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Drug Deaths to be Measured in Effort to Properly Assess State of UK Drug Treatment

The UK Department of Health has updated its Public Health Outcomes Framework (PHOF) to include a new sub-indicator on the number of deaths from drug misuse.

The framework sets out the key objectives of Public Health England, which, as a Department of Health Executive Agency, has been responsible for drugs and alcohol services since 2013. Through the addition of measuring drug misuse deaths, PHE should begin to gain a fuller understanding of the efficacy of drug treatment in the country and how the government’s 2010 drug strategy – “Supporting people to live a drug free life” – is working.

Prior to the inclusion of drug misuse deaths, only successful completions of drug treatment had been measured under the PHOF.

This is a particularly timely inclusion in light of the worrying increase in drug misuse deaths under the government’s drug strategy, one that pushes abstinence as the overarching goal. In 2014, the highest number of drug poisoning deaths were registered since records began, with deaths from drug misuse (those involving an illicit substance) accounting for two-thirds of the overall number. This rise has been driven, in part, by heroin and/or morphine overdose deaths which jumped 65 per cent from 2012 to 2014.

With such an alarming spike in drug deaths, many questions have been raised as to the effectiveness of the abstinence and “recovery” agenda of the drug strategy. Though recovery from problematic drug use is, of course, a goal for a number of people, it is dangerous when it becomes an all-encompassing strategic commitment.

For example, if people are engaged in an opioid substitution therapy (OST) programme to treat opioid dependence and are made to go OST-free on short notice in order to push recovery, this can prompt a relapse into drug use along with increasing the likelihood of a potentially fatal overdose. Indeed, anecdotal evidence collected by Release suggests that this forcing of people off their OST programmes is a tragic reality.

Sadly there have been attempts to ingrain this approach in clinical guidelines for drug misuse and dependence (also known as the “orange guidelines”), with a push for time-limited OST in 2014 so as to align with the recovery agenda.

Ultimately, the consultation process led to no change and the guidelines’ recommendation against coercive exits from OST held fast. However, the guidelines are due to be reviewed yet again this year.

The problematic nature of the recovery agenda has furthermore been exacerbated by the onset of localism in drug treatment funding. At first this appeared to have the potential to be beneficial; a local focus means that health services can be more mindful of local needs. In practice, however, local authorities have found themselves savaged by funding cuts from central government, with a disproportionate effect on the charities commissioned by local authorities to deliver their public services.

Drug and alcohol services in particular have found themselves to be subject to a “postcode lottery”, wherein their funding and flexibility is dependent on the sympathies of the locality’s public health director. With financially strained directors placing a renewed focus on their financial bottom line, and a payment-by-results model that rewards service providers for success as demonstrated under the approved results framework, many services have understandably found themselves limiting their services to those for which they are being incentivised – those “that sustain recovery”. The abstinence agenda, then, is king.

Under this regime, there is little room for “square pegs” – cases with complexity – in a drug treatment setting. A Public Health England review in 2014 found that service providers were prioritising meeting recovery targets to the detriment of these more complex cases, including those of people with “dual diagnoses” of both substance misuse problems and mental health issues. Harm reduction approaches, invaluable for these complex cases, were seen as “underfunded and undervalued”. Services were no longer fitting the client; rather, clients were selected on their ability to fit the service.

Since this review, local authorities have faced a further £200m in cuts to the national public health budget in the 2015/16 period – a reduction of 7.4 per cent in the devolved annual public health budget. The prognosis for the future is even bleaker. For services hoping to widen their net, the situation has only worsened. The victims at the end of all of this are, of course, the individuals for whom the focus on abstinence is not, and cannot, be the right approach.

In light of the rather bleak state of the drug treatment sector, the changes to the PHOF are a step in the right direction, albeit a small one. However, this should only serve as the start toward providing proper scrutiny over the efficacy of drug treatment in the country, with the positives of sustained engagement if needed recognise. For some, abstinence may be a goal that is far from being realised and the stability that continued treatment can offer must be acknowledged. 

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