RIOTT Community Impact Study-Full Report

8/3/2019 RIOTT Community Impact Study-Full Report

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An investigation

of the community

impact of a Medically

Supervised Injectable

Maintenance Clinic


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Dr Peter Miller, BA (hons),

PhD

Anthea Martin, BSc (hons)

Jane Walker, BA (hons)

In association with:

Professor John Strang,

MBBS, FRCPsych, MDDr Nicholas Lintzeris,

MBBS, PhD, FAChAM

National Addiction

Centre, South London and

Maudsley Trust

4 Windsor Walk, Denmark

Hill, London SE5 8AF

Contact:Peter Miller, School of

Psychology, Faculty of

Health, Medicine, Nursing,

and Behavioural Sciences,

Deakin University,

Waterfront Campus, Level

3, 27 Brougham Street,

Geelong Victoria 3217,

Australia.

Tel: +61 3 5227 8138

Fax: + 61 3 5227 8621

[email protected]

Executive Summary

The social problems associatedwith alcohol and other drug(AOD) use often play a major

role in the provision of servicesto the client group and affect thewider community in a myriad ofways. One of the major issuesfacing those providing services todrug users (current or ex-) is thecommunity backlash when suchservices are proposed within alocal community. This can oftenhave very serious effects onthe service and has led to the

closure of some much-neededdrug treatment services. Such abacklash is often lumped underthe banner of NIMBYism (NotIn My Back Yard). This studysought to: a) investigate theimpact on the local communityof a Medically SupervisedInjectable Maintenance Clinic(MSIMC) implemented as part

of the Randomised InjectableOpioids Treatment Trial (RIOTT),a trial into the effectivenessand efficacy of the provisionof injectable opioids versusconventional oral methadone; andb) document the expectations,fears and experiences of the localcommunity.

Methods

The research was conductedin two stages over a two and ahalf year period commencingin July 2005. These were: pre-trial key informant interviews;two year follow-up in-depth keyinformant interviews; analysisof Metropolitan Police crimestatistics and; analysis of datafrom the records of fortnightly

Camberwell Street PopulationForum (CSPF) meetings between12/11/2004 and 08/09/2006.

ResultsAt the end of data collectionfor this study, 35 subjects

had participated in the RIOTTover two years. The MSIMCcommenced treating five patientson the 3rd October 2005.

Pre-Trial Key InformantInterviews - summary of keythemesA total of 22 individuals wereinterviewed prior to the RIOTT

commencing. The most commonconcern raised by key informantswas that the RIOTT would havea honey-pot effect or wouldresult in an increase in thenumber of drug users comingto the area. This was closelyfollowed by concerns aroundassociated increases in crime,most particularly burglary andtheft. Two key informants felt that

the provision of a chill-out zonefor clients was necessary. Keyinformants also reported that alack of community consultationby SLaM (also described assecrecy) was a major problem.

Two Year Follow-Up In-Depth Key InformantInterviews summary of key

themesForty key informants tookpart in the follow-up in-depthkey informant interviews. Keyinformants recalled how thecommunitys reaction to theforthcoming trial had beenprimarily one of concern andin some instances outrightopposition, the most obvious

expression of which was theorganisation of a petition signedby more than one thousandpeople.


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A handful of key informantsbelieved that the local communityhad now largely forgotten aboutthe trial. The three key concernscurrently were said to be streetdrinking and anti-social behaviour,alcohol licensing, and youngpeople and violence. Very few

key informants reported either apositive or a negative effect onthe local community that could beattributed to the trial specifically.Most reported no change in levelsof crime, drug use and trading,street drinking, public intoxication,street cleanliness and local tradesince the start of the trial.

Crime StatisticsMetropolitan Police figures showno significant changes in monthlyor average annual crime levels ineither the Borough of Southwarkor the Camberwell Green Wardover the two year study period

(see Figures 1 and 2).

Figure 2 reports crime statisticsfor the local council Ward of

Camberwell Green where theRIOTT is being conducted atMarina House a division ofSLaM. As would be expected, thecomparatively small numbers ofcrimes involved mean that datatends to fluctuate substantially.

Camberwell StreetPopulation Forum Data

Data was collected on theCamberwell street populationbetween 12/11/2004 and08/09/2006. In that time, 81individuals were identified asengaging in anti-social behaviouror being a part of the streetpopulation. Four of the peopleidentified in the street populationdied during the study period. Ofthe 81 individuals identified in

CSPF records, seven (8.6%) hadalso taken part in the RIOTT.There was a clear treatmenteffect for those RIOTT

participants:

All 7 people appeared in the

records of the CSPF whilethey were participating in theRIOTTNo RIOTT participants weresubsequently noted in CSPFrecordsAll RIOTT participantsdropped off CSPF recordswhile enrolled in RIOTTRIOTT participants spent an

average of 20 weeks less onthe CSPF register than thegeneral street population

ConclusionsTeasing out the effects of a small

intervention on a communityinfluenced by so many differentfactors is necessarily difficult. Thelevel of surveillance provided bythe CSPF allows unprecedentedsensitivity in measuring localimpact and suggests an avenuefor further research into theimpact on local communities.The background picture

within Camberwell was one ofoverall stability and all availableinformation suggests that theRIOTT has had little impact either positive or negative.

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Figure 2. Met Police crime statistics Camberwell Green Ward Jan 05-Dec 06


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However, the use of CSPFrecords suggests a substantialtreatment effect for the individualswho appeared on its register,even when considering thepossible confounding effects ofthe street drinking initiative.

This study has also demonstratedthe importance of informingthe community and setting upsystems whereby their concernscan be addressed and theirquestions answered in a timelyand personalised fashion. Theemployment of a Community LinkWorker was repeatedly referredto by many key informants as

being a valuable position for thecommunity. The real value camefrom the community having aknown individual who was a facefor the agency who was there toanswer their concerns.


