Drugs policy in England & Wales is failing, according to public health experts in The BMJ. Figures released from the Office for National Statistics last month revealed that there was a 65.7% increase in drugs-related deaths between 2012 and 2015, and a 107% increase in opioid-related deaths. The authors of The BMJ report claim that this is largely due to a focus on abstinence and they make suggestions for a more effective approach.
The same day these statistics were released Public Health England (PHE) published a report that suggested contributors to the rise in drug-related deaths were an ageing population of drug users, variations in street purity, availability of opiates and interactions with other drugs. Their suggestions for decreasing deaths included extensive availability of naloxone, which is used to treat overdoses, updated prescribing guidelines and a new Pubic Health Outcomes Framework indicator for drugs-related deaths. However, John Middleton, President of the Faculty of Public Health, and the other authors of the BMJ article, suggest there are systematic factors that have led to a steep rise in deaths that are being ignored.
The BMJ article outlines factors that they believe have contributed to the rise in drug-related deaths, centred around national policy, commissioning and treatment systems which they say had a pivotal change in 2010. Firstly, responsibility for drug and alcohol treatment was transferred to Local Authorities, which means there is a lower level of clinical governance, integration with other health interventions and commissioning practice. The treatment provider is chosen by the health commissioners, so the treatment that you have access to is somewhat of a postcode lottery.
“With drug and alcohol services now being managed by the public health department of local councils (rather than the NHS), the tendering for those services is decided by councillors who have no idea at all about problematic drug and alcohol users”
Their other main point is that there was a change of focus from harm reduction to abstinence in 2010, with the aim to be to get people to make a “full recovery”. A key method of measuring success used by the Public Health Outcomes Framework was the number of people successfully discharged from drug treatment programmes abstinent from all substances. This is despite the fact that drug users who receive pharmacological and psychosocial interventions have a 50% lower risk of death compared with those following abstinence regimes.
The BMJ article made some suggestions for a better approach to drug policy. They advocate harm reduction initiatives such as substantial provision of naloxone to opiate users and their families and friends, access to clean injecting equipment and immunisation programmes, as well as drug consumption rooms. Opiate substitution therapies should also be on offer and the new measure of drug-related deaths in the outcomes framework suggested by PHE should be supported by structured death reviews. They also said that the government needs to follow through on their 2010 promise of a forensic early warning system informing drug users and services in changes in the quality of street drugs. Finally, they proposed that the NHS and Local Authorities need to jointly commission and plan services and work together for better integration of health care services for drug users.
They concluded: “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 a system failure”.
There has been some support for their conclusions that national drug policy is to blame for the increased deaths. Shirley Cramer CBE, Chief Executive of the Royal Society for Public Health, said: “We agree that the UK’s rising drug death is a sign of system failure and not something that should be explained away as merely the inevitable consequence of an ageing opiate-using population or increased purity. These are certainly significant factors, but we need to build a system that is resilient to these fluctuations and sensitive to the needs of the most vulnerable users. We must do better at engaging and retaining these people within treatment and support.”
She went on to add: “To an extent, the recent focus on abstinence as a measure of treatment success was ideologically driven, and not in line with the evidence of what works in terms of health outcomes for vulnerable uses.”
However, Paul Hayes, CEO of Collective Voice which represents treatment providers, believes that it can’t be concluded that drug policy is failing, as drug-related deaths is just one indicator of harm, whereas both use of drugs and drug-related crime have reduced. He also suggests that a more holistic view of the situation is necessary.
Hayes said: “The emerging crisis facing drug treatment is the increasing fragility of the ageing cohort of heroin users who began using opiates 30 years ago and still represent the bulk of the drug treatment system. The key message in the article is the failure of the current system to join together under NHS commissioned mainstream health care and Local Authority commissioned specialist drug and alcohol treatment.”
He added: “More than anything else the increase in deaths in this population is a consequence of their increasing vulnerability and the inadequacy of the current fractured system to respond to it. It’s a shame this powerful message is obscured by the preceding paragraphs which reflect the prejudices of the authors much more accurately than they do the history of drug treatment policy.”
Others are also questioning how far this article really explains the sharp rise in drug-related deaths, as there are still questions that need answering. Harry Shapiro, Director of DrugWise and former Director of Communications at DrugScope said: “While the reasons given for the steep rises in opiate-related deaths may be valid, there are still many unanswered questions. Why are around half the deaths occurring in those who have never or not recently engaged in treatment. Is the user grapevine about ‘recovery-oriented treatment’ keeping people away? The older user is also least likely to engage with the recovery agenda – so are they being forced out of treatment by service policies?”
This article has shone on a light on how drugs policy in England and Wales, as it stands, could be contributing towards the increased mortality we have seen in the past few years, particularly regarding opioid-related deaths. What seems evident is that different people require different treatment and that having access to both recovery-focused and maintenance-focused treatment is crucial. Whilst some people will want to choose abstinence-based treatment, an over-emphasis on this can drive others away, cause them to drop out or not seek help at all, increasing their risk of death. In this way, it is important for services to be adaptable to the needs of individuals, rather than taking an ideological stance on how people should be treated.
Words by Abbie Llewelyn. Tweets @Abbiemunch