Drug-related deaths in the UK

Alex Stevens University of Kent

With thanks to Tim Millar, Claudia Wells and Annette Dale-Perera

This talk

1.Causes of increased deaths 2. Effective responses 3. Conclusion: preventing preventable deaths.

Potential causes of recent increase

• Probable • An ageing cohort of prematurely ageing heroin users,

with high vulnerability, chronic conditions and health risk behaviours.

– The ageing ‘new heroin users’.

• Possible • Changes in the availability of heroin at street level. • Changes in the commissioning and provision of drug

treatment. • Socio-economic changes, including increasing

deprivation and cuts to support services in deprived areas.

Age at drug-related death (England and Wales)

Age at drug-related death (Scotland)

0

50

100

150

200

250

300

350

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Number of drug-related deaths by age group and year

>25 25-34 35-44 45-54 >54

Source: National Records Scotland

Changes in the availability of heroin

• In 2010-2012, a shortage of heroin was observed in many European countries.

• Provisionally attributed to: –Poor weather and crop blight in Afghanistan. –Law enforcement on the ‘Balkan’ through Turkey.

• Purity of heroin seized at street level: • 2009: 46% • 2012: 17% • 2014: 36%

Trends in the type of opiate(s) involved in opiate-related deaths: 1993-2013: England and Wales

0

200

400

600

800

1000

1200

1993

19

94

1995

19

96

1997

19

98

1999

20

00

2001

20

02

2003

20

04

2005

20

06

2007

20

08

2009

20

10

2011

20

12

2013

Heroin/morphine

Methadone

Tramadol

Codeine (excl. compound formulations) Dihydrocodeine

Oxycodone

Fentanyl

Buprenorphine

Other specified opiate

Socio-economic deprivation

Age standardised mortality rates (drug misuse deaths per 1 million population) by lower super output areas sorted into quintiles of the Index of Multiple Deprivation (1 is the most deprived), 2001-2014.

Chart1

20012001200120012001

20022002200220022002

20032003200320032003

20042004200420042004

20052005200520052005

20062006200620062006

20072007200720072007

20082008200820082008

20092009200920092009

20102010201020102010

20112011201120112011

20122012201220122012

20132013201320132013

20142014201420142014

1

2

3

4

5

72.4680840391

39.9837249448

22.9636442967

18.8137366106

10.5863412038

58.7047001335

36.4998404132

24.7130488363

16.2444506537

11.0223846658

53.8697950122

32.1542130992

18.705822976

13.8859684849

10.1142847442

59.9319471543

33.6469297631

22.5247231442

15.4781040371

9.3080661268

62.78137181

36.2559969743

23.8461873017

14.6765716223

11.6790778981

62.5617227507

34.1082738957

19.6313236353

17.4221755923

10.4997988457

66.2947940455

38.5104464169

23.0497587134

17.0894443219

11.3600694849

77.0514581321

42.3097191375

25.4930701827

16.8628211889

13.0266153386

74.3908223145

38.4290383606

24.0951919079

19.6594062576

14.9368107804

68.8199255158

40.6206818677

25.3690476336

15.3719495583

12.8596349012

64.1977748622

34.5068560127

22.5513575943

16.4983899958

11.3908580003

62.2888949526

33.6059842459

21.1925436997

14.3242432955

9.0697822361

70.8267261121

40.7656881656

25.1364983448

19.191338304

13.4591169049

83.0946769431

47.9419091143

30.4924936542

21.286502455

14.9687251911

Sheet1

Year12345

200172.540.023.018.810.6

200258.736.524.716.211.0

200353.932.218.713.910.1

200459.933.622.515.59.3

200562.836.323.814.711.7

200662.634.119.617.410.5

200766.338.523.017.111.4

200877.142.325.516.913.0

200974.438.424.119.714.9

201068.840.625.415.412.9

201164.234.522.616.511.4

201262.333.621.214.39.1

201370.840.825.119.213.5

201483.147.930.521.315.0

To resize chart data range, drag lower right corner of range.

Redistribution away from people in poverty

• Welfare cut per working age adult p.a.: Blackpool -£910 Westminster -£820 Knowsley -£800 Liverpool - £700 S. Oxfordshire –£260 Cambridge -£250 City of London -£180

Source: Beatty & Fothergill (2013) Hitting the Poorest Places Hardest

Cuts in drug treatment funding (England)

• Past: • 30 – 40% cuts in community drug treatment 2008-09

to 2016-17. • Survey of local commissioners:

– Half of commissioners said local substance misuse service are underfunded by 2016.