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BackgroundThe social problems associatedwith alcohol and other drug(AOD) use affect the widercommunity in a myriad of waysand often play a major role in theprovision of services to the clientgroup. One of the major issuesfacing those providing servicesto AOD users (current or ex-) is

the community backlash whensuch services are proposedwithin a local community. Suchbacklash is often lumped underthe banner of NIMBYism (Not InMy Back Yard). However, whilstsome of these reactions comeabout because of ignorance and/ or fear, there are also manyinstances where local residents

do genuinely suffer because ofthe provision of drug services intheir neighbourhood. Anecdotally,many AOD services face someform of community opposition andon occasion this has led to eitherexisting services being closed orproposed services never opening.In the end this means a reducedlevel of service provision for bothdrug users and the community.

This may lead to a consequentincrease in the levels of harmobserved. This phenomenon canapply in the context of clinicaltrials, harm reduction servicesand even traditional abstinence-based treatment services.

Most of the literature surroundingthe efficacy and impact of drugtreatment interventions revolvesaround clinical outcomes forpatients or gross crime figures. Inmany ways this is unsatisfactory,as the health of a community is

multi-faceted and impacts directlyon each of its inhabitants. Recentsociological and anthropologicalwork has demonstrated theimportance of community settingand well-being in terms of on-going management of drug-related harm.

This study documents the impact

on local communities of SouthLondon (Camberwell) of aMedically Supervised InjectableMaintenance Clinic (MSIMC),implemented as part of a trial intothe efficacy of the provision ofinjectable heroin and methadoneversus oral methadone. It alsodocuments the expectations,fears and experiences of thelocal community using qualitativemethods.

The opportunityThe commencement of theMSIMC offers a uniqueopportunity to investigate thisvery complex and importantelement of the implementationof drug services in a communitysetting. While most drug services

are controversial within localcommunity settings, a servicewhich provides injectable heroinis undoubtedly more unpalatableto the community than most. Thistrial offers the unique opportunityof documenting and contrastingthe expectations and experiencesof the local communities wherethis trial is being implemented.The randomised controlled trial(RCT) model of the main trialalso means that findings canlegitimately be compared to thecurrent service provision context.

International contextInternationally, there have beena number of proposed andactual clinical trials which arerelevant to the RIOTT trial.Previous programs have beenconducted in: Switzerland, theNetherlands, Spain, Germanyand most recently Canada. Inaddition to prescription heroin

trials, there are also DrugConsumption Rooms (DCRs)running in Germany, Australiaand Canada. None of theseprograms have yet publishedcomprehensive communityimpact evaluations, althoughsome noted a number of relevantvariables. For example theSwiss prescription heroin trialsreported that both the numberof offenders and the number ofcriminal offences decreased byabout 60% during the first sixmonths of treatment (accordingto information obtained directlyfrom the patients and from policerecords). It was also reported thatincome from illegal and semi-legalactivities decreased from 59% ofindividuals total income originally

to 10%. It was noted that Nodisturbance of note was causedto the local neighbourhoods, orif so only temporarily. However,whilst it has been assumed thatthese findings mean that therewas little or no impact on thelocal community, this was notdemonstrated definitively.

One example of how communityresponses to drug problems canaffect the implementation of drugservices was seen in Melbourne,Australia where the proposed

An investigation of the community impact of a

Medically Supervised Injectable Maintenance

Clinic


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implementation of five DCRsthroughout the city was ceasedby the government following asustained campaign by a numberof community lobby groupsand media outlets. The localVictorian State Governmentproposed the introduction of

these DCRs, following therecommendations of a number ofmajor independent reports andRoyal Commissions. However,once the Government outlined itsplans to implement these DCRs,there was outcry from communitygroups in two of the proposedareas and following a protractedcommunity consultation process,

the proposed DCRs wereabandoned. Unfortunatelydocumentation of this series ofevents was poor and valuablelessons have been lost.

The clinical trialWe recommend that a properevaluation is conducted ofdiamorphine prescribing forheroin addiction in the UK,

with a view to discovering itseffectiveness on a range of healthand social indicators, and its costeffectiveness as compared withmethadone prescribing regimes.(Paragraph 178, House ofCommons Home AffairsCommittee, 2002)

The Randomised Injectable

Opioids Treatment Trial(RIOTT) is a prospective, open-label randomised controlledtrial. Eligible patients (in oralsubstitution treatment andinjecting illicit heroin on a regularbasis) are randomised to one ofthree conditions: (1) enhancedoral methadone treatment (controlgroup); (2) injected methadonetreatment; or (3) injected heroin

treatment. Subjects in injectablearms of the study self-administerdoses up to twice daily in asupervised injecting clinic locatedin South London. The clinical trial

examines the role of treatmentwith injected opioids (methadoneand heroin) for the managementof heroin dependence inpatients not responding toconventional substitutiontreatment. Specifically, thestudy explores whether efforts

should concentrate on optimisingconventional treatment for suchpatients (e.g., ensuring regularattendance, supervised dosing,high doses), or whether suchpatients should be treated withinjected methadone or injectedheroin.

Subjects are followed up for

six months, with between-group comparisons madeon an intention-to-treat basisacross a range of outcomemeasures, including drug use,injecting practices, psychosocialfunctioning, criminality, treatmentretention and incremental costeffectiveness. The primaryresearch site is Marina House, aservice run by the South London

and Maudsley NHS Trust inCamberwell. Stages two andthree of the RIOTT are beingconducted in Darlington andBrighton. However, no measuresof community impact are beingcollected at these sites. Thestudy was proposed as a multi-site trial, with 50 patients in eachgroup, 150 in total. At the end of

data collection for the communityimpact study, 35 drug usershad participated in the RIOTT inLondon.

