Reducing heroin-related deaths

Drug treatment key

Maintaining the capacity and quality of drug treatment is essential to prevent further increases in opioid-related deaths.

That is the principal conclusion of a new (12 December 2016) report ‘Reducing opioid-related deaths in the UK’ by the Advisory Council on the Misuse of Drugs (ACMD) which investigates the causes of the increase in drug-related deaths and the most effective potential responses.

The figures

There has been a sharp rise in the number of people dying from heroin and other opioids over the last three years:

The findings

The ACMD’s Drug-Related Deaths (DRDs) Working Group found that there is a sizeable number of people who have used heroin since the 1980s and 1990s with complex health problems. These people are increasingly vulnerable to opioid-related deaths as they age.

The figure below shows that people born in the 1960s and 1970s have continued to be at the highest risk of opioid-related death for 20 years:

The report says:

We can assert with a good degree of confidence that the increasing vulnerability of the UK’s ageing cohort of heroin or opioid users with increasingly complex health needs (including long-term conditions and poly-substance use), social care needs, and continuing multiple risk behaviours is highly likely to have contributed to recent increases in drug-related deaths.

The panel of experts also outlines other potentially important issues:

Other factors, including changes in the availability of street heroin, socio-economic changes (including cuts to health and social care, welfare benefits and local authority services) and changes in treatment services and commissioning practices may also have contributed to these increases.

The recommendations

In response to the increase in opioid-related deaths, the report makes the following recommendations:

  • improve the current data processes by creating data standards for local reporting that feed into national systems
  • central and local government implement strategies to protect current levels of investment in evidence-based drug treatment to promote recovery
  • central and local governments continue to invest in high quality, tailored opioid substitute therapy (OST) of optimal dosage and duration
  • naloxone, medication used to reverse the effects of opioid overdose, is made available routinely, cheaply and easily to people who use opioids and to their families and friends
  • governments consider the potential to reduce drug-related deaths and other harms through the provision of medically supervised drug consumption clinics in localities with a high concentration of injecting drug use
  • governments encouraged to carry out more research on drug-related deaths and treatment services
  • an integrated approach for drug users at risk of drug-related death that includes access to physical and mental health and social care services

The expert panel raised concerns that ‘drug treatment and prevention services in England are planned to be among those public health services that receive the most substantial funding cuts as a consequence of the government’s decision to cut the public health grant’.

Annette Dale-Perera, co-chair of the ACMD’s Drug-Related Deaths Working Group, said:

We can assert with a good degree of confidence that the ageing profile of heroin users with increasingly complex health needs, social care needs and continuing multiple risk behaviours has contributed to recent increases in drug-related deaths.

The greater availability of heroin at street level, the deepening of socio-economic deprivation since the financial crisis of 2008, changes to drug treatment and commissioning practices, and the lack of access to mainstream mental and physical health services for this ageing cohort have also potentially had an impact.

Alex Stevens, co-chair of the ACMD’s Drug-Related Deaths Working Group, said:

We welcome the government’s commitment to reducing preventable heroin-related deaths but they must ensure the current standard and availability of drug treatment is at least maintained.

Without continued government intervention, it is likely that opioid-related deaths will continue to rise.

There are evidence-based steps that the government could take to limit and potentially reverse this increase. Most importantly, national governments in the UK could at least maintain investment in opioid substitution therapy of optimal dosage and duration.

Governments’ previous investments in effective drug treatment have limited increases in opioid-related deaths in the past. They now have the opportunity to act to save more lives.

This report vindicates the importance of the ACMD; the advisory group took its own decision to produce a report on this key, and increasingly worrying issue (that is to say, it was not asked by government to produce it) and has been prepared to emphasise that funding sufficient good quality treatment is the only way to stop an increasing number of individuals dying from their heroin (and other opioid) use.

8 thoughts on “Reducing heroin-related deaths”

  1. Although the ACMD make a passing reference to ‘changes in treatment services’ when considering the causes of the record number of opioid-related deaths in England & Wales, it comes across as tokenistic. Many experts in the drugs field believe that the switch from harm-reduction to recovery-based drug services around 2010 is a major contributory factor in the significant rise in deaths among heroin users. For instance, in the Wirral in Merseyside, CGL took over the local drug treatment service in February 2015, replacing the award-winning HR service with a recovery-based service. According to a recent review of the service, in the 18-month period following February 2015 the number of drug-related deaths in Wirral climbed to about one a week – compared with about one a month in the 3 years prior to CGL taking over. Given that the ‘ageing cohort’ of heroin users has continued to get older at a steady rate, this significant upturn in the mortality rate is very likely linked to the change in treatment regime. This hypothesis is also consistent with anecdotal reports from local drug workers and drug users, who report that service users turfed out of treatment with drug-free certificates are dying at an unprecedented rate. The impact of the UK’s ‘Full Recovery’ treatment strategy on deaths among heroin users needs to be independently evaluated as soon as possible, including follow-ups of ex-service users for up to 2 years beyond their leaving treatment ‘drug free’ – to assess how many are back on street heroin, using alcohol and/or tranx, in prison, homeless or dead. Dead heroin users certainly won’t re-present for treatment within a six-month period or any period at all.

