Redressing the Balance: How to Reduce Drug-Related Deaths.

 

There were 4,359 deaths related to drug poisoning in England and Wales in 2018, the highest number and the highest annual increase (16%) since the time series began in 1993. (ONS 2019)

Since the ONS released the drug related death statistics on the 15th August, we have seen responses from the sector attempting to explain this continued growth in drug related deaths, and the measures that can be taken to reverse this trend.  

A default narrative is that this is an ageing cohort. Indeed, those aged between 40 and 49 years had the highest age-specific drug misuse rate at 125.7 deaths per million people. However, this group clearly are not old and it begs the question of where else in the health, or any other sector, would those aged between 40-49 years be classified as ‘old’? 

Others call for overdose prevention sites and heroin assisted treatment. Both are legitimate and evidenced-based suggestions, but they would require additional funding that is separate from the traditional local authority funding. 


‘It is worth noting that prior to 2010, the delivery of OST and harm reduction in the UK was envied by many across the world.’


We are now more frequently hearing about better access to OST and longer duration and optimisation for those that require it. A call for increasing access to harm reduction is also being made, both to reduce deaths and the harms caused. By improving in these two areas, along with the upscaling of Naloxone provision, we can have an impact on drug related deaths.

It is worth noting that prior to 2010, the delivery of OST and harm reduction in the UK was envied by many across the world. So, what went wrong and why did these interventions go into reverse? The introduction of the 2010 Drug Strategy heralded a change in direction from the previous strategy, whereby the emphasis was on waiting lists, retention in treatment, prescribing and harm reduction. 

In contrast, the new strategy was about supporting people to have a drug free life, freedom from dependence on drugs and alcohol. To accelerate this process, targets were set for drug free exits and payment by results was introduced in order to incentivise providers. The process of re-tendering was occurring with increased frequency and any provider bidding for these contracts had to ensure that their recovery makeover would yield results (more drug-free exits).

Why is this important? Well, to engage in this process and deliver on these targets for almost 10 years takes a significant change in workforce culture. The cultural change that has taken place cannot be underestimated in moving from a predominantly harm reduction treatment workforce to a recovery-focused one.

The evidence for accessible and optimised OST alongside well delivered harm reduction not only reduces harm, it ultimately saves lives. 

NHS SMPA reducing drug related deaths

Most organisations will now be encouraging this approach in the knowledge that it could have an impact on reducing drug related deaths. It will also be acknowledged that this change being directed at a strategic level is not being fully embraced on the ground. This will be a source of frustration to some but is to be expected, responsibility for organisational culture sits firmly with the organisation. The sector moved from one extreme to another, harm reduction vs. drug free exits, it now needs to be re-balanced.

We can no longer sit back as bystanders. We need to acknowledge the evidence and address the barriers that prevent the full implementation of a whole range of harm reduction measures. This clearly means we need to: 

  • Redesign drug services to reinstate outreach

  • Move NSP away from pharmacy and back to drug services 

  • Recognise methadone maintenance is in fact the bedrock of evidenced OST. 

  • Re-orientate and retrain the workforce so that the ‘Hierarchy of Harm Reduction’ is not only understood but is core to all that the entire frontline workforce undertakes. 

None of this is anti-recovery (in fact it is pro-early recovery) but only when these changes are realised, might we see a slowing of the current trajectory of these shaming levels of drug-related deaths. 

Most importantly, we need to avoid these mistakes in the future.  As a sector, we should not be silent bystanders meekly implementing government policy that we all know can have significant consequences.  

We should be the guardians of evidence and best practice; and tread very carefully when we step away from this as the implications take a long time to undo.