The local contextCamberwell is bounded byBrixton to the west, Peckham tothe east, Walworth to the northand Dulwich to the south. It hadan estimated resident population

of 51, 2671 people in 2006,with approximately 52% female.Camberwell had more than twicethe national average of childrenliving on benefits in 2006.

Camberwell has a long historyof AOD problems at a streetlevel. There are a number offactors which have contributedto problems experienced inCamberwell. These are outlinedbelow.

Historical factorsThe history of Camberwell as theformer site of the CamberwellResettlement Unit (the Spike),its subsequent closure, andthe ensuing array of rehousingdifficulties factor both into theestablishment of Camberwell as amajor node for the homeless and

into the enduring difficulties facedby poorly placed members of thisgroup.

Social factorsStreet drinkers possess a numberof social and economic problemsof which their drinking behaviouris a major manifestation. Thesocial isolation arising fromsuch disadvantage fosters the

development and maintenanceof public drinking schools,which serve vital social supportfunctions for this group.

Environmental factorsThree elements of theCamberwell environmentmake it one which fosters thepublic presence, behaviour and

persistence of street drinkers andother vulnerable people:1.The concentration andpractices of several serviceproviders which service thisgroup2.The existence of several openpublic parks having no specificuse and the corresponding lackof alternative open space3.The existence and practices of

a large number of off-licences inthe area

Street drinkers and othervulnerable persons can have


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a significant impact on theCamberwell area. They do soin six major ways: 1) they causedamage to public property, 2)they discourage use of publicparks, 3) they hassle traders,4) they panhandle and attemptshoplifting, 5) they contribute to

local safety fears and generaldiscomfort, and 6) they createpublic disorder. Not all streetdrinkers engage in the above-listed practices nor do streetdrinkers represent the solegroup engaged in such activitiesin Camberwell. Despite theircontribution to local fears oversafety, street drinkers and other

vulnerable people are more likelyto be victims than perpetrators ofviolent crime.

During 2002 and 2003, thesize of street drinking groupsincreased significantly as did thelevels of anti-social behaviourthey were engaging in. It isbelieved locally that the increasein anti-social behaviour amongst

street drinkers was the influenceof Marina House and an influxof clients who were using thisservice and socialising with theother clients in the Camberwellarea. This increase in the streetpresence of street drinkersalso coincides with the closureof the open access day centreat St Giles Trust in 2001 that

was used by street drinkers fivedays a week. This service hadbeen open as an open accessday centre for six years in thatlocation. It was used by 80 90people a day. In 2001, it becamemore outcomes-focused withclients requiring an assessmentto determine their need beforethe project was able to workwith them. For some clients this

caused unrest and displacementon to the streets of Camberwell.In January 2005, the day centreclosed completely.

There was considerable concernfrom tenants associations,Camberwell Traders Association,Camberwell Community Counciland Community Forum. In early2003 a Street Drinkers ServicesCo-ordinator (SDSC) post wasestablished. This post holder

facilitated discussion of possiblesolutions with street users, localagencies and local groups.

The result of this post was theCamberwell Street DrinkingInitiative and its operationsforum the Camberwell StreetPopulation Forum (CSPF). TheCamberwell Street Drinking

Initiative was composed of twodistinct forums: the StrategicForum and the OperationsForum.

The Strategic Forum wasestablished to meet on amonthly basis. This operated ata management level to providedirection to the front line staffin terms of the action planning

process and the overall strategyof the Camberwell Street DrinkingIntervention. The membershipwas composed of representativesfrom: the Primary Care Trust(PCT), local community, councillegislative, voluntary sector,Southwark Council, police, SouthLondon and Maudsley NHS Trust(SLaM) and local traders.

The Operations Forum wasestablished to support and informfront line workers and to establishclear communication pathwaysbetween front line workers. Thisforum met bi-monthly. Workersdiscussed individual cases,strategies for working withclients, and the implications ofany strategic decisions made.

The membership was composedof representatives from: theCommunity Safety PartnershipTeam, the Safer NeighbourhoodPolicing Team, St Giles Trust and

SLaM / Marina House.

Between November 2003 andJune 2004, the St Giles TrustCamberwell Street UsersOutreach Service engaged with150 clients. Of this number, 34were identified as being regularly

seen on the street in Camberwelland as the core group of streetdrinkers in the area. The SaferNeighbourhood Team was ableto take this mapping furtherusing their enforcement powers.Using police surveillancepowers and methods, theSafer Neighbourhood Teamphotographed street drinkers

for the purpose of intelligencegathering. The policephotographed a number of streetdrinkers over the course of athree month period, informingclients wherever possible of thereasons for the photographs.From these photographs, theOperations Forum was able toidentify and name a Camberwellstreet drinking population of 150

individuals.

The Operations Forum beganto enact strategies to reduceanti-social behaviour. This wasdefined as including the followingbehaviours: congregatingin groups; threatening andintimidating behaviour; swearing;begging; urinating in public;

defecating in public; spitting;fighting; obstructing walkways orpublic pavements; using offensiveor abusive language; committingassault, criminal damage or theft;using and dealing illegal drugs,and; inciting anyone else toengage in the above behaviours.The Forum, through MarinaHouse staff, also changed theprescriptions of some clients to

coincide with other interventions.Marina House introduced anacceptable behaviour contractfor their service users. Thisrequires clients to agree to not


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engage in unacceptablebehaviour within the Camberwellarea. Increased outreach tenancysupport was also supplied by StGiles Trust.

The next stage identified bythe partnership was to use

Acceptable Behaviour Contracts(ABCs) with street drinkerswho were still congregating inthe area. ABCs are not legallybinding but they do provide theopportunity to highlight to theindividuals they are served on thebehaviour they are engaging inthat is not acceptable to the localservices and community. It was

felt that ABCs could be usefultools to impact on the behaviourof the street drinkers.

