Additional advice regarding Substance and Gambling Harm

Introduction

Mental health and the harm from gambling and alcohol and other drugs are frequently considered and experienced together. In recognition of this, the Diagnostic and Statistical Manual of Mental Disorders (DSM) and other medical texts, government strategies, and health sector organisation management responsibilities generally incorporate substance harm alongside or under the ‘umbrella’ of mental health.

Many of these similarities are described in the Ministry’s submission to this Inquiry. To summarise:

There is no one path through which people experience mental health and addiction. Issues occur across a spectrum, and there is no single path to life-long recovery and wellbeing

In both areas interventions and care need to be in place across that spectrum from primary prevention and self-help to tertiary interventions. Preventative and low-threshold interventions are generally lacking at present in New Zealand

The social determinants of mental health and substance and gambling harm are the same. In both cases there is a complex interplay of factors that lead to (and result from) the issues that an individual may experience

Likewise, the issues that people experience alongside mental health and addiction also vary, and include trauma, violent offending, poverty, homelessness, stress and life changes/transitions.

Māori remain disproportionately affected by mental health and addiction issues. In 2015/16, 37 percent of Māori were classified as hazardous drinkers. Estimates from the 2012 National Gambling Study suggested that close to 50 percent of problem gamblers and close to 40 percent of moderate-risk gamblers are Māori or Pacific people. Equity issues are particularly stark when considering the criminal justice sector, with Māori three times more likely to be arrested, prosecuted and convicted.

Mental health and addiction issues are often chronic relapsing conditions but are treated using the same medical model that envisages a beginning, middle and end point to illness.

As suggested in the Ministry’s submission to this Inquiry, there are number of system changes needed across workforce training, models of care and other aspects to address this issue.

This paper focuses specifically on issues related to substance and gambling harm; the current services and approaches in place, and further work being considered to address these issues.

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1. Current Challenges and Issues

Demand management

All substance addiction treatment services would report that there is strong demand for their services. This would include demand for the full range of addiction treatment, including assessment, withdrawal management (detoxification), counselling, residential treatment, and specialist services such as opioid substitution treatment (OST).

The recent commencement of the Substance Addiction (Compulsory Assessment and Treatment) Act 2017 highlighted concerns within the treatment sector that they would be overwhelmed by new demands for people requiring assessment. Four months post-commencement the Ministry has instituted a formative evaluation of the legislation’s implementation. While the data so far would indicate that the commencement of the Act has not resulted in a huge wave of new assessments and consequent committals, comments in surveys as part of the evaluation reinforce the view that resourcing (funding and staffing) of services in the face of strong demand remains a significant factor.

For OST services, access in many instances is immediate. However, this is for assessment only, and people may have to wait 1-3 weeks before they commence on medication. In addition, an important part of that service is providing psycho-social support as part of an agreed treatment plan. For some people, this may be so they eventually withdraw completely from prescribed opiate use. In reality services may become so busy in assessing clinical matters that there is little time available to address those psycho-social issues. Services then become stuck in a cycle of increasing clinical loads when there may be people who could transition out if only there was time to address this. This also highlights the difference between a medical model and a wider recovery-focused approach for addiction treatment.

Residential treatment providers contracted by the Ministry to address the harm caused by methamphetamine frequently report strong demand, and extensive waiting times and lists for people wanting to be admitted. The Ministry and the Department of Corrections are working together to align the way residential treatment services might be contracted in the future. This is because the agencies appreciate that they, and DHBs, are contracting with the same limited number of providers.

There is a risk that the public (and political) perception is that residential treatment is the preferred, or “default” treatment of choice for methamphetamine addiction. This could result in people not seeking help because of perceived or real delays in being admitted, when in fact there are other treatment options, and that there are steps that can be taken prior to a bed becoming available. In 2017, the Ministry revised its website to highlight the range of treatment options available.

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There has been only limited progress in societal attitudes towards substance and gambling harm in New Zealand

Alcohol, drug use and gambling are common in New Zealand, for example it is estimated that 80 percent of New Zealanders aged 15 years or above drank alcohol in the last year (Ministry of Health, 2013) and the 2012 National Gambling Study (Abbott et al 2014c) found that 62 percent of adults bought at least one Lotto ticket in the last year.

