation either attached to prison or not... "Somewhere like that you are not locked up, you donґt feel like you are locked up in a room where there is nothing there just padded walls or whatever yeah. But somewhere where you feel safe and that yeah. But even if they did another prison there is actually more like, for people who are on drugs and that do you know what I mean" "It could be like the teenager druggies who do crack and that yeah, and the young ones like maybe taking get them all together like a rehabilitating scheme and take them away for the weekend or something like that. And try and keep them off it do you know what I mean, I could play the man instead of thinking about drugs and even thinking about something else." "Do you know what I think they should do, I think that when they get sentenced and they have got the last three months left. They should be going to rehab everybody, it is as simple as that. So they have got in their head drug free coming out drug free." "It's a big fat jail a local jail (Swansea) like this, right, and they've got all the courses you have got here, more courses than you have got here. Right they have got a proper rehab centre attached to the jail and they are now in the process of building a hostel with the salvation army the prison and outside probation and people like that. For people who get out of jail with drug problems and everything like that, and they want to stay clean and make a fresh start." Ш Other comments Future prediction - meth-amphetamine use will increase M4 "........ Ice they call it on street,......that is going to be the next thing and it is going to take over crack." M2 "Yeah because it is cheap." M4 "It is cheaper and it is a better buzz ......" M4 "I do honestly believe that in three years time we will be sitting here talking about Ice and how it effects" Older people need help with current behaviour "They want to know why you went on the drugs in the first place they are all saying to me why you went on drugs in the first place it is easy for you to stop. Well I have done drugs for twenty odd years and my problem isnґt why I went on drugs I can handle that with no problem why I went on drugs in my past. No my problem is staying off again." 122
Drug use as stability in a life of change "Well with me moving around a lot .........., the only thing I knew like I started smoking (cannabis) and because I moved around, it is a thing I knew that would be definitely around and it has always been the same. It's kept me in a way sane. So otherwise if I werenґt smoking it would just totally piss me off because I couldnґt be bothered with it, but you lay there thinking well itґs happened I canґt do fuck all about it 123
Appendix 7 Comments from survey respondents (community sample) Norwich Bure Centre It was OK sort off It is a shame the process takes so long. I lost my family and got arrested for possesion whilst awaiting treatment I've never had any help, because I've never asked for any. Until now. I refered myself to CADs in Gt Yarmouth last summer to help me get of heroin but was never contacted with an appointment. I was not happy Still waiting for treatment Very helpful I got approp. med care ie. Px subs for heroin, but psychologically, needs improving.It took > 18 months before I found the therapy/counseling I needed.Previously I had been fobbed off. I had to find my own treat. It should have been offered at start Its been life changing. Praise the Lord and his helpers. I thought I was seen to and sorted out a prescription reasonably quickly To start and now O.K. but worried about future what say in my treatment I will have. Quite good Sometimes good, sometimes not Yeh its good & my key worker is very good at her job Very good support To long waiting time Very helpful, ***** ***** has been a great help to me, with battling with my problems! Because I have moved around I need to start from the beginning with each new councilor eg. supervised consumption I don't like methadone. I was only put on it to come down off dyhrocodeine because of GP I have always been treated with sympathy, respect and professionalism throughout many years of treatment at the Bure Clinic I have had endless support from my family and ***** ****from the Bure Clinic Could be better It could be done a bit quicker, plus I'm not so keen on coming down here (Colegate) cos theres so many people still using. Not enough help - because of waiting list but now on D.T.T.O Yes they have been very helpful and understanding, specifically **** **** very helpful and understanding. I went to Rehab and done well at it but didn't have a lot of help when I came out of Rehab and went right back to where I was. Managed most myself - + counselling has helped problems underneath Not flexible enough for people in employment. Not fast enough system. Yes it's very hard - leaving myself ill for titraition. I can say that all the people at the Bure have been very helpful The Bure have been brilliant Quick service The staff at both Bure Centres have always worked hard to help me Beitlofex didn't work out on a home detox Very good care The care, help and support I have received has been excellent. Helped me to see things differently, mostly very helpful It is not very good in fact it is poor very poor 124