A clear and objective protocol forimplementing the ABC processwas established. Supportservices were in place beforeABCs were used. Decisionswere made at the OperationsForum every two weeks. At each

meeting individuals who hadcome to the polices attentionfor committing anti-socialbehaviour four or more times inthe preceding four weeks wouldbe offered an ABC. Beforethis process was implementedthere was a three week graceperiod. This enabled the serviceproviders Marina House and St

Giles Trust to talk to clients aboutthe ABC process, to show themthe ABC document and to explainthe consequences of breachingthe ABC. It also allowed timefor this to be explained to staffin these services. Key workerswere encouraged to explorestrategies with clients of howthey could adhere to their ABCsif these were imposed (this

may have included supportingaccommodation issues, etc.). Theprotocol for Anti-Social BehaviourOrders (ASBOs) mirrored thatof the ABCs. If any individual

breached their ABC more thanfour times in four weeks, thatindividual would be referred foran ASBO.

Each step in this process wasdocumented in Operations Forumrecords. These records have

been kept and form the basis ofthe Camberwell Street PopulationForum data presented below.

MethodsA flexible and reflective studymethodology was adopted.The methodology is based onthe concept of triangulation,which has found that the use

of three or more distinct datasources provides the bestpossible description of a socialphenomenon. This methodologyhas been extensively validated insocial research settings.

The study design incorporateda blend of epidemiological andsocial research methodologies inorder to gather data from three

complementary data sources:crime statistics; key informantsfrom the local community, healthand law enforcement sectors, andcouncil employees and; data fromthe Camberwell Street PopulationForum (CSPF) (documentingindividual level data such ascriminal offences, ASBOs, andpublic disorder offences).

Data sourcesThe research was conducted intwo stages over a two and a halfyear period commencing in July2005. These were: pre-trial keyinformant interviews; two yearfollow-up in-depth key informantinterviews; and analysis ofsecondary indicator data.

Key informant interviewsPre-TrialKey informant interviews wereconducted with 22 selected

individuals interested in thelocal community for the purposeof developing and prioritisingthe study research questions,and to inform the developmentof the in-depth key informantinterview schedule. Stage Onekey informant interviews focused

on participant experiences andperceptions of the current contextin Camberwell or the existinglocal provision of substance useservices.

Twenty-one key informants tookpart in the study:

9 lived in the vicinity of MarinaHouse (i.e., in the surrounding

streets)2 worked in and / or ownedlocal businesses2 local politicians4 worked in local governmentagencies3 worked in local health andsocial care organisations9 belonged to local communitygroups (SE5 Forum,Camberwell Society, and /

or Grove Lane ResidentsAssociation)2 officers from theCamberwell Green SaferNeighbourhood TeamOne key informant worked forthe local Drug and AlcoholAction Team

All participants were interviewed

face-to-face (19 at or near theirplace of work; 2 in their home).Interviews were conductedbetween May and October 2005.Each participant was asked:

How they learned about thetrial and what they thought itinvolvesHow the trial compares toother local issues

What impact they thoughtit would have on the localcommunity in terms of crime,anti-social behaviour (drugproblems / trading, street


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drinking, public intoxication),street cleanliness, and tradeDid they have other concernsabout the trialWhat benefits did theyenvisage from the trialWhat issues they hadexperienced in relation to drug

users in the past monthWhat they would like to seehappenWhether they had anyadditional commentsTo suggest other keyinformants

Two Year Follow-Up In-Depth KeyInformant Interviews

Forty key informants took partin the follow-up in-depth keyinformant interviews:

13 lived in the vicinity ofMarina House (i.e., in thesurrounding streets)8 worked in and / or ownlocal businesses (5 workedin local shops; 1 in arestaurant;1 owned a public

house; 1 owned and workedin a property developmentbusiness)2 local politicians3 worked in local governmentagencies7 worked (1 formerly) inlocal health and social careorganisations9 belonged to local community

groups (SE5 Forum,Camberwell Society, and /or Grove Lane ResidentsAssociation)7 officers (6 current; 1 former)from the Camberwell GreenSafer Neighbourhood Team6 local community wardens

Thirty-four participants wereinterviewed face-to-face (30

at or near their place of work;2 at their home; 2 at theAddiction Sciences Building,National Addiction Centre), sixby telephone. Interviews were

conducted from 1st April to 14thAugust 2007. The interviewschedule for this arm of the studywas developed from the pre-trialkey informant interviews study.Each participant was asked:

How they learned about thetrial and what they thought it

involvesHow the trial compares toother local issuesWhat impact they thought ithas on the local communityin terms of crime, anti-socialbehaviour (drug problems/ trading, street drinking,public intoxication), streetcleanliness, and trade

Did they have other concerns

about the trialWhat benefits did theyenvisage from the trialWhat issues they hadexperienced in relation to drugusers since the start of thetrialWhat they would like to seehappenWhether they had any

additional commentsTo suggest other keyinformants

Crime StatisticsCrime statistics for the Boroughof Southwark and the Wardof Camberwell Green wereaccessed from the MetropolitanPolices crime statistics website

(http://www.met.police.uk/crimestatistics/index.htm). Datawas collated in Microsoft Exceland analysed using SPSS. Crimestatistics are reported for theBorough of Southwark betweenNovember 2004 and November2006. The earliest data availablefor the Ward of CamberwellGreen is for January 2005. TheMetropolitan Police Service

publishes detailed figures forthe numbers of crimes reportedwithin its operational area andthe numbers of cases that aresuccessfully cleared up.

It was decided to reportoffences in this study asthe most relevant statistic todemonstrate the impact on thelocal community. Offences areconfirmed reports of crimes beingcommitted. All data relates tonotifiable offences, which are

designated categories of crimesthat all police forces in Englandand Wales are required to reportto the Home Office.