Use of alcohol and other drugs and participation in gambling occurs on a continuum from no use/gambling activity to addiction or dependence, with a range of levels of harm in between that people may find themselves in at various stages in their lives. A complex interplay of social and criminal justice issues leads to societal attitudes and expectations towards substance and gambling harm which can in themselves increase harm.

Alcohol and gambling are legal, but regulated. For some population and age groups, levels of drinking and gambling that are harmful remain normalised and accepted, and this can be exacerbated by marketing campaigns. It is worth noting that misuse of, or addiction to, alcohol and gambling is often associated with illegal activities (for example, drink driving, fraud, theft). However, it is often seen as being due to a lack of self-control, rather than driven by neurological change caused by substance misuse or gambling harm.

The system and services can inadvertently create barriers and stigma

Different service models have been used to provide an integrated approach at a service level in New Zealand. However this alignment remains far less apparent for clients, who will frequently receive treatment from different people, often at different locations, using different types of intervention (there is much greater use of pharmacological interventions for mental health), and in some cases different attitudes in terms of when someone could or should access treatment.

Services themselves can at times unwittingly reinforce stigma – particularly self-stigma – by focusing on abstinence and an individual’s apparent level of motivation, requiring clients to reduce substance use or consumption before addressing other confounding factors, and by instituting stand-downs from treatment due to relapse.

In addition, often mental health and addiction services treat the medical need alone at the expense of physical health and other social needs. While referrals can be made, the time and effort required by clients to manage this process result in lack of service and not feeling valued. In order to address this, an unsustainable situation often exists where practitioners individually endeavour to take on a range of roles that better encompass a wellbeing framework.

Services to prevent and minimise gambling harm are funded through the Problem Gambling Levy, with a separate strategy required under the Gambling

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Act 2003 to inform how this levy will be spent. While this creates a sustainable funding source for services, and is cost-neutral to the government (the Ministry of Health receives an appropriation which the Crown then recoups through the levy), it also drives a silo for these services there is only limited scope for supporting clients’ other needs. Current contracts acknowledge this by allowing for facilitation to other services, however loosening the legislative framework would reduce this barrier.

There is also unmet need amongst people who may have inadvertently become dependent on prescription pain medication. While this is a considerably greater problem in other jurisdictions – for example in North America where fentanyl has become a significant cause of harm – people in this situation do not always recognise the need for help, and can experience barriers to accessing services.

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Workforce

Addiction services are often available through non-governmental organisation (NGO) providers who may have a broader approach and scope to treatment than their DHB counterparts. Historically, the workforce has been peer-based, with many people in recovery forming the basis of both the professional workforce and the peer and consumer workforce. While a desire for a more skilled workforce over recent years has been necessary to an extent, this risks eroded funding for peer-based support, and may become a barrier to multi-disciplinary approaches.

At present, clinical training for addictions incorporates mental health, but mental health does not incorporate addictions. This reinforces the separation of services and the barriers this creates for clients (as mentioned above) some of whom are ‘bounced’ from one service to another, rather than being seen and supported holistically.

Treating substance use as a criminal issue is stigmatising and creates barriers to treatment and help-seeking

Possession and use of illicit drugs is treated as a criminal justice issue. The involvement of legal issues plays a significant role in the stigma and discrimination experienced by people living with addiction, and are a key driver of unwillingness to seek help. Legal issues can result in the breakdown of relationships, the loss of employment and/or housing – in other words, the weakening or loss of social determinants of health. This, in turn, can become a driver of more intense substance use or gambling as a means of temporary ‘escape’.

For some people, particularly those experiencing illicit drug-related issues, this results in a prison sentence. The link between prison sentences and drug harm is clear - substance dependence for those in prison is 30 times the general population, and 20 percent of those in prison have both a mental illness and an addiction issue (Indig, D., Gear, G., Wilhelm, K., Comorbid substance use disorders and mental health disorders among New Zealand prisoners, Department of Corrections 2016). Treatment for addiction and substance misuse is available in Corrections facilities, however links to services ‘outside the wire’ are not strong, with health-funded services often unwilling to take Corrections clients (particularly gang whānau) in large numbers or in some cases, at all. In addition, while some clients will be abstinent during their time in prison, the environment into which they are released has the influences that resulted in their substance misuse or addiction in the first place.