• Futures: • Local public health grant ringfence removed from

2017/18 • Evidence of predicted cuts of 60% to substance

misuse treatment funding in some areas.

Changes in commissioning

• Local authorities deal with cuts by re-procuring • High flux in treatment services

– E.g. three year commissioning cycles

• Damage to performance at the area level • Perception that initial dips in service quality take

months to recover… • … just in time for the next commissioning round.

• Damage to the continuity of individual treatment • E.g. arbitrary changes in prescribing and supervision

of consumption.

Changes in treatment

• Recovery, not harm reduction? • Pressure on services to produce “drug-

free exits”

• Denigration/disavowal of maintenance in OST:

• “We only do reduction ‘scripts”.

Effective responses • Opioid substitution treatment (OST)

• Optimal dosage • Optimal duration

• Naloxone • Practitioners • Peers and potential ‘bystanders’ • Intra-nasal and over-the-counter? • Carried by police?

• Heroin assisted treatment (HAT) • Medically supervised drug consumption

rooms (DCR/SIF)

Opiate substitution treatment

• Findings of systematic reviews: • Increased engagement and retention of problematic

drug users in health services. • Reductions in HIV and other infections. • Reduction in criminal offending.

• Observational studies show reductions in deaths. E.g:

• Introduction of OST in Barcelona associated with an increase of 21 years in the life expectancy of heroin users (Brugal et al 2005).

• Threefold increase in OST in Sweden, 2000-2006, associated with a reduction in opiate deaths of 20-30% (Romelsjö et al 2010)

Treated Opiate User Cohort: Crude Mortality Rate per 1,000 person-years: In vs. out of treatment (n=151,983 )

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In Treatment Out of treatment

Out of treatment aHR*= 1.72 [1.55, 1.92]

* adjusted for demographic and behavioural covariates

No naloxone: 8 times higher odds of death from OD

Source: Giglio et al (2015) in Injury Epidemiology, 2:10

Heroin Assisted Treatment versus optimised oral methadone

% of patients achieving abstinence from street heroin

Source: Strang et al (2010) The Lancet, 375(9729):1885-1895

Comparing costs

£0

£2,000

£4,000

£6,000

£8,000

£10,000

£12,000

£14,000

£16,000

Injectable Heroin

Injectable methadone

Oral methadone

Cost of service for 26 weeks

Crime committed Other services Urine tests Case mgt Clinic Drug costs

Source: Byford et al (2013) British Journal of Psychiatry, 203: 342-349

Medically supervised drug consumption rooms

• Clinics where people can use drugs (purchased elsewhere) under medical supervision.

• Evidence from Vancouver and Sydney: • Reductions in overdoses • Reductions in injecting risk behaviours • Reduced BBV transmission • Reductions in drug-related litter • No evidence of increases in crime or drug use • Reductions in ambulance call-outs and deaths in the

immediate vicinity – Potier et al. 2014

New dangers to the same people

• Synthetic opioids • E.g. fentanyl, carfentanil • More powerful and kill more quickly than

heroin.

• The solutions? • THE SAME AS FOR HEROIN, BUT MORE SO.

UK Government response to ACMD report

• On poverty • Welfare changes are increasing poverty

• On OST: • Continued cuts in funding

• On naloxone: • No new national initiatives.

• On heroin-assisted treatment • Will not fund nationally

• On supervised drug consumption rooms • “The Government has no plans to introduce drug

consumption rooms. It is for local areas in the UK to consider, with those responsible for law enforcement, how best to deliver services to meet their local population needs.”

Preventing overdose deaths in the UK

• We have good evidence for how to reduce these deaths.

• It is clear that the UK government will not take the necessary actions.

• Will Scotland lead the way?

THE UK’S EUROPEAN UNIVERSITY

www.kent.ac.uk

Drug-related deaths in the UKThis talkPotential causes of recent increaseAge at drug-related death (England and Wales)Age at drug-related death (Scotland)Changes in the availability of heroinTrends in the type of opiate(s) involved in opiate-related deaths: 1993-2013: England and WalesSocio-economic deprivationRedistribution away from people in povertyCuts in drug treatment funding (England)Changes in commissioningChanges in treatmentEffective responsesOpiate substitution treatmentTreated Opiate User Cohort: Crude Mortality Rate per 1,000 person-years: In vs. out of treatment (n=151,983 )No naloxone: 8 times higher odds of death from ODHeroin Assisted Treatment versus optimised oral methadoneComparing costsMedically supervised drug consumption roomsNew dangers to the same peopleUK Government response to ACMD reportPreventing overdose deaths in the UKSlide Number 23