I feel the care I have and still getting over my drug problem is 100% Thanks I felt the subutex the best for stopping heroin. I couldn't help not using since I stop with the subutex because I didn't want the Naltrex I started using heroin again. I couldn't help it. NORCAS Great Yarmouth Yes more notice ie. coming of meth amp. two week notice ie after 7 years prescribing at CAD madness. Two weeks notcie Not really. CADS are good and have helped me. Helpful but run out of pills CADS = a life saver for me, would have died 12 yr ago. Am scared treatment will be stop. Cos urine samps. come back dirty when I haven't used, happens to others too, makes you so depressed. suggest ahir samples. Like book of rights GP doesn't listen, discriminated Rubbish GP doesn't listen to his problems Big stigma in drugs and treatment, particularly with doctors, told to "go away" Long wait to go into treatment Take to long in helping people Need to increase capacity I don't know where I would be if I didn't have ***** ***** probably dead v good generally, once admitted to CADS (NORCAS) scheme, but GP was not helpful. Took far too long to be admitted onto CADS treatment regime they've been excellent at NORCAS and really helped me, I no longer have any desires to take drugs. I hate heroin and at one point thought I'd never be able to get off it, but I have the treatment I receive is second to none too long before starting treatment good treatment. Stopped ampules and changed to liquid methadone over a short period (2 weeks) Happy with how things are at the moment Too busy at clinic although I am working and was clean for 4 weeks I lost my script fpr a month, I used once done good Nurses (female) are fantastic and helpful and receptionists great. Don't like management upstairs. Run ridiculous long waits for appointments. Nurses overworked. Waited 11 months for treatment in Lowestoft then transferred to GY The team are eager to help but if you relapse you get kicked off your script which makes it worse. Ie. Crime, housing and relationships Very helpful. Very accomodating. The only help. Terminally ill, lots vomiting because of problems Yes I have found that being on a maintanance script has helped me to come off drugs and become a more stable person as my life is concerend. I have found subutex great. I have been on methadone before but you can always use on it, I would of been tempted. I think they should put everyone on subutex. The staff have been great towards me. I am very pleased with the treatment and care I have received. I think if it wasn't for ***** I would be dead now. This has been very good for me and it has also given me confidence Brilliant I have not had any help from anyone. I can't moan about the treatment I received The treatment I received here was impeccable. ***** and ***** in particular have helped me beyond expression. I thank people at CADS especially ***** It takes too long for a person to get on a methadone script, which causes the habit to become worse! Are kind and unerstanding When relapse occurs the agency puts you and your children in worse positions by cutting off script. Yes pretty good at moment Very good 125
Sometimes some of the staff have been a bit short tempered and you feel like a burden, but I understand that it is a very stressful job, so I hope that I don't come across as snotty myself. It takes too long for first appointment, too long before starting script, so some people give up waiting and never come off drugs I was put on methadone too young, hence at 33 being on it for nearly 18 years. Very good? Very good Not enough help has been offered because of my situation. Not enough after care Care & treatment was OK. There was one problen, I was working mon-sat, my hours was 7am-7pm and I could not pick up my subutex from **** Chemist in **** Then my subutex was stop! I have received so much care and support, I couldn't ever of done this on my own. I was quite new on the drug scene and I'm happy to say I still am or was. CADS has helped me a great deal to deal with my drug problems etc. Getting clean Service is brilliant once into treatment Too long wait to start treatment Long wait to sort out problems re medication level. Problem with one of the wkrs not being very helpful. Everyone else helpful and nice and friendly. One time script wasn't here, their fault had to use and was stopped script treated ok otherwise If you are in a relationship/both users, problem if one is on a script and one waiting and still using. Problems and pressure for partner on script. Not enough cameras, people trying to sell stuff out side NORCAS. Meetinhg point would prefer chemist think NORCAS Great, take time to help CADS Kings Lynn I have not had a lot of help with housing Bad ? (unreadable word) from GP's and doctors. I think the waiting list to see someone from CADS is far too long when people need help they need it almost immediately so that there in the same place mentally. Two months down the road you could be in completely different circumstances. I don't think no one listened to me or what I was trying to do. Im very happy about help from CADS Try to get things sorted out better inadequate care