  2. Thanks for your informed comment Russell. I know the new drug strategy has been delayed but don’t know if it will seek to recommend a balanced approach which both promotes recovery but safeguards harm reduction.
    This binary obsession within the drugs field for so many years on abstinence/recovery OR harm reduction has never made sense to me and many others.
    Surely we need both and different individuals may well need both at different times in their lives.
    Russell

    1. I totally agree with you Russell: harm reduction and recovery are complementary, not alternatives. After a third of a century researching drug users, its obvious to me that we need ‘courses for horses’. That is, while many people are seeking or would benefit from recovery and abstinence. many others – particularly those who have repeatedly ‘failed’ on methadone/Subutex reduction and detox programmes – should clearly be offered maintenance scripts. The latter option should also incorporate diamorphine scripts – including injectable and smokable heroin – for which there is much evidence of effectiveness, both in the UK (RIOTT trials) and across Europe (Netherlands, Switzerland, etc.). There’s one clear conclusion which can be reached about our current drug treatment strategy – it’s ideologically driven and far from evidence-based. Because of this, drug users will continue to die and be harmed unnecessarily. Ultimately, legal regulation – a combination of licensed sale (eg. cannabis, psychedelics), pharmacy provision (eg. cocaine, ketamine) and medical prescriptions (eg. heroin, opioids) – offers the only solution to our failed drug policies.

      1. Thanks for taking the time to reply again Russell. One of the main difficulties (it seems to me) is not only getting the right objectives in the strategy but in translating those into outcomes which make sense to commissioners, providers and, most importantly, service users.
        The other thing I’m not clear about is how helpful a national strategy is with different drug preferences in different parts of the country. It’s certainly easier to get a good small local system going than it is to direct change from the centre.
        Here’s hoping for a better 2017
        Russell

  3. The report highlights the issues well however there is a distinct lack of reference to mutual aid, community and connection. To discharge from treatment without the support of and connection to a community whatever that may be is a huge risk. The treatment system should include aftercare with the same importance as all other interventions in order to reduce risk.

  4. Thanks for posting this useful summary of the report. I also agree with you and Russell N’ that recovery and harm reduction should be complementary and provided in mutually supportive, integrated and individually tailored services (I recently presented on the integration of harm reduction and recovery: https://www.academia.edu/28133073/Friends_or_foes_The_roles_of_harm_reduction_and_abstinent_recovery_in_the_treatment_of_drug_dependence). This should certainly include heroin-assisted treatment for people for whom methadone or buprenorphine have not worked (as the ACMD report recommends). As the co-chair of the working group that drafted the report, I think it’s a little harsh to call our reporting of the potential effect of changes to treatment practices in increasing deaths “tokenistic”. The report covers it in several sections. It gives equal weight to this potential cause and to the effect of the increased availability of street heroin. Figure 1 in the report shows that there was an increasing trend in deaths in England before the 2010 heroin shortage. This was interrupted around the time of the shortage, which itself ended around the same time as service recommissioning kicked in after the 2010 strategy. So, at national level, it’s difficult to disentangle the effects of heroin availability and treatment changes in the bounce back of deaths towards the pre-existing trend. We only have figures for deaths by actual year of death up to 2013 (due to delays in registrations of many months after death). So it is possible that the more recent numbers will exceed the pre-existing trend. The report notes a worrying, recent increase in deaths among people who are in treatment, suggesting that treatment may be becoming less protective. This is one of the areas where we have recommended more research (as well as protection of funding and development and integration of services), as is the topic of how to promote sustained recovery. Mutual aid probably has an important role to play here, as Dot Turton suggests, but the evidence bases for this is currently underdeveloped. One worrying, recent finding is that exiting “drug-free” is just as risky for death as other forms of exit from drug treatment. This is one of the reasons we emphasised the importance of retention in optimal treatment, and the provision of naloxone at times of transition (including leaving treatment).

    1. Thanks very much for taking the time to comment Alex.
      As the least expert person commenting here, it seems to me that the development of user-led recovery communities, especially those with the “no warrior left behind” philosophy championed by Mark Gilman have a huge part to play in preventing further deaths. The presence of these communities is, of course, extremely patchy.
      However, there seems to be little equivalent for those in OST and who may be even more at risk.
      I think this makes pushing peer provision of naloxone particularly important, not just for its obvious life-saving potential, but as a way of creating communities of active drug users looking out for each other.

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