Reducing opioid-related deaths in the UK
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Reducing opioid-related deaths in the UK.

Advisory Council on the Misuse of Drugs
[UK] Advisory Council on the Misuse of Drugs, 2016.
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The UK’s official drug policy advisers conclude that the ageing profile of heroin users with increasingly complex health needs has contributed to recent increases in drug-related deaths, and that to hold down the increases government must maintain investment in substitute prescribing programmes like methadone maintenance.

Summary The UK’s Advisory Council on the Misuse of Drugs (ACMD) was established under the Misuse of Drugs Act 1971 to advise the government on the control of dangerous or otherwise harmful drugs, including classification and scheduling under the Misuse of Drugs Act 1971 and its regulations. In March 2016 the Council agreed to initiate an investigation into the recent increases in drug-related deaths in the UK. In December 2016 the featured report was sent to government in the person of the Home Secretary with a letter co-signed by the chair of the Advisory Council on the Misuse of Drugs and the co-chairs of the working group of the Council which produced the report. The first part of this account consists of extracts from the letter and the second part extracts from the report’s own summary.

Letter to Home Secretary

In recent years, there have been substantial increases in the number of people dying in the UK where illicit drugs are reported to be involved in their death. The largest increase has been in deaths related to the misuse of opioid substances; 2,677 opioid-related deaths were registered in the UK in 2015. The ACMD therefore set up a dedicated working group to examine how to reduce drug-related deaths, with a focus on opioid-related deaths.

Through our brief review of the potential causes of recent trends in opioid-related death, the ACMD can assert with a good degree of confidence that the ageing profile of heroin users with increasingly complex health needs (including long-term conditions and poly-substance use), social care needs and continuing multiple risk behaviours has contributed to recent increases in drug-related deaths.

Other possible causes of recent increases include greater availability of heroin at street level, deepening of socio-economic deprivation since the financial crisis of 2008, changes to drug treatment and commissioning practices, and lack of access to mainstream mental and physical health services for this ageing cohort.

The ACMD welcomes the considerable expansion in the use of OST (opioid substitute treatment) [based on the long-term prescribing of drugs with opiate-type effects which ‘substitute’ for the drugs the patient is dependent on but which are less damaging, primarily in the UK methadone but also buprenorphine and other opioids] in the UK since the mid-1990s. The ACMD would like to re-iterate the evidence that being in OST protects heroin users from overdose, and increasing coverage of OST has had a substantial effect in limiting the increase in drug-related deaths that would otherwise have occurred. The most important recommendation in this report is that government ensures that investment in OST of optimal dosage and duration is, at least, maintained. Access to allied healthcare and other services to treat comorbid, chronic physical and mental health issues, and to promote recovery from problematic drug use will also be important in reducing premature deaths.

Report summary

The Advisory Council on the Misuse of Drugs (ACMD) has a statutory duty under the Misuse of Drugs Act 1971 to advise ministers on measures that may be taken to reduce the harms associated with illicit drugs. Death is the most serious harm related to drug use. Since 2012, there have been substantial increases in the numbers of people dying in the UK where illicit drugs are reported to be involved in their death. Table 1 displays the numbers of deaths that have been registered as drug misuse deaths and as opioid-related deaths in the most recent year for which data is available in each country of the UK. It also shows the percentage change in deaths recorded as opioid-related between 2012 and 2015.

Table 1: Drug misuse and opioid-related deaths in the UK (by year of registrations)
Country Drug misuse deaths (2015) Opioid-related deaths (2015) % increase in opioid-related deaths 2012–2015
England 2,300 1,842 58%
Wales 168 141 23%
Scotland 706 606 21%
Northern Ireland 114 88 47%

As shown in Table 1, a very large number of drug misuse deaths are related to opioids, and this number has grown substantially in recent years. Indeed, figures from the Office for National Statistics (ONS) for 2015 registrations suggest that opioid-related deaths ... accounted for a larger number of fatalities than traffic accidents. People who use opioids are also highly vulnerable to other causes of death; 43% of deaths recorded among a large cohort of opioid users in England were due to fatal overdose, with the majority dying of other causes.

[T]his report is based on analysis of published research, on research undertaken by members of the above-mentioned working group and consultation with stakeholders in the field. The main conclusions of the report are as follows.

That the UK has high-quality systems for the recording of opioid-related deaths, but that more could be done to improve national information, especially on toxicology and prescribing, as well as on the contribution of opioid use to levels of mortality from other causes.

That a probable cause of the recent increases in drug-related deaths is the existence of a prematurely ageing cohort of people who have been using heroin since the 1980s and 1990s.

The vulnerability of these and other people who use heroin is likely to have been reduced by a reduction in the availability of heroin at street level that occurred in the UK in 2010 to 2012. Recent increases may represent a return to the underlying, increasing trend as heroin availability subsequently increased.

Other contributory causes of recent increases in deaths include multiple health risks (including poly-substance use and chronic use of alcohol and tobacco) among an ageing cohort of heroin or opioid users, deepening of socio-economic deprivation since the financial crisis of 2008, and changes to drug treatment and commissioning practices.

There are a number of evidence-based approaches that can be used to reduce the risk of death among people who use opioids. The strongest evidence supports the provision of opioid substitution treatment (OST) of optimal quality, dosage and duration.

Other substance misuse treatment options could be further developed in order to reduce the risk of death including broader provision of naloxone, heroin-assisted treatment for those for whom other forms of OST are not effective, medically-supervised drug consumption clinics, treatment for alcohol problems, and assertive outreach to engage heroin users who are not in treatment into OST (especially for those who are homeless and/or have mental health problems).

Improve[d] access for heroin users to treatment for mental health problems, smoking cessation and tobacco harm reduction, HIV/hepatitis B/hepatitis C prevention and treatment, physical healthcare treatment for long-term conditions such as coronary and pulmonary heart disease, and other services (such as housing and employment services) which support wider recovery outcomes could reduce vulnerability to [drug-related deaths].

The report makes a number of recommendations for the reduction of opioid-related deaths; most importantly that investment in evidence-based OST be maintained. It is estimated that OST was preventing approximately 880 deaths per year in England in 2008 to 2011. Without the expansion of OST that occurred in the 2000s, it is likely that opioid-related deaths would be even higher than they currently are. These services are currently under threat from reductions in local and national funding, especially in England.

The age profile of opioid-related deaths ... suggests that relatively few young people are initiating problematic opioid use. Numbers of opioid-related deaths among people under 30 have fallen substantially since the early 2000s. This suggests that the UK is likely to see a long-term reduction in opioid-related deaths, as long as there is no new wave of initiation into problematic opioid use (eg, larger increases in the misuse of heroin, fentanyl and/or oxycodone), as was seen with heroin in the 1980s and 1990s.

However, in the short to medium term, we are likely to see an increasing number of deaths among a shrinking population of prematurely ageing, increasingly vulnerable heroin or opioid users. Deaths among this cohort have been reduced and limited by previous government interventions, including those implemented after the ACMD’s report in 2000. ACMD calls on the government to renew and extend efforts to prevent these deaths.

Findings logo commentary An Effectiveness Bank hot topic has addressed why the fall in UK drug misuse deaths in 2009 to 2012 so decisively reversed in the following years. The featured report is commented on in the hot topic, which also offers a comprehensive account of the statistics, research, the policy background and the debates on drug misuse deaths (and specifically opioid-related deaths) in the UK.

Last revised 15 March 2017. First uploaded 15 March 2017

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