(counselling) - knowledge of staff and motivation or even willingness to help addicts who require and ask for help. Found counselling helpful as useful to talk. A lot of doctors will not prescribe or even see you. I need help because I'm dependent and no fixed abode. **** **** has helped me very much with mental and medical help through my GP. I am very happy with the care/treatment I have recieved. I am never looked down upon because of my drug use here, which is often the case elsewhere, including the regular doctors surgery Mancroft Advice Project I have tried to refer to the Bure but would have to wait a month for any help so didn't bother No where to go other than for advice Tier 3 The worker is great and it has helped me. His name is **** **** give him a promotion or more money 126
WSDAS Thetford While having a heroin habit, I found it easy to access services, however whilest having a speed habit (of * yrs) I did not access services because I thought I didn't have a problem when clearly I did. Sometimes its very good, but sometimes it very bad. It depends on what Doctor you have at the time you see them I have only ever received help by methadone script. I found it very helpful, but Benzos have always been a problem. Was not enough help has in one to one Time delay from first appointment and first Meth script Contact NR5 I feel better than I did. Sometimes it winds me up because it is inconvenient. I can't keep appointments. Keep missing them. Don't remember them. Because I have a mental health and an alcohol problem, as well as drugs, it is difficult to get the help I need Its better here than where I've been before. Kept appointments for me. Supported my Mum and Dad to help me get treatment I've received a great deal of help from Ferry Cross - Contact Centre I'd like to thank*** ****. Thanks. Methadone was the biggest mistake of my life. I believe it should be banned as it is worse than heroin. I have been stable on subutex for 16 months. Its been very good Coming out of prison. Need support to stay clean. The Service is tickety boo The care I received from Contact NR5 and my GP has been excellent and has helped me change my life. I am thankful to all concerned. Daily pick up is a good thing but can interfere in other aspects of your life (work) I found that the key workers did seem very helpful, but it did seem that they thought everybody was tarred with the same brush When I wanted care I got it. I was not tested for Hep C in the past. I Now have it. Methadone helps eventually but it takes time to settle down. MATRIX Project Its not just a treatment I need, I need help with lots of other things There's no treatment for crack! Contact NR5 have been a big help Matthew Pro ject very helpful I was successfully on subutex for 9mths until drug worker was changed at B Ctr. She then sent letter to the wrong address and I was kicked off treatment for not replying Arrest Referral Advice from school Got kicked of script for fighting in NORCAS. Am just starting again with NORCAS but it's a long wait It has taken several attempts at getting help and getting "clean". I'm happy I'm now getting help In Highpoint Prison Takes to long to get prescribed Methadone or any other drugs Too long await contact (2 weeks) - Assessment (2 weeks) - Medical (many weeks) - Script. I lost motivation and failed to engage. Failed I breached my DTTO also. Very well looked after Meets 'wrong' people when he goes to the agncy - (dealers) 127
Arrest Referral & Probation for advice. Stopped using myself for 5-6weeks but have relasped and started drinking. Don't want to go to NORCAS-that's where drugusers/dealers are and I'm avioding them In Peterborough - not sure what is in Yarmouth! Advice through Arrest Referral ok but wait for NORCAS too long - too many assessments The Bure Centre take too long Advice through YOI/T's & Arrest Referral No help on coming out of prison Re: alcohol problem Breached DTTO. Trying again - more motivated now. Help good - but need more support in keeping clean. 24 hours not just 5mins/day The people I have spoken to about my problems have told me about the disadvantages that may occur & I think its very helpful. With regard to them, I am glad they come along when they did. I wish they had come sooner maybe I would not be in prison now Not available due to chaotic lifestyle on my behalf Yes it can work if you really want it to With NORCAS but I wanted to reduce methadone quicker than NORCAS did - found last 3mg hardest and relapsed then gave up on NORCAS. Back using for past 4 months Arrest Referral only source of advice I have had no help or support for my drug probs everytime I'v asked for it, apart from when I in Rehab for assessment in 1999. It was not fully my fault that the rehab failed. I feel that I should be entitled like others to be offered help/support Was on script-missed 2 urine tests (chest infection)-got kicked off NORCAS books 128
Appendix 8 - Professionals' questionnaire detailed re sponses
1. What is your organisation's current experience of clients with crack
problems in terms of the approximate proportion of referrals and workload?
