Safe Supply Heroin Clinics, costly or called-for?

Criminal supply results in thousands of deaths each year, impacting those whose lives are defined by poverty, trauma and family breakdown disproportionately. After witnessing the treatment in action, I can see how HAT, if widely adopted, could limit the most distressing impacts of heroin addiction, benefit the public purse and offer hope that far outweighs the initial cost.

A Question of Funds

As a prescriber already pinched by underfunding, Kaleidoscope’s commitment is to make treatment accessible to the most people. When prescribing pharmaceutical grade Diamorphine, unsurprisingly, costs soar. Prescribing a cheaper opiate substitute like methadone expands treatment places available. And so initially, I felt sure that HAT was at odds with our primary aim.

Interested to learn more about this model of care and its impacts, I travelled from Newport to Middlesbrough to visit Foundations, alongside Gwent Drug and Alcohol Service lead Rondine Molinaro and Elwyn Thomas, who provides outreach to our most vulnerable cohorts and advises on co-production across Kaleidoscope.

A Tale of Two Cities

When it comes to demographics, Middlesbrough is broadly similar to Newport. Both populations live under the weight of an industrial past, have a history of docking and a working transporter bridge. The town centres have seen better times with any up and coming shops and restaurants choosing to locate outside the centre.

Foundations is the primary treatment provider in Middlesbrough, supporting more than a thousand people in the area, of which just 20 are currently prescribed heroin assisted treatment.

To qualify for HAT, certain criteria must be met. The individual must attend a treatment setting twice daily, making a commitment to the programme and willingness to limit other drug use necessary. The treatment is therefore aimed at the most challenging cohort; those trapped in repetitive cycles of drug use and criminal behaviour. And its places are funded via the Home Office’s ADDER Project.

The True Cost

Currently, Public Health England requires HAT provider Foundations to dispense Diamorphine via individual vials, rather than direct from a bottle. Dispensing from the bottle would cut costs to roughly £5000, compared with the current cost of £15,000 per treatment place, per year. I struggled to see the logic in PHE’s position on this. The requirement leads to increased waste, inflated cost and no discernible value.

I also wondered, why Diamorphine specifically? A regulated opiate imported to help local farming economies in poorer parts of the world could be worth exploring.

Danny Ahmed, Foundation’s Clinical Partner, outlined the true cost of not acting, when public costs associated with the most entrenched drug users, such as those supported in this project, are estimated at £2 million. If these 20 people were caught and imprisoned for example, the bill for a single place in a UK prison costs the taxpayer more than £43,000 a year.

If we move away from pure costs there are significant health gains. Critically, the people accessing this care have failed to benefit from other substitute programmes, dropping out of them and continuing to live in the chaos of addiction. Those we spoke with shared how they had re-connected with family, were able to enjoy a holiday or even become peer Naloxone Champions, as a direct result of HAT treatment.

A Day at the Clinic

Danny Ahmed showed us around and introduced us to those benefitting from the treatment. They were happy to chat with us, showing trust in the project’s staff.

Rondine and Tommy, who both have lived experience of addiction, met with people as they injected.

Rondine said; “I was lucky to meet with three of those benefitting from HAT. As

they injected Diamorphine they shared their stories, and how HAT had improved their lives. Two were living in hostels and had endured repeated cycles of drug use, harm, offending and prison for decades. ‘Without HAT’ they agreed, ‘I would definitely be back in prison right now, or I’d be dead’.

As a contract manager, the sad reality is cost will always be a factor. However when you calculate the cost to the public purse of drug related crime, imprisonment, probation, overdose and death – HAT starts to feel necessary.

All three had a light in their eyes, something that is often missing from people fighting to stabilise in treatment. They demonstrated hope, dignity, respect and most importantly – renewed connection with their families and with wider society. Colleagues who deliver services to the most hard to reach cohort, those entrenched in these cycles, will appreciate how moving that was to see.’’

Elwyn said; “What struck me immediately was how the people receiving twice daily doses of diamorphine presented. They were clean and tidy, well-nourished and hydrated. They were calm and respectful toward staff and waited orderly for their turn.

Upon entering the supervised injecting space we were met with a nurse and a clinical key worker who took it in turns to prepare the diamorphine whilst the other supervised the injecting. I shadowed three males injecting, two of whom chose to inject in their legs, the third into his arm. The first man injected into his shin with ease, no anxiety whatsoever. He had used the same site for the last two years, with no damage to tissue or veins, or reddening or inflammation whatsoever. All three men were long-term IV users, yet their injecting sites were clean of any infection or inflammation.

All three were given time to inject at an unrushed pace. The knowledge that the diamorphine is of a pharmaceutical grade reduced the anxiety considerably.”

Following our visit, I would support Kaleidoscope following the lead of Foundations and Daniel Ahmed, without any real doubts. The challenge is cost and securing additional resource from the Welsh Government. Current budgets are tight and if it were not for Welsh Government’s additional support, we would not even be able to prescribe Buvidal, the long acting buprenorphine injection. As is often the case, the real problem is a lack of joined up thinking between criminal justice, health and other areas.

The current situation means too many clinical decisions are not based on need, but on the budget one is given. This is an issue that needs urgent remedy so those most in need get the help they deserve.

Martin Blakebrough

CEO at Kaleidoscope