Drug related deaths in England and WalesBMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5259 (Published 17 October 2016) Cite this as: BMJ 2016;355:i5259
- John Middleton, president1,
- Sara McGrail, independent health policy specialist2,
- Ken Stringer, independent consultant in substance misuse2
- Correspondence to: J Middleton,
Figures from the Office for National Statistics published last month show that total drug related deaths in England and Wales increased by 65.7% and opioid related deaths by 107% between 2012 and 2015.1 These figures exclude deaths from bloodborne viruses and other conditions related to use of illegal drugs, so the actual mortality associated with drug use will be higher. In a report published the same day, Public Health England2 suggests contributors to the increase in deaths, including the rising age and increased physical frailty of drug users, interactions with other drugs and new psychotropics, and variations in the street purity and availability of opiates. Over half of the drug related deaths were among people who used opiates and had had no recent contact with drug services.
Public Health England suggests local and national actions to counter this public health emergency, including use of its updated prescribing guidelines, more extensive availability of naloxone, and a new Public Health Outcomes Framework indicator for drug related deaths. The report is silent, however, on systemic factors that may have led directly, or indirectly, to the steep rise in mortality. There have been massive changes in national policy, commissioning, and treatment systems since 2010 and hard lessons need to be learnt.
Focus on abstinence has failed
Between 1997 and 2010 the English national drug strategy followed a harm reduction approach, including the use of opiate substitution therapies.3 4 5 This changed in 2010 when the government reframed strategy to place abstinence at the heart of all treatment.6 7
At the same time, within the Public Health Outcomes Framework,8 the key measure of success became the number of people successfully discharged from drug treatment programmes who were abstinent from all substances—including substitute medications—and did not return to treatment for 6 months or more. Thus the system created targets and financial incentives to get people out of drug services.9 However, time in contact with services is protective2 10; drug users who receive pharmacological and psychosocial interventions have a 50% lower risk of death compared with those following abstinence regimens.10
The Health and Social Care Act 2012 transferred responsibility for public health to local authorities. Drug and alcohol treatment were no longer classed as NHS services and became subject to a lower level of clinical governance, commissioning practice, and integration with other health interventions. Earlier changes had curtailed both the commissioning and the strategic role of local partnerships, reducing their ability to work in a coordinated way to manage substance use.11 The provider market and commissioning practices increased treatment provision by large corporate charities.12 In the current aggressive procurement culture we risk losing much NHS and local expertise in this area.
The effect has been startling. Our treatment population has begun to fall.13 The numbers of people defined as “successful completions” is now equalled by the numbers of people dropping out of or discharging themselves from the treatment system.13 Investment in lifesaving interventions like naloxone has been sluggish.14
More effective approach
Public Health England’s report makes some welcome suggestions, but we need to do more. Local authorities must ensure substantial take up of naloxone to opiate users and their family and friends for administration at overdose. We need to expand the options available to people seeking help and ensure treatment is personalised and effective. Non-structured interventions, including the provision of safer injecting advice, access to clean injecting equipment, and immunisation programmes, should be priorities for investment, and new initiatives such as drug consumption rooms should be developed to ensure we are able to attract drug users into treatment and protect them when they are not.
New guidelines on opiate substitution therapies should be followed diligently, with heroin substitution therapy as part of the prescribing toolkit.4 15 The new measure of drug related deaths in the outcomes framework should be supported by mandatory structured death reviews. The government’s 2010 promise of a forensic early warning system informing drug users and services of changes in the quality and type of street drugs must be delivered if we are to stand any chance of identifying harmful new substances.6
General practitioners need better support in providing primary care, particularly for an ageing cohort of opiate users. Underlying respiratory disease exacerbates the respiratory complications of opiate use and leads to a higher risk of death.16 Further research is needed into the place of respiratory screening in older users. Smoking cessation services need to be offered systematically. The NHS and local authorities need to jointly commission and plan services, as well as work together to ensure that all hospital specialists caring for drug users are fully joined up with primary care and specialised treatment services.
Helping people achieve their own recovery remains an important aim of any drugs strategy. However, efforts to provide drug users with access to better housing, jobs, and incomes that support recovery are not helped by austerity policies.
The lessons of a failing national policy need to be learnt. The approach of harm reduction was born—under a Conservative government—in response to the threat of HIV. It saved countless lives. When focus shifted away from harm reduction, deaths began to rise. We welcome the incorporation of drug related deaths as a measure in the outcomes framework. However, if death rates are an accepted measure of system performance, the current trend is surely evidence of system failure.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.