Camberwell Street PopulationForum DataPaper records from everyfortnightly Camberwell StreetPopulation Forum (CSPF)

meeting between 12/11/2004and 08/09/2006 were kept.These records were entered intoa Microsoft Access database.Data was subsequently analysedusing Microsoft Excel andSPSS. Fields recorded for eachindividual appearing on CSPFrecords included: demographicdetails; whether or not theywere Marina House clients or

RIOTT participants; date of firstmention; date last mention; datecommenced trial, if applicable;date finished trial; whether theyhad received an ABC or ASBO,and if so, when.

Fields recorded for each meetingrecord on CSPF recordsincluded: date of meeting;

individual housing status atmeeting date; borough ofresidence; the number of timesthey had been sighted / reportedin the past fortnight; whetherthey were SLaM clients; streetactivity / behaviours observed;whether their photograph washeld; whether they had attendedthe wet centre; whether theyhad been arrested in the past

fortnight; which area they wereobserved in; the nature of thereport; suggestions from thereport; agencies mentioned in thereport; agency referred to; other


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services / care plan; any otheroutcome details; whether an ABCor ASBO was added; whetherfurther intervention was requiredfrom SLaM, St Giles or thepolice.

ResultsAt the end of data collectionfor this study, 35 subjectshad participated in the RIOTTover two years. The MSIMCcommenced treating five patientson the 3rd October 2005.

Key Informant Interviews:

Pre-Trial Key Informant Interviews- summary of key themes

A total of 22 individuals wereinterviewed prior to the RIOTTcommencing. Key informantsreported that they had mostlyheard about the RIOTTthrough: newspapers (n=6),other community members(n=2), community disclosureprocesses at work (CamberwellStrategic Meeting, n=6) andthrough work contacts (NHS orother government employees,n=6). Table 1 reports the majorconcerns of key informants priorto the RIOTT commencing.The most common concern

raised by key informants was thatthe RIOTT would have a honey-pot effect or would result in anincrease in the number of drugusers coming to the area. More

specifically, key informants wereconcerned that the twice-dailyvisits of the RIOTT subjects tothe clinic would result in manymore people hanging aroundthe streets. This was closelyfollowed by concerns aroundassociated increases in crime,

most particularly burglary andtheft. Two key informants felt thatthe provision of a chill-out zonefor clients was necessary.

Key informants also reported thata lack of community consultation(also described as secrecy) bySLaM was a major problem. Keyinformants said that they believed

SLaM had deliberately avoidedinforming the community aboutthe forthcoming trial and thatthis undermined community trustin the institution. It was furtherreported that this underminedany confidence in the possiblebenefits associated with the trial.One key informant also expressedconcern about increased drugdealing in the area and wasworried that the knowledge ofdrugs being stored in the facilitywould lead to burglary. Otherconcerns included: increase ininjecting litter (n=2); drain on

public transport (n=1); safety forlocal residents (n=1) and; thetreating of the community as aguinea pig (n=2)In general, key informants did

not believe that the RIOTT wouldhave any substantial benefitsfor the local community. Onlyworkers from associated servicesand one police officer believedthat there might be a decrease indrug-related crime.

Prior to the start of the RIOTT,these key informants reportedexperiencing few specific issuesin relation to drug users (notstreet drinkers) in the past month.The most common issue reported(n=2) was a small bit of injectinglitter. These key informantswere understandably unable togive specific details about how

commonly this occurred or howmany needles were involved.One key informant also reportedone or two instances of publicinjecting.

Most non-service providerkey informants reported thatthey would like to see betterinformation about the trial givento the community. Other issues

included: better control overpatients; provision of a chill-out area, ensuring that clientshanging around is not a problemand; regular community dialogueand feedback.

One of the major points raisedby local residents was that theyfelt that they had no control over

what was happening in theirneighbourhood. They also feltthat Marina House and statutorybodies had a similar lack ofcontrol and that if it was clearthat there were people whowere responsible, accountableand dealing with the issues theyfaced, they would be happy forsomeone else to have control.

Two Year Follow-Up In-Depth KeyInformant Interviews - summary ofkey themesAll of the people interviewed inthe pre-trial phase of this study

Major Concerns Prior to Trial

Increase in Street Population

Lack of Community Consultation by SLaM

Increase in Crime

None

Probably Wont Make a Difference

Increased Drug Dealing

N

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11

6

7

1

1

Table 1. Key Informant Concerns.

Respondants were allowed to answer more than once.


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participated in the follow-upinterviews.

Awareness of the trialWhen asked where they hadheard about the RIOTT, 13of 36 people who respondedsaid that they were previously

unaware of the trial. Theseincluded the majority of boththe local Camberwell GreenSafer Neighbourhood PoliceTeam and the local communitywardens. It might be noted thatthe members of both teamswho were not aware of the trialhad come into post after it hadstarted. Two people reported

knowledge of the trial only after ithad started; twenty-one learnedof the trial before it started. Someof these latter were directly orindirectly involved with the trial orworked in local services and hadlearned of the trial through workor colleagues. Some learnedof the RIOTT at a communitygroup meeting or from a groupmember in a less formal context.

Others however reported thatthey had heard of the RIOTT onlyincidentally, second hand or byaccident.

Concerns about the trialThe majority of service providers(working for health and socialcare organisations, the police andcommunity wardens) reported no

or few concerns about the trialspecifically. Some of those livingin the close vicinity of MarinaHouse and community groupmembers voiced a number ofconcerns. Key among these isthe issue of the security of drugsstored at Marina House, that thetrial would bring more clients intothe local area, and that clientswould remain in the area between

doses, behaving anti-socially.

