Title: Unmet Need for Substance Misuse Treatment Among Opioid, Crack and Dependent Alcohol Users
Funder: Department of Health and Social Care

Abstract: Research question: What are the current circumstances and histories of substance use among out-of-treatment substance users, what are the barriers to treatment engagement and how might these be addressed in future? Background: It has been estimated that 47% of opiate users, 60% of crack users and 83% of dependent drinkers are currently out of treatment. These cohorts are associated with particularly high levels of mortality, morbidity, crime, homelessness and associated costs. Evidence demonstrates that engaging people in structured treatment significantly reduces these harms. However, little previous research has been undertaken on out-of-treatment substance users and the obstacles to their engagement. There is therefore a pressing need for the current study. Aims and objectives: cohorts of crack users, opiate users and dependent drinkers who have not engaged in treatment for at least one year will be accessed and interviewed. Questions will explore users current living circumstances, past and current patterns of substance use, previous encounters with treatment services, current barriers to engagement (including those experienced by female, BAME and LGBTQ+ users), and the types of treatment support that they would like to receive. These cohorts will be compared with local and national in-treatment populations. Methods: This research will involve: Two case studies in Hackney and Middlesbrough (employing both quantitative and qualitative elements); A literature review and an analysis of NDTMS; Interviews with 15 professionals in each site with knowledge of out-of-treatment groups; 40 interviews with out-of-treatment drug users in each site, eliciting quantitative and qualitative data on 15 heroin, 15 alcohol, and 10 crack users; Quantitative data on an additional 25 crack and opiate users in each site (Total across both sites = 130); A national survey of treatment providers to test the generalisability of our findings; and Three policy-focused workshops with key stakeholders (including peer researchers) to develop recommendations. Supported by the presence of lived experience within the research team, we will train and support four peer researchers drawn from local drug services to recruit drug users out of treatment. Interviewees will also be accessed through Hospital Alcohol Health Workers and NGOs working with vulnerable groups. Timeline: The work for this study will start in January 2022 and run for 18 months. Months 1-6 Comprehensive literature review; analysis of NDTMS data on in-treatment populations; 30 interviews with professionals working in drug treatment and other sectors. Months 4-15 80 interviews and 50 questionnaires with our three out of treatment cohorts. Months 15-17 We will undertake a rapid survey of treatment providers and other agencies to test the generalisability of our findings. End Month 18 Report to NIHR PRP Dissemination: four journal articles will be prepared for submission and two conference papers presented at international conferences. Articles for the Conversation and Drink and Drug News will be prepared and submitted. The team will also explore with NIHR the potential for a national conference chaired by Dame Black, aimed at drug service commissioners and drug agencies, with a focus on different models of engagement with out of treatment users.

Lay abstract: There are approximately 250,000 people using heroin and other opiates, 180,000 using crack cocaine and 600,000 people dependent on alcohol in England. However, only 50% of the opiate users, 40% of the crack users and 20% of the dependent drinkers are receiving treatment for their substance use. This substance use is linked with large numbers of deaths, ill-health, crime, homelessness and economic cost. Furthermore, there is good evidence that drug and alcohol treatment is effective &ndash; saving lives, improving health and reducing crime. It is therefore a high priority to get the untreated into treatment. We know remarkably little about these three groups and this study aims to address this gap by interviewing people in each group who have never been in treatment before or been out of treatment for at least one year, asking them about: current substance use pathways into substance use life circumstances (e.g. accommodation, relationships) previous treatment experiences knowledge of treatment barriers to treatment, including for BAME and LGBTQ+ users impact of COVID-19 support they would like in future This 18 month study will be in two locations: Hackney, London and Middlesbrough. Both have particularly high levels of opiate and crack use and dependent drinking. It will involve: A review of previous research, focusing on the factors that enable or discourage people from entering treatment. 15 interviews with key professionals in each location &ndash; including people working in drug and alcohol treatment, health services, probation and charities. 40 interviews with substance users out of treatment in each location &ndash; 15 with opiate users; 15 with dependent drinkers; and 10 with crack users who do not use opiates. A short survey with a further 25 crack and opiate users in each site. Researching substance users who are not in treatment is challenging and we will use three approaches. Firstly, we will work with specialist alcohol nurses in hospitals to identify patients with drink and/or drug problems, who are not in treatment for interview. Secondly, we will work with four people currently (or recently) in treatment in each location who will help us to identify people in our target group, set up interview and administer the short survey ('peer researchers'). Thirdly, we will work alongside organisations who work with the homeless, sex workers and other vulnerable groups to identify people in our three groups for interview. Our peer researchers will be identified early in the study and will form a vital part of the study s development. We will work with them in each site to ensure that their input informs how the study is undertaken and involve them in making sense of the findings and their implications for policy and practice change.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: MENTAL HEALTH