Clients with poly-substance misuse presenting with opiate dependency
and crack as occasional use.
A large percentage of our drug using clients use crack at a recreational
level. A smaller number experience difficulties.
Less than 10 referrals for crack as main drug. Out of 12 caseload of D.T.T.O. 6 have crack as 2nd drug.
BC - C
I would say that 80% of clients I deal with use crack regularly or have
used crack recreationally in the past.
Almost 30% of referrals use cocaine as a component issue. Almost 10%
of referrals have significant problem most in association with opiate use (referrals approximately 1250 p.a.).
A large percentage of clients have duel use heroin/crack, approximately
60% at referral. Tends to come from the same dealer.
v What approximate proportion of your work is with people whose main drug of
misus e is crack?
30% (Suffolk clients not Thetford clients)
BC - C
v What approximate proportion of your work is with people whose main drug is not
crack, but who also frequently use crack:
WSDAS CNR5 PR-CADS BC - C BC NORCAS
70% (40% Thetford) 60% 50% 80% 30% 60%
2. What barriers might there be to individuals entering treatment? What sorts
of things do you believe make it difficult for users to have treatment for crack
Users not seeing drug services as being the relevant services for them.
Seeing services being for opiate users: no `substitute' prescribing
options: ambivalence about use therefore. Availability of 24 hour service.
Services have little (perceived) to offer. Chaotic lifestyle. Enjoying
lifestyle and drug use
No prescription available. Waiting list of 6-8 weeks.
BC - C
No real treatment plan. Referral System. No substitute prescription. No
funding for alternative treatments. Waiting time for psychological
Profile of service perhaps not seen as being for them. Difficulty keeping appointments. I believe duel use clients do not have a problem entering the agency. Cocaine users only, I believe do not enter the agency due to the stigma of entering the building or they feel they don't have a problem/addiction.
v How do you "engage" crack using clients?
Offering immediate appointments identification of crack users already in
service. Developing effective client relationship. Supporting other issues
ie. Detox, housing, relationship problems offering high level support to
motivate clients to engage. Address immediate concerns.
Usually over health issues in general practice. In crisis.
As any other client.
BC - C
Offer as much time as possible for `talking' therapy. Try to see them
when they need time.
Client focused appointment arrangements. Frequent initial contact is
Yes mainly on a reduction programme with counselling.
v How open do you believe your clients are about their crack problems when
disclosing information about their drug use?
Having `engaged' clients I have found that they are honest about use.
Problematic group have been these with complex needs ie. Mental health
D.T.T.O. clients do not disclose easily as courts may want this tested
regularly and take action ie. prison
BC - C
Fairly open I feel, though I'm not sure about the frequency of their use.
Usually open. Client self reports match urine drug screen results pretty
Very. We do urine tests twice a week.
3. How accessible do you think your treatment services are to crack cocaine
New service development able to offer immediate access, I have been able to identify existing clients already known to the service and offered
interventions. Further development and advertising service in the future.
Very accessible. No appt service.
I feel people think of the Bure Centre as a service for opiate users only.
Good for greater Norwich and via NORCAS in Great Yarmouth and
Lowestoft. Much less for county.
I think ideally we would have a separate building for crack users, as we
mainly have duel use clients.
Are any of the following issues which affect their access to treatment (tick all that
apply and add any further relevant details). v Your location
Tick. Rural location worker travel time wide area covered.
Tick. Situated in community area.
Tick. Doesn't serve rural location well.
v Your opening hours
Tick. 9-5 only Mon-Fri.
Tick. Need drop in/out of hours.
BC - C
Tick. Evening access may help engage some clients more easily
(currently 1 evening per week)
v Your waiting list
No (positive) aim to offer immediate access prioritising these clients
Tick. We don't have one.
Tick. 6 weeks too long.
v Agitation AK-CNR5 BC - C BC NORCAS
Tick. Drop-in available no appointment Tick. Tick. Possibly Tick. Lack of patience
v These clients not being able to cope with the waiting room
Tick. As above (have a cigarette outside the surgery)
BC - C
Tick. Colegate other arrangements are made if known
4. What crack related behavioural issues are there when providing treatment
Anxiety, paranoia, depression, memory and concentration, mood swings,
panic, thought disorder.