Perceived benefits of the trialSome key informants discussedthe potential benefit of the trial

to clients and to the community.Nearly all key informants whocommented saw the trial asbeneficial to the clients involved.Some saw the provision ofinjectables and / or injectableheroin specifically as a way ofhelping clients toward abstinence;

others as a way of enablingthem to lead healthier, non-criminal lives. Some of those whocommented saw the benefits ofthe trial as entirely to the clients.Others however thought that thecommunity would benefit becauseclients were injecting in the clinicrather than on the street therebyreducing the risk of injecting

waste, by reducing the diversionof drugs, and by reducing theincidence of crime committed tobuy drugs.

Introduction of and initial reactionto the trialKey informants recalled howthe communitys reaction tothe forthcoming trial had beenprimarily one of concern and

in some instances outrightopposition, the most obviousexpression of which was theorganisation of a petition signedby more than one thousandpeople. This reaction was seenas warranted given the localsituation into which the RIOTTwas introduced.

The first key feature of thissituation was the number ofexisting services in Camberwell,such that many residentsperceived Camberwell asinundated with services. Thesecond was the street population/ drinking problem and itsrelationship with Marina House.Key informants mentioned thefollowing anti-social behaviours in

relation to the street population:congregating in groups andtaking over public spaces andamenities, abusive language,drinking and using drugs publicly,

urinating and defecating publicly,littering, begging, shoplifting,opportunist crime, sex working,trading drugs, and violenceamong themselves.

Several key informantsdescribed this situation as

being compounded by a lackof adequate information aboutthe trial. As with certain ofthe concerns voiced aboutthe trial, it was felt that somepeoples reactions were basedon a misunderstanding of whatthe trial would involve. It wasacknowledged, for example,that many people were unaware

that Marina House requiretheir clients to leave the areabetween treatments and werealso unaware of the relativelysmall number of clients whowould be recruited onto the trial.With regard to the presentationsat community meetings byrepresentatives of the trial,a significant number of keyinformants were critical that

these failed to engage with localconcerns. The lack of communityconsultation was also raised asan important issue. Conversely,all those who commented praisedthe subsequent appointment andthe work of the Marina HouseCommunity Link Worker.

Reaction to the trial now

A handful of key informantsbelieved that the local communityhad now largely forgotten aboutthe trial. The three key concernscurrently were said to be streetdrinking and anti-social behaviour,alcohol licensing, and youngpeople and violence.

The impact of the trial on the localcommunity

Very few key informants reportedeither a positive or a negativeeffect on the local community thatcould be attributed to the trialspecifically. Some suggested


13/208

that an increase in crime mightbe expected on account of theadditional clients coming intothe area to attend the service;while others suggested that theprovision of injectable heroin toclients should lead to a decreasein criminal conduct. However,

most reported no change in levelsof crime, drug use and trading,street drinking, public intoxication,street cleanliness and local tradesince the start of the trial. Thosewho did notice some differencein one or more of these domainsdid not relate this to the trial. Keyinformants mostly reported theimpact of the trial as a complex

issue.

The impact of Marina House andthe street population on the localcommunityWhile key informants saw the trialas having little or no impact onthe local community, the inabilityof the community to differentiateRIOTT clients from otherMarina House service users is

problematic. This state of affairswas attributed to the overlapbetween the street population andMarina House clients. The healthand social care providers whowere interviewed identified onegroup of clients as significantlymore visible and liable tobehave anti-socially than others.Specifically, these are clients who

share the characteristics of thoseidentified by the Street DrinkingInitiative, namely those whoreceive a supervised consumptionmethadone prescription and arealso street drinkers.

Crime Statistics

Metropolitan Police figuresshow no appreciable changesin crime levels in the Borough

of Southwark over the two yearstudy period (see Figure 1). Thisprovides an overall context inwhich the crime statistics of localwards can be better understood.

Figure 2 reports crime statisticsfor the local council Ward of

Camberwell Green where theRIOTT is being conducted atMarina House, a division ofSLaM. As would be expected,the comparatively small numbersof crimes involved mean that datatends to fluctuate substantially.

Paired samples t-testcomparisons of annual averagesdemonstrate no significantchanges over the study period forany of the different categories ofcrime (see Table 2 overleaf).

Reporting these figures in adifferent manner, Figures 3-7

report the trends for each offencein Camberwell Green Wardduring 2005 and 2006. None ofthe analyses show any significantchanges in crime over the twoyear period.

Camberwell Street

Population Forum Data

Data was collected on theCamberwell street population

between 12/11/2004 and08/09/2006. In that time, 81individuals were identified asengaging in anti-social behaviouror being a part of the street

1800

1600

1400

1200

1000

800

600

400

200

0 Nov06

Oct06

Sep06

Aug06

Jul06

Jun06

May06

Apr06

Mar06

Feb06

Jan06

Dec05

Nov05

Oct05

Sep05

Aug05

Jul05

Jun05

May05

Apr05

Mar05

Feb05

Jan05

Dec04

Nov04

Burglary Criminal Damage Drugs Offences


Date

Numberofoffences

RIOTT commence date


8

7

6

5

4

3

2

1

0Dec06

Nov06

Oct06

Sep06

Aug06

Jul06

Jun06

May06

Apr06

Mar06

Feb06

Jan06

Dec05

Nov05

Oct05

Sep05

Aug05

Jul05

Jun05

May05

Apr05

Mar05

Feb05

Jan05

Burglary Criminal Damage Drugs Offences Fraud or Forgery

Other NotableOffences


Date

Numberofoffencesper1000

RIOTT commence date



14/209

Crime

Burglary

Criminal Damage

Drugs Offences

Fraud or Forgery

Other Notifiable Offences

Robbery

Sexual Offences

Theft and Handling

Violence Against the Person

Mean 2005

(Per 1000

Population)

1.43

1.67

1.22

0.89

0.27

1.67

0.15

4.98

4.13

t-value

(df=11)

