Mortality matters – but how much does it matter?

The unwelcome arrival of fentanyl onto the UK heroin market made this important Addaction conference even more timely. But hand-wringing is not enough. What needs to be done? By Harry Shapiro.

The figures are not huge, about 3000 drug-related deaths at the last count, mainly heroin and nowhere near as many as those related to alcohol or tobacco which are upward of 100,000. But for every death, there is pain, suffering, grief, despair and anger experienced by those family and friends left behind. Every single death is a human tragedy and worse still, many of these deaths are preventable or at least there are interventions which if properly implemented could bring the death toll down. But is anybody really listening? It is salutary to reflect that pretty much every ecstasy incident hits the national press, but when was the last time there was coverage of a heroin overdose?

Professor Alex Stevens is a well respected academic with many peer-reviewed publications to his name. But dispassionate he is not when it comes to the subject of drug-related deaths (DRD). In a trenchant keynote speech, he set the tone for the whole day, by enumerating the best ways of cutting down on DRD. His four step approach began with care which seems in pretty short supply outside the treatment agencies whose overworked and stressed front line workers struggle to keep their clients on an even keel and who (according to Addaction) will lose a client they’ve been working closely with on average once every two years, but often more regularly than that. Alex took us through the figures pointing out that unlike the death toll from tobacco and alcohol, the statistics on DRD were going up and as more people – the Trainspotting Generation from the 1980s – come into that older cohort category, the figures will continue to rise. As we currently don’t have new waves of young people adding to the heroin/crack population, it is reasonable to assume that at some point the figures will start to go down, but if there is one certainty about the illegal drug scene, it is that nothing is certain.

The often quoted reasons for the rise were rehearsed again – high purity levels of heroin and the ‘ageing body’ syndrome. But as Alex noted, it is no coincidence that most deaths occur in the areas of worst economic and social deprivation together with cuts in local spending on services and damaging commissioning practices all of which pushes some of the blame upstream. One commissioner delegate made the shocking point that the requirement of no re-admittance to treatment within six months, meant somebody dying in that time would count as a treatment ‘success’. Yet as other speakers observed, the sector must also look to itself for some of the answers.

Alex’s second observation focussed on investment in naloxone and OST – optimal doses for the optimal time as recommended by both Professor John Strang in 2012:

and the ACMD in 2014:

Yet going back to the 2010 drug strategy (and despite those subsequent reports)  –  while the detail was reasonably balanced, the megaphone that everybody heard was abstinence-based recovery. Drug workers became recovery workers, harm reduction became (and still is) seen as ‘quaint and old fashioned’ meaning that as one worker was reported as saying, ‘we only do reducing scripts’. Psychiatrist Dr Jan Melchior made a despairing reference to the  ‘homeopathic levels of methadone prescribing’ he had come across when all the evidence is that once you fall below 60mg a day, you increase the chances of people using on top

Then there’s innovation, actually measures that really are not that ‘innovative’ but have failed to gain any sort of traction in the English treatment system. So despite the global evidence of effectiveness, England seems as far away as ever to opening up its first medically supervised drug consumption room (DCR). Alex said that these would best be sited in those areas where the purchase and use of heroin was close by (like Canterbury) rather than in more diffuse drug cultures like Brighton where a proposal for a DCR was rejected. Speaking to a journalist from Volte Face during a break, I said that usually DCRs were often set up, not (as ever) through concerns about the health and well-being of drug users, but because the local community were up in arms about drug litter and open drug markets. A DCR was seen as the lesser of two evils.

Heroin assisted treatment was piloted through RIOTT but never took off, the headline reason being the expense and it is true that providing diamorphine is more expensive than methadone (exacerbated no doubt by one company having the supply monopoly). Alex showed that heroin prescribing could be as cheap if not cheaper than methadone. What lies beneath though is a zeitgeist that has been anti-maintenance and a fear of tabloid attacks against what would inevitably be described as “a junkies’ charter’”.

Alex’s final point reiterated the importance of service integration covering among other things, the range of health problems experienced by long term users, an issue discussed by GP Dr Sandra Oelbaum. She stressed the importance of clients being tested for COPD and how her study in Liverpool, showed the extent to which user lung function was compromised and how much clients welcomed the opportunity of being tested.

Moving away from heroin use, Dr Mark Piper from Randox Testing took the delegates through the problems of testing for NPS while Dr Owen Bowden Jones demonstrated a drug alert system he is piloting called  Reporting Illicit Drug Reactions (RIDR). It works in a similar fashion to the yellow card system for medicines whereby adverse effects are reported to the MHRA. RIDR focusses on NPS harms and aims to square the circle of drug information coming down from national and international agencies with information coming up from the grass roots. The trial runs for a year during which time it is only available to organisations. [Please note that PHE has decided not to continue the Reporting Illicit Drug Reactions (RIDR) pilot beyond the end of 2019/20]

The user voice was represented appropriately enough by two members of the CJS-based User Voice organisation. Dillon Stott gave a brief but warmly applauded account of his experiences while User Voice founder Mark Johnson narrated the history of UV, but then zeroed in on the issue of spice in the CJS. In a sense, what he had to say underpinned the reasoning behind RIDR in that information about drugs affecting people on the ground can take a very long time to filter down to practitioners relying on the centre for their information. Mark says the problem with spice had been apparent as far back as 2012 and media reporting on the situation in prisons made it clear that the situation was getting out of control. He reckons not much has changed since the passing of the Psychoactive Substances Act in May last year and that (despite Ministry of Justice claims about a testing regime roll-out) he hasn’t heard of anybody being tested in prison for spice. Accusations are made on the basis of suspicion rather than forensics.

What next – was the subject of the final panel session. The analysis done on the DRD figures by PHE revealed that around half of deaths occurred in people who had never been in touch with services. So a sizeable elephant in the room is why do people not come forward for treatment? One reason posited chimed with a point raised by Mark Johnson. If you bang prisoners up for 23 hours with nothing to do, don’t be surprised if they use drugs – and where people have been asked why they don’t go into treatment, the answer often comes back, ‘well, there’s nothing to do’ demonstrating that it isn’t just about the script.

On providing easily accessible guidance on DRD prevention work, Paul Hayes CEO of Collective Voice said that CV was working with their opposite numbers in the NHS to provide this for services to sit alongside the yet to appear ‘War and Peace’ document that is the latest clinical guidelines.

But the elephant’s big brother centred around the need for industry standards, information sharing  and a collective resistance to external pressures. Dr David Bremner, Clinical Director of Turning Point stated frankly that the sector should never have accepted payment by results nor the ‘get them through and out asap’ demand of local commissioners nor the often misdirected concerns of CQC. His message was ‘start kicking back’. But can this happen in a climate of rampant competition?

Back in 2001, the Audit Commission produced a damning report on the state of the treatment system much of which derived from the complacency which had set in where services were automatically recommissioned on an ‘even if it is broke, don’t fix it’ view of some commissioners. We don’t want to go back to those days, but it seems like the commissioning process has gone too far the other way and maybe the services with clout should start kicking back where the interests of clients are being undermined or worse, lives put at risk. The most telling point was made by Addaction’s Karen Tyrell as she closed the meeting when she said that whatever the pressures on services political or financial, “the fundamental job is to keep people alive”.