Unpredictable daily patterns, poor concentration, irritability.
Crack users lack for an alternative fix (as methadone) they confuse
mental and physical addiction.
v Are these clients particularly demanding or difficult to cope with?
Importance of regular staff supervision to deal with the demands of this
client group importance of prioritising clients needs.
BC - C
A few heavy users are like that often because of abnormalities in
mental state which have developed.
Perhaps a lack of patience.
v Is violence or intimidation an issue? (for you as staff)
Occasionally usually in context of resolving aggression between clients.
Not as staff. There is an increase in anger and violence outside the
agency with crack users.
v Have you found that violence is an important issue amongst crack users
Fear of violence, usually around debts to dealers.
Yes. Threats of violence frequently reported. High level of secrecy
BC - C
Yes. There is a new level of more serious and organised intimidation.
Yes. Much more so than heroin users.
5. What positive experiences have you had treating crack users?
Regular appointment keeping indicating engagement; recognition of their
own self worth and ability to make change entering into structured day
Clients getting fed up with what goes with it.
People with real commitment to resolve their use. Massive
improvements in psychological health. Return to constructive social
Mainly with duel use (again) we have to have crack off their urine results
before they receive a methadone/subutex prescription.
v What aspects of your treatment do you think clients have found most helpful?
Opportunities to develop new patterns of behaviour setting own short
term goals and achieving them.
Flexibility. Pragmatism to their issues.
Being able to ventilate their feelings.
Engagement with key worker to enhance support and personal
Counselling / support
v Why? WSDAS CNR5 CADS BC - C DR-BC SF-NORCAS
Motivation increases. Self confidence and esteem develops. Care-plan around their paranoid needs. Not ours agenda - less Able to disclose information It's the only immediate service that we can offer. This is the care skill of behaviour change:- a belief in the possibility! Talking through mental addiction triggers/patterns looking at reasons for using etc.
6. What negative experiences have you had treating crack users? What were
Rigidity of a day programme not allowing clients to lapse once and
remain in treatment.
Keeping contact during chaos
Dropped out of contact after waiting list 6-8 weeks.
BC - C
Chaotic lifestyles, agitated, difficult to engage in service, forensic history.
Clients distracted by external pressures/intimidation. Paranoid mental
states and other effects as barrier to engagement.
v Why do you think they occurred?
Organisational issues attitude of team members.
Drug/lifestyle specific problems.
No rapid access.
Crack often leads to desperate measures. Often high levels of criminal
activity (prison sentences!, Bure unable to see client when they need
Drug related social setting. Direct drug effects on individual.
7. What help with other issues are people looking for when they attend
Accommodation, detox, physical health problems, mental health
problems, GP liaison, family/relationship problems, Sex industry, Criminal
activity, childcare, harm minimisation, safer injecting.
Health! Money! ACPC + legal problems
BC - C
Financial advice, housing support, debt problems, childcare issues,
Social Services support.
Treatment for concomitant opiate and alcohol dependence. Psychiatric
treatment. Housing and other social problems.
v What specific health issues do crack users need help with?
Fatigue, respiratory, immune system linked to poor diet, Hep C, liver
damage, dental, skin problems, cardiovascular, sexual health.
S.T.D, sex work, sleep problems, exhaustion, low weight, depression.
BC - C
Respiratory problems, sexual health problems, health screening.
Mental health, HIV and immunisations, sexually transmitted infections,
physical, IV damage, nasal damage etc.
Advice/info around injecting (Hep. C, HIV etc.), infections, cancer
smoking, heart problems etc.
v Do you find that many crack users also need help with alcohol problems, and is
this particularly different to clients using other drugs?
Yes: the effects of crack and alcohol, need to be highlighted as part of
harm minimisation interventions. Alcohol use trigger to crack use. Often
alternative eg. decrease in crack = increase in alcohol as a
BC - C
No & No.
Yes they often do. No it's not different.
v What practical issues/problems do you think crack users are looking for help
Detox, Housing threat of eviction, employment issues, welfare rights,
support for family.