1.43

1.67

1.22

0.89

0.27

1.67

0.15

4.98

4.13

Mean 2006

(Per 1000

Population)

1.43

1.67

1.22

0.89

0.27

1.67

0.15

4.98

4.13

p-value

(df=11)

1.43

1.67

1.22

0.89

0.27

1.67

0.15

4.98

4.13

Table 2. Camberwell Green mean crime rates 2005/6

8

7

6

5

4

3

2

1

0 Dec06

Nov06

Oct06

Sep06

Aug06

Jul06

Jun06

May06

Apr06

Mar06

Feb06

Jan06

Theft and Handling 2005 Theft and Handling 2006



2

1.8

1.6

1.4

1.2

1

0.8

0.6

0.4

0.2

0 Dec06

Nov06

Oct06

Sep06

Aug06

Jul06

Jun06

May06

Apr06

Mar06

Feb06

Jan06

Burglary 2005 Burglary 2006

population. The vast majority ofthese people were identified as

street drinkers. There were 19(23%) females and 52 (77%)males. Four of the peopleidentified in the street populationdied during the study period.

Individuals identified in CSPFrecords were mentioned for anaverage of 45 weeks (range:0-95, SD=35 weeks). The maindrug of choice of the street

population was alcohol, followedby: crack, heroin, methadone andcannabis (see Table 3).

Of the 81 individuals identified in

Drug of Choice

Alcohol

Crack

Heroin

Methadone

Cannabis

Unknown

N

11

11

6

7

1

1

Table 3. Drug of Choice in Camberwell

Street Population


15/2010

2.5

2

1.5

1

0.5

0Dec06

Nov06

Oct06

Sep06

Aug06

Jul06

Jun06

May06

Apr06

Mar06

Feb06

Jan06

Drugs Offences 2005 Drugs Offences 2006

2

1.8

1.6

1.4

1.2

1

0.8

0.6

0.4

0.2

0 Dec06

Nov06

Oct06

Sep06

Aug06

Jul06

Jun06

May06

Apr06

Mar06

Feb06

Jan06

Fraud or Forgery 2005 Fraud or Forgery 2006

3

2.5

2

1.5

1

0.5

0 Dec06

Nov06

Oct06

Sep06

Aug06

Jul06

Jun06

May06

Apr06

Mar06

Feb06

Jan06

Criminal Damage 2005 Criminal Damage 2006

Figure 5. Drugs Offences (Per 1000 Population) 2005-06

Figure 6. Fraud and Forgery (Per 1000 Population) 2005-06

Figure 7. Criminal Damage Offences (Per 1000 Population) 2005-06

the CSPF records, 7 (8.6%)had also taken part in the RIOTT.There were two females and five

males. One person appearedin CSPF records before theytook part in the RIOTT, but hadceased being identified by thetime they enrolled. The remaining

six people appeared in therecords of the CSPF while theywere participating in the RIOTT.

All six individuals were identifiedas part of the street populationprior to participating in theRIOTT.

All of the six RIOTT participantswho appeared in CSPF recordshad stopped being identifiedin the street population by thetime they finished treatment inthe RIOTT. On average, theywere enrolled in the RIOTTfor 15 weeks (range 1-33

weeks, SD=13.2) before theywere last mentioned in CSPFrecords. Last mentions typicallyreported that the individual hadnot been sighted for a longtime, suggesting that some ofthese individuals had not been aproblem for the local communityfor longer than this figureindicates.

In comparison, the average timeon the CSPF register for thewhole street population was45 weeks (median 40 weeks;SD=35.0). The longest timespent on the register was 95weeks. This suggests that RIOTTparticipants spent an averageof 20 weeks less on the CSPFregister than the whole street

population.

As reported in Table 4 (overleaf),RIOTT participants who appearedin CSPF records were mostoften reported for being seenon the street (n=4), drinking onthe street (n=2), giving hassleto Police Community SupportOfficers (PCSOs) (n=2) and

begging (n=1).

One individual had also signed anAcceptable Behaviour Contract(ABC) four months prior to theirinvolvement in the RIOTT. Noneof the RIOTT participants whoappeared in CSPF recordsprogressed to ASBOs orcustodial sentences. None of theRIOTT participants were arrested

during this time for criminaloffences.


16/2011

DiscussionThe triangulation of data sourcesgives a strong picture of crimeand public disorder in the Wardof Camberwell Green and thewider Borough of Southwark. Itwas clear that from the outset,the problems related to streetdrinking threatened to drownout the possibility of measuringany impact related to the RIOTT.However, this same problem,

and the subsequent communityresponses, has also provideda unique vehicle for monitoringthe effect of any interventionat an individual level. CSPFdata has allowed this study to

map community impact froman independent direction tothose usually employed. Byhaving an unprecedented levelof surveillance on this streetpopulation, this study was ableto identify whenever a RIOTTparticipant became a noticeableproblem for the local community whether for a criminal offence or

for anti-social behaviour.

Pre-trial key informant interviewshighlighted the importance ofengaging with the communityprior to opening new services inthe area. The lack of informationavailable about the trial and theperceived secrecy of its launchcombined to create a situationwhere misinformation was

allowed to rule. This allowed localresidents very understandableand justified fears to come to thefore. Subsequent interventionssuch as the employment of a

Community Link Worker andthis Community Impact Studyhad a significant impact on thecontext in which the RIOTT wasconducted. The CommunityLink Worker, whose role was toengage with the local community,deal with any drug-related issues

which might arrive and educatethe community about drugtreatment, was employed for oneyear. Community members were

also satisfied that conducting astudy of the impact of the RIOTTon the local community wouldmean that their voice wouldultimately be heard. Most keyinformants felt that a good deal

of anxiety and ill-feeling amongcommunity members could havebeen avoided if the introductionof the trial had taken place earlierand the approach had beenmore appropriately tailored to theaudience.

