Drug related deaths: getting some fundamentals right

ADPH Vice-President Prof Jim McManus argues for the importance of getting the fundamentals right when it comes to tackling the complex issue of drug-related deaths

Today the Office for National Statistics published the latest figures on drug related deaths. And we have seen an increase. In particular, on top of the news about accidental poisoning a couple of weeks ago, we have cause for concern.

But as usual with this topic people will seize on it to provide easy solutions to what is a complex problem. So let’s bust some myths before we get down to the fundamentals we need to get right to stop people dying.

Myth 1: It’s all down to the changes in commissioning in England

This is simply not true. Scotland has had no changes in commissioning of drug treatment and has seen numbers of deaths rise far beyond England rates, and continue to rise, year on year. Similarly, the rise in England started in 2011, well before transfer of responsibility.

A major national review of drug related deaths concluded there were multiple factors including the age, immune system and respiratory health of some cohorts of opiate and opioid users, access to a range of treatment including NHS treatment and supply of drugs. We also know overdosing becomes more likely if your treatment is not properly calibrated and you use drugs on top of what is prescribed.

This is not about who commissions drug treatment. It is about how we ensure people get into the right services for their needs. And this means clear pathways for drug treatment needs, and for other needs like physical health, mental health and housing.

Myth 2: There is no residential rehabilitation left

Despite the efforts of one or two for-profit companies including UKAT (UK Addiction Treatment Centres) to convince us that this is all down to residential rehabilitation placements, this simply isn’t true.

First, the Scottish and English experience have both seen significant rises in drug-related deaths so the attempt to claim a move away from residential rehabilitation centres is the cause simply does not stack up.

Second, no amount of residential rehabilitation will treat people who need lung or chest treatment because of long term respiratory suppression from smoking and opiate use, plus multiple other conditions. In and of itself this is not the solution.

The examples of service innovation in the 2017 Collective Voice report demonstrate more appropriate approaches to preventing and managing overdoses than an approach based primarily on residential rehabilitation. One clearly effective intervention is ensuring Naloxone is available for appropriate use – this will save lives.

We know residential rehabilitation doesn’t work for everyone. For some it works well as part of a pathway of care. But it isn’t, never was, and never will be the main way we need to address this public health challenge.

Does that mean nothing can work?

No, there are things which can work. But in order to get to them we need to set aside the self-interested myths put about by people who stand to profit from them while the issues remain unaddressed. I mentioned above the Collective Voices approach, which collected a range of innovation from various places in reducing drug related deaths. Some of these are being adopted elsewhere. Some of these tools and methods are slow to roll out.

We can reduce drug-related deaths, but there are two vital ingredients we need. The first is proper funding – this is an area that has experienced severe cuts over the last 11 years (see Commissioning Impact on Drug Treatment report and Drug and Alcohol Services in Scotland publication). And the second is for public health commissioned services and NHS commissioned services to work together – integration is the way we will succeed.

So what should be done?

Here are my key steps:

1. Identify the populations at highest risk – we do know mostly who they are, and we will typically find they have multiple needs , many are ageing, many have suppressed immune and respiratory systems and they are vulnerable for a number of reasons including housing and social support
2. Ensure they all have good primary care which understands the complexity of their needs and ensures they can access services appropriately
3. Ensure they get good quality drugs treatment
4. Get every commissioner and provider together and build a pathway around this population, with a range of treatment. Specific lung and chest health, for example, needs to be included in this. So does housing
5. Continue to make Naloxone more available and more usable
6. Ensure clear joined up pathways from custody into the community. NHS England has often been conspicuous by its absence and people have often been discharged from prison without clear links into community services or given Naloxone. This is failing them.
7. A national review of what works and roll out of evidence-based practice and innovation where we don’t know what works best
8. A national strategy for drugs and one for alcohol which focus on saving lives and keeping people healthy.

This needs funding, and both the cuts in public health funding and the lack of anything about drugs in the NHS Long Term Plan should give us major cause for concern.

Drug treatment remains almost absent from the heath policy debate. While the NHS Long Term plan suggested a greater say in commissioning of sexual health, it was telling it didn’t mention drug treatment. It was telling that the Green Paper on prevention mentioned sexual health, but didn’t mention drugs. This is not policy which is focused on burden of disease to people and society. If it was, we’d have drugs higher up the agenda.

People who use drugs and who have complex needs as a result are still fellow-citizens whatever some may think of them. They have rights, and the NHS constitution applies every bit as much to them as it does to anyone else. Intervening effectively will save lives.