Health, money, legal, housing, Child Protection
, dom. Violence, abuse
from dealers, sex work.
Information / knowledge.
Financial, debts, recreational, jobs, activities, criminal justice system
Healthcare, housing and social, occasionally issues of personal
protection especially the under 20 year age group.
Housing, career/job advice.
8. What are clients looking for in a crack treatment service?
A service that responds positively to their concerns. Availability of worker
and services location and flexibility as to where they are seen.
Knowledge of substance and understanding the effects.
Help with above
BC - C
Something to fill their time / activities / group work. Advice and links with
other agencies. Time to talk.
Problem focused. Personnel care and interest.
Prescribing, counselling/support, information, advice, Poss Hep C
v What would encourage them to make use of a service?
24hr availability. A worker they can trust/relate to. Effective services for
ethnic minority groups. Availability of alternative therapies. Evidence
based psychosocial interventions. Availability of alternative services with
If it were perceived as being on offer, with no other agenda.
Triage, assessment, drop in referral/assessment.
BC - C
More groups, activities, alternative treatments, relaxation classes,
acupuncture, fast track referrals, support groups.
Workers identified as having "specialist skills and interest".
More info. leaflets, possibly separate building, more drop in
Some have mentioned needing .... what do you think?
v `Somewhere to hide' /safe place/drug free space
Assisting with developing safe networks,
BC - C
Referring to drug free space: Often for few days ? few weeks + medical
Tick (safe place).
v Counselling or therapy
Not suitable while using.
BC - C
v Alternative therapies e.g. acupuncture
Many clients have highlighted this as a positive aspect in relapse
BC - C
Tick. Attractive to clients (poor efficacy evidence)
9. Do you think that your services are geared towards treating those
dependent on crack?
New appointment as `stimulant worker' involves the development of this
service. Recognition of this client groups needs.
BC - C
The team members have relevant kills but perhaps not the confidence to
apply them in a formal way of being "geared towards".
Yes, but ideally would offer more if we had more sole use.
v What are the skills you feel drug treatment professionals need to treat crack
Empathy and understanding. Liaison with other services. Compencies
including cognitive behavioural therapy. Psychosocial interventions.
Biopsychosocial model of care. Knowledge re effects of crack. Relapse
BC - C
Counselling skills, listening skills, knowledge, education, patience,
interest, understanding, motivation.
Specific motivational enhancement/cognitive behavioural skills with
confidence to apply these to crack cocaine service users.
Crack cocaine training, counselling skills, understanding of street use and
v Are there aspects of your skills you feel you need to develop to help treat crack
Specific training and skill development. Acupuncture.
BC - C
More training (always helpful). Visit a drug centre that already has a
good working relationship with crack users.
My needs relate more at available time for such focus.
I have had some crack training, further training with sole use agencies
would be beneficial.
10. How could things work better within the current drug services structure for those
dependent on crack?
24hr availability of service. Dedicated stimulant worker.
BC - C
Longer opening hours. 24hr referral. Telephone support. Fast track
referrals. Immediate access. Support groups. Safe houses.
A special interest group within the team whose skills and availability
would enhance practice and service provision.
v How would you promote services for crack users?
Making services accessible and suitable (next day appointments) or on
contact. Use of posters advertising service in key areas. Client network.
Local newspaper, radio. Ensuring continuing care/after care.
Outreach and info legal services, money services, health services.
Fast track, open assessment, drop in.
BC - C
Local newspapers. Hospitals. Police. Leaflet distribution.
Networked word of mouth through existing service users.
11. Overall, do you think that crack users believe that your service is of help to
Clients have on the whole engaged well 0 have benefited from consistant
approach and I feel that I have been able to offer alternative lifestyle
If they use it!
BC - C
No, not for crack as first drug of choice.
v If yes, what is particularly useful? (only add things different from what you may
have mentioned above)
Funding availability for activities structured day care programmes.
Working in partnership with housing/mental health/voluntary and support
v If no, why not? (only add things different to what you may have mentioned
Years of being seen as mainly opiate treatment facility.
R Holland, V Maskrey, J Sadler, R Vivancos, I Harvey