Community concernsThe major concerns about

the trial expressed in pre-trialinterviews were an increase inthe street population, an increasein crime and an increase indrug dealing. Crime statistics,CSPF records and subsequentkey informant interviews havedemonstrated that none of theseconcerns have been realised. Aswill be discussed in greater detaillater, it is difficult to determine

how much of a positive effectthe RIOTT has had on the localcommunity. The majority of thedata presented here can onlystate that there has not been a

Offence

Seen on Street

Drinking on Street

Hassling PCSOs

Begging

Number of Individuals

4

2

2

1

Table 3. Drug of Choice in Camberwell Street Population

negative effect.

A positive effect?The findings from analysis ofcrime statistics and in-depthkey informant interviews showno gross positive effect on thelocal community. Of course,

only 35 people were involvedin the RIOTT during the studyperiod. It is not clear how muchdifference 35 individuals couldmake, although were each tobe a prolific offender, changesmight be reflected in local crimestatistics. Left at this level of data,which has been the approach inprevious trials of heroin-assisted

treatment, it would appear thatthe RIOTT had failed to achieveone of its major goals thereduction of criminal behaviour.

However, the findings fromCSPF records demonstratea clear treatment effect. All ofthe six RIOTT participants whoappeared in CSPF recordshad stopped being identified

in the street population by thetime they finished treatment inthe RIOTT. On average, theywere enrolled in the RIOTT for15 weeks (range 1-33 weeks,SD=13.2) before they were lastmentioned in CSPF records.This time line more than likelyoverestimates the length of timethat people were on the register.

People on the register wouldbe noticed long after they hadceased to be a problem becauseit was the same group of peopleidentifying them (and so morehighly attuned to individuals whohad been on the register in thepast). Regardless of this, it isclear that every individual whopresented a problem for the localcommunity prior to enrolling in the

RIOTT, ceased to be so withinan average of 15 weeks. Thisaverage of 15 weeks was foundto be 20 weeks less than theaverage amount of time spent on


17/2012

the register by the general streetpopulation, suggesting thesepeople did far better in treatmentthan their street-based peers notenrolled in the RIOTT.

LimitationsComparing data from different

sources across different timeperiods has many inherent flaws.The greatest confounder forthis trial comes from its mostsensitive data source. The factthat the RIOTT was running atthe same time as the CamberwellStreet Drinking Initiative meansthat causality is very difficultto attribute. However, CSPF

data showed that the RIOTTparticipants spent an averageof 20 weeks less on the CSPFregister than the general streetpopulation. This should onlybe taken as suggestive of thepositive treatment effect of theRIOTT, as it may be that thosemost likely to succeed wereattracted to the trial. Exclusioncriteria for the trial might have had

a similar effect.

The other major limitation forthis study is the extremely lownumbers of people enrolledin the RIOTT during the studyperiod. On the whole it is unlikely,outside of the worst casescenario, that 35 individuals willhave a major effect on a local

community. The use of CSPFrecords has addressed this issuesubstantially in terms of beingable to document the behaviourof those who were visible to localenforcement officers and healthworkers. However, this maymean that people who are lessnoticeable do not appear on therecord, but still have an impact onthe local community.

Key informant data was alsoconfounded to some degreebecause it is virtually impossibleto distinguish normal Marina

House or St Giles serviceusers from those who areenrolled in the RIOTT. This hasimplications for being able toestablish causality of impact beneficial or detrimental on thelocal community. Similarly, thisstudy was unable to objectively

document other indicatorssuch as injecting litter (dumpedneedle and syringes). It would beadvantageous to have a systemwhich recorded the impact ofinjecting-related litter in localcommunities.

ConclusionsTeasing out the effects of a

small-scale intervention on acommunity influenced by so manydifferent factors is necessarilydifficult. The level of surveillanceprovided by the CSPF allowsunprecedented sensitivity inmeasuring local impact andsuggests an avenue for furtherresearch into the impact on localcommunities. The backgroundpicture within Camberwell was

one of overall stability and allavailable information suggeststhat the RIOTT has had littleimpact either positive ornegative. However, the useof CSPF records suggests asubstantial treatment effect for theindividuals who appeared on itsregister, even when consideringthe possible confounding effects

of the Street Drinking Initiative.

This study has also demonstratedthe importance of informingthe community and setting upsystems whereby their concernscan be addressed and theirquestions answered in a timelyand personalised fashion. Theemployment of the MarinaHouse Community Link Worker

was repeatedly referred to bymany key informants as beinga valuable position for thecommunity. The real value came

from the community having aknown individual who was a facefor the agency who was there toanswer their concerns.


18/2013

AcknowledgementsThis study is funded by the

Austin and Hope Pilkington

Trust, GlaxoSmithKline

and Action on Addiction.

PM is jointly funded by

the J. Paul Getty Junior

Charitable Trust and ThePilgrim Trust. NL was

funded by an Australian

government NHMRC Neil

Hamilton Fairley Clinical

Research Fellowship

during the development

of the study. The authors

would also like to

acknowledge Lesley King

Lewis, Annabel Kennedy,

Amanda Thomson, BeckettVester and staff at Action

on Addiction, staff and

clients at SLaM NHS

Trust. We would like to

particularly thank David

Johnson who helped us

setting up this study and

introduced us to many of

the key people and themes

surrounding this topic.Solomon Brown assisted

with data entry and

analysis for this study and

Julie Latimer was endlessly

helpful in supplying us

with detail and context of

the street drinking issue.

Marcia Martins (formerly

Community Link Worker for

Marina House) conducted

some interviews. We wouldlike to thank all of our key

informants for giving their

time and knowledge freely.

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Documents

RIOTT Community Impact Study-Full Report