Unmet and unrecognised need results in intergenerational harm

One result from the interplay and impact of issues identified above is unmet or unrecognised need, frequently ‘passed on’ from generation to generation. This can range from the normalisation of harmful substance use or gambling in the household or community to conditions such as Fetal Alcohol Spectrum Disorder, regarded internationally as the leading preventable cause of intellectual and developmental disorders. Continued cycles of harm such as these drive a loss of

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wellbeing through lower educational levels, the insecurity of employment, and generally erode the determinants of health, leading to worsening quality of life and increased harm.

2. Current Services and Approaches to Dealing with Substance Abuse and Gambling Harm

The Ministry supports taking a holistic approach to drug use, and addiction generally, with services reporting that people are presenting with increasingly complex needs. This means that sometimes the substance abuse is not the immediate priority for example the person may be in a violent relationship, be dealing with trauma, needing accommodation. However, contracts may be too narrow if they are for treatment only. The Ministry has recognised that a “health” or a “holistic” approach will help address a possible range of co-existing issues. The methamphetamine residential treatment service contracts are for a package of care, and include elements to support whānau ora approaches and continuing care: other contracts include whānau plans that recognise the part that reduced substance use can play if wider aspirations are to be achieved for families/whānau.

Over time this approach has the potential to address the stigma and discrimination associated with substance and gambling harm, and to increase help-seeking and reduce intergenerational harm.

As identified previously, addiction treatment is not a single type of service, but includes assessment, withdrawal management (detoxification), counselling, residential treatment, and specialist services such as opioid substitution treatment (OST). Each of these in turn can include elements of prevention, early intervention, and continuing care and relapse prevention, as well as a medical intervention.

Funding for service provision is fairly evenly split between DHB delivered services and those provided by NGOs. DHBs do not directly provide residential treatment services, but instead contract for some 450 beds nationwide from the NGO sector.

While traditionally, DHB services were the specialists, this is not always the case, for example, in the Wairarapa, the DHB has withdrawn from providing specialist services, and has contracted an NGO provider to deliver specialist OST services.

Other specific initiatives currently in place are outlined in the following sections. Several of these initiatives involve multiple agencies to try and join up services for service users.

Alcohol and Drug Treatment Courts

The Ministry is responsible for the funding and procurement of the treatment services supporting the Alcohol and Other Drug Treatment Courts (AODTC) located in Auckland. It is a cross-agency collaboration involving Health, Justice, Corrections and Police and is being evaluated over the coming months. The

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AODTC is an abstinence-based model designed to work with offenders facing up to a three year prison sentence with an alcohol and/or other drug (AOD) dependency that drives their offending.

Once in the programme, the court participants are supervised through a judicial process (courts) and a treatment programme to help them address their AOD issues and prevent them from re-offending. Funding for the AODTC is in addition to services already funded by the local district health boards.

Te Ara Oranga Methamphetamine Reduction Pilot

This is a joint initiative between Northland District Health Board and local Police, and includes an investment in additional services, and allows for Police referrals into those services. An initial review of Te Ara Oranga Methamphetamine Reduction Pilot in Northland has shown that having Police able to refer to services, alongside the increase in services available to enable faster access, has meant an increase in new clients (meaning those not already known to services) to treatment.

Pregnancy and Parenting Support Service

The Pregnancy and Parenting Support Service is an assertive outreach initiative that provides case co-ordination and intensive services for parents of children under three and pregnant women who are experiencing problems with alcohol and other drugs, and are poorly connected to health and social services. It aims to reduce harm and improve wellbeing of children by addressing the needs of parents whilst working to strengthen the family environment. Assertive outreach involves bringing services closer to the community, working with social and other community services such as Oranga Tamariki to identify and support women and their pēpi/whānau.

