We must re-energise our response to increasing drug-related deaths

The Office for National Statistics (ONS) has published its annual drug misuse deaths report, which shows that there were 4,115 deaths last year due to drug poisoning. The figures show another record high in England and the seventh year in a row of increases. Now more than ever we need to re-energise our efforts in national and local government to help the most vulnerable people get the support that could save their lives.

This blog looks at some of the report’s main findings and the actions we’re taking to prevent future drug-related deaths.

Understanding the challenge that we face

Most drug misuse deaths are related to heroin (46%). Heroin deaths have more than doubled since 2012 and these deaths drive the overall trend.

Most people using heroin started in the 1980s and 90s and are heavily dependent. They are some of the most marginalised members of our society and experience considerable health inequalities. Many will have had very difficult lives well before they first used heroin, and now face increasing physical and mental health problems as they get older, due in part to their long heroin use. In this context, the high rate of heroin deaths is likely to continue.

But this ageing group of heroin users does not fully explain the increases. We know that drug treatment protects against drug-related death but, as Dame Carol Black reported in her first Review of Drugs, we also know that the size and quality of the treatment workforce has been depleted. In many areas, the range of treatment options has reduced, and inpatient detoxification and residential rehab services are both increasingly rare.

So, it’s reasonable to expect that a reduction in treatment services alongside drug support services helping people with other aspects of their lives (like housing) have played some role in drug deaths reaching current levels.

Deaths related to other drugs have also increased. For example, cocaine deaths have risen six-fold since 2011. A large proportion of these were heroin overdose deaths where crack cocaine was also used. This is consistent with other evidence of increased crack availability, purity and use. However, it is likely that some of the increase in deaths is due to powder cocaine which is used more widely across society.

Factors that could lead to much higher deaths in future

In Scotland, the common use of benzodiazepines alongside heroin (a dangerous combination) has contributed to historically higher deaths rates. As new and more potent benzos have emerged, deaths have surged. While this pattern of use is far less common in England, there are signs that it’s increasing, which could make the situation here worse.

North America has high rates of drug-related deaths like those in Scotland. This is driven by powerful synthetic opioids like fentanyl, often taken unwittingly by heroin users. A spate of deaths in England linked back to a single small drug gang in 2017 showed how devastating fentanyls could be if they became an established feature of the heroin market here.

The long-term outlook

Once addicted to heroin, it is very difficult to stop. It’s notable that despite two decades during which far fewer people have started using it, the impact of the epidemics of the 80s and 90s is still reflected in increasing heroin-related deaths. Perhaps the most important determinant of the level of drug-related deaths in two decades’ time will be the numbers in which younger people start taking drugs today.

There are some signs that recent progress made on tackling drug uptake is at risk of being lost. For example, increases in drug prevalence among school children, an emerging group of younger adults using crack cocaine, and the exploitation of young people through ‘county lines’ all ramp up this risk. There is also a very strong link between deprivation and drug use, so it’s critical that through any economic downturn there are good quality services and opportunities for young people.

How has COVID-19 affected the drug using population?

We are taking a close look at the impact of COVID-19 on deaths among people who use drugs and alcohol, as well as the impact of the lockdown and resulting changes to treatment.

The high level of comorbidities among heroin users could make them more vulnerable to serious illness. However, although they are getting older, few are yet in the age brackets where COVID-19 poses the highest risk.

There may be long-term economic implications affecting the services and opportunities available for people with drug problems, which could have a greater impact on this population than the virus itself. An economic downturn and high unemployment could also lead to an increase in the number of people dependent on drugs and alcohol.

Drug treatment and recovery services, like all services across health and social care, have had to adapt to the COVID-19 pandemic. From the outset they have stayed open to protect the vulnerable people at greatest risk, helping reduce the burden on other healthcare services. As we all learn to live with the virus, services are again increasing hepatitis C testing and treatment and resuming hepatitis B vaccination schedules, where they have been interrupted. There is still some way to go and we must remain focused, returning services to normal as soon as it is safe to do so and adapting wherever we can.

What we’re currently doing to prevent drug-related deaths

There is important work underway, aimed at preventing mortality and morbidity among drug users.

For example, our opioid substitute treatment (OST) good practice programme will provide practical and user-friendly tools and resources for drug treatment and recovery workers. We also want to help people in drug and alcohol services stop smoking and will help key workers identify lung problems with a simple lung health screening tool.

Wound infections resulting in amputations, kidney failure and death are increasing, so we’re producing resources for commissioners, services and service users to help identify and stop them.

PHE is also providing advice and guidance on how to maximise the availability of naloxone and is reviewing how services and individuals, other than drug services and their staff, can provide naloxone.

The Ministry of Housing, Communities and Local Government and the Department of Health and Social Care is investing £262m over the next three years to ensure that people who experience homelessness are supported to get drug and alcohol treatment services when they need it, especially as some move from emergency accommodation into longer term accommodation.

Looking ahead

Part two of Dame Carol Black’s independent review of drugs will report to the government at the end of this year, which will hopefully lead to a more consistent focus on what nationally and locally we can do to tackle drug misuse and the preventable deaths that arise from it.

While we must remain realistic about what will be possible, we must create an ambition to prevent the conditions that could lead to a new generation finding themselves dependent on drugs. Evidence and experience tell us the consequences will stay with us for a very long time if we fail.

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Contributor: Rosanna O’Connor