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Failing national drugs policy behind rising death toll, say experts

Moving from harm-reduction approach to a focus on abstinence led deaths to rise

Louise Prime

Tuesday, 18 October 2016

We must learn lessons from our failing drugs policy in England, experts have warned in The BMJ this morning. They argue in their editorial* that the current situation is a public health and primary care emergency. They call for better support for GPs looking after an ageing cohort of opiate users, better commissioning of services and more coordinated work between the NHS and local authorities.

Office for National Statistics figures published last month showed that, between 2012 and 2015, total drug-related deaths in England and Wales increased by 65.7% and opioid-related deaths by 107%. Professor John Middleton, president of the Faculty of Public Health, and co-authors pointed out that actual mortality associated with drug use is even higher, as these figures exclude deaths from bloodborne viruses and other conditions related to use of illegal drugs.

They said there is good evidence that time in contact with drugs services is protective – drug users who receive pharmacological and psychosocial interventions have a 50% lower risk of death compared with those following abstinence regimens – and from 1997 to 2010, in response to the threat from HIV, the English national drug strategy followed a harm-reduction approach, including the use of opiate substitution therapies.

But despite this, in 2010 the Conservative government reframed drugs strategy to place abstinence at the heart of all treatment, and created targets and financial incentives to get people out of drug services. The new ‘measure of success’ became the proportion of service users successfully discharged from drug treatment programmes who were abstinent from all substances (including substitute medications) and did not return to treatment for at least 6 months.

Following this, the Health and Social Care Act 2012 transferred responsibility for public health to local authorities. Because drug and alcohol treatment were no longer classed as NHS services they became subject to a lower level of clinical governance, commissioning practice, and integration with other health interventions; earlier changes had already made it more difficult to take a coordinated approach to managing substance misuse, and the provider market and commissioning practices increased treatment provision by large corporate charities. Professor Middleton and colleagues warned: “In the current aggressive procurement culture we risk losing much NHS and local expertise in this area.”

They called for a far more effective approach, including better support for GPs in providing primary care, particularly for an ageing cohort of opiate users, adding that underlying respiratory disease exacerbates the respiratory complications of opiate use and leads to a higher risk of death. They advised that the NHS and local authorities must jointly commission and plan services, as well as work together to ensure that hospital specialists are teamed up with primary care and specialised treatment services.

They also called for:

  • local authorities to ensure substantial take up of naloxone to opiate users, and their family and friends, for administration at overdose
  • expansion of the options available to people seeking help, ensuring that treatment is personalised and effective
  • establishment of a forensic early warning system to inform drug users and services of changes in the quality and type of street drugs
  • investment to be prioritised for non-structured interventions – including the provision of safer injecting advice, access to clean injecting equipment, and immunisation programmes
  • development of new initiatives such as drug consumption rooms to attract drug users into treatment and protect them when they are not
  • new guidelines on opiate substitution therapies to be followed diligently, with heroin substitution therapy as part of the prescribing toolkit.

They concluded: “The lessons of a failing national policy need to be learnt. The approach of harm reduction … 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.”

* Middleton J, McGrail S, Stringer K. Editorial: Drug related deaths in England and Wales. A public health and primary care emergency. BMJ 2016; 354: i5259 doi: 10.1136/bmj.i5259.

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