PPS originally operated from one site (Waitemata DHB) and serving approximately 100 women and their families per annum. This programme has developed over the past fifteen years to reach 200 women across metro-Auckland. In 2017, it was replicated in three other sites (Northland, Tairawhiti and Hawke’s Bay DHBs), at similar scale (i.e. to serve approximately 300 additional women and their families in total per annum across the three sites). A particular challenge has been to transfer a service that has evolved and developed over a long period of time and to have it implemented in those other sites in a much narrower timeframe. This has been achieved through the Ministry funding Waitemata DHB to facilitate and coordinate the implementation with the other sites, as well as funding project management in the other three DHBs. The relationship between the four sites has now developed from a mentoring one to one of peers.

A concurrent evaluation of the pilot is being carried out to inform any potential roll-out of this type of service. Engaging the evaluation team early has developed trust about the information being gathered and will help ensure the right

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information is available after three years, when recommendations will be made about continuation and possible extension.

Asian Family Services

Asian Family Services (AFS) are part of the Problem Gambling Foundation and are currently the only service that provides public health and intervention services specifically to Asians in New Zealand who are experiencing gambling harm. The establishment of this service recognised that “Asian” is the fastest growing ethnic community in New Zealand with a population of 471,708 (11.8%) according to the 2013 census, and it is expected to increase to approximately 900,000 by 2025.

This growing population has significant emerging health and social issues that require attention to ensure they do not exacerbate and become a greater burden to New Zealand’s Asian community and the health system. Emerging mental health issues include problem gambling, alcohol and drug addiction.

AFS provides culturally appropriate services in different Asian languages, including Cantonese, Mandarin, Korean, Vietnamese, Japanese and Thai. Interpreters can also be arranged for other languages.

At present, there are no Asian specific substance use services. Clients with co-existing issues are required to be referred to local DHB treatment services or to mainstream NGOs. Clinicians in those organisations are not culturally trained and talking therapies are usually done through an interpreter. This process reduces the effectiveness of psychological interventions as it becomes difficult for clinicians to build a connection with their clients. Asian clients also feel that clinicians may not fully understand their issues as they do not speak the same language nor understand their culture, so they believe clinicians can only provide very minimal help and support.

Rebuild of Auckland City Mission

The Ministry recently supported a process to allocate $16.7 million in Proceeds of Crime to contribute to building two floors of a planned rebuild of the Auckland City Mission (Mission HomeGround). The floors will house social and medical detoxification services funded by the local district health boards. This aims to achieve positive outcomes for people who are experiencing substance dependence as well as other complex needs by supporting the development of co-ordinated primary and secondary health, addiction treatment, housing and social services, provided in a single location, at the right time and by the right service.

3. Further Work Being Considered

It is clear that addiction services have been under pressure and further work is required to address this. It is also apparent that a more focused overall approach would be useful to ensure services and initiatives complement each other and so that the workforce can be deployed in ways that are more efficient and effective.

Some other areas the Ministry has focused on to begin to achieve this and to address the issues identified earlier include:

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Gambling Harm Prevention

Updating the Gambling Harm Strategy

Legislation mandates that there be a specific strategy to address gambling harm. This is required to be updated at regular intervals, and requires the Ministry to undertake a needs assessment (commissioned externally), and broad consultation with a variety of stakeholders, including the industry, service providers, and the wider community.

This work is currently underway.

Investigating areas where the equity gap appears to be growing, for example in the Waikato

The Ministry has been aware that there has been limited service provision to reduce gambling harm across the Waikato region, and a particular gap for Māori and Pacific communities. It has initiated work with the DHB and service providers that will address future service provision.

Substance Use Treatment

Collaboration with Other Agencies

It is becoming more common for agencies to work together to address the causes of substance use issues including addiction, and the provision of addiction treatment. While cross agency programmes such as the Prime Minister’s Tackling Methamphetamine Action Plan and the Prime Minister’s Youth Mental Health Project required agencies to work together, agencies are likely to seek opportunities to work together.

The Te Ara Oranga Methamphetamine Reduction Pilot is an example of this, but there is also other work such as the Department of Corrections working with the Ministry to align service specifications and procurement processes for methamphetamine residential treatment services. Some DHBs are working with Police to facilitate access to treatment following drug-related operations.

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