We hope our latest edition of Health Matters – on the subject of “Preventing drug misuse deaths– will help you and other health professionals by compiling key facts, figures and evidence of effective interventions.
Where we can, we’re also committed to answering your questions and taking on your feedback. In this blog we’ve published the answers to a number of Health Matters preventing drug misuse deaths questions we received from professionals across the UK at and after the launch teleconference.
We’d love to hear from you at healthmatters@phe.gov.uk.
Question 1 (Disinvestment in drug and alcohol services)
I wonder whether the Health and Social Care Act coming into force (in 2012), and then disinvestment from community drug services over subsequent years, was a factor. I also wonder whether there is increased heroin availability because of increased demand partly as a result of people coming out of services. Should we be pressing for local authorities to have a statutory duty to provide these services?
Answer
We have focused on the increasing numbers of deaths associated with drug misuse and the ageing nature of them and, as you’ll know, there’ll be a number of reasons behind that.
We know that money is tight within the NHS. We’re not going to be able to buy our way out of this. So, we’re going to have to look at how we use what we’ve got, with ever-increasing creativity. We will have a drug strategy coming out of government – hopefully fairly soon – and that will sort of ‘reset’ us (government, the NHS, providers) about what we’re all trying to achieve here.
When the public health ring-fenced grant comes to an end there will also be something said about what’s going to replace it and there will be possibilities there: from statutory guidance to mandation or regulation. Certainly, we’re as concerned as we know local government are, to ensure that we keep a focus on investment in drugs and alcohol treatment and recovery. So watch this space.
Question 2 (Drug related deaths after custody)
There is clearly a small but significant proportion of deaths that occur after custody. Men and women coming out of custody haven’t necessarily had the chance to practically manage themselves for a number of years in a lot of cases. Has this been included in any of the thinking so far or is there something that could go into the collaborative action around good treatment and release planning within custody?
Answer
The evaluation of the Integrated Drug Treatment System (IDTS), which saw the introduction of evidence-based drug treatment into prisons, has recently been published. It is a good news story for the effectiveness of prison drug treatment. And the National Drug Treatment Monitoring System (NDTMS) has reported for the first time on prison drug treatment. One point that stands out is the relatively low number of people that get from prison into treatment in the community and, as a result, PHE will have a major work stream on that in the coming year.
I’m sure you will want to engage with that and we will welcome working with you. Community rehabilitation companies (CRCs) have responsibility for people on release and these agencies need to be galvanised into action, particularly when dealing with people who have been on short sentences and need to be linked into treatment, so that we all take appropriate responsibility and make sure that those people at that very vulnerable point are captured by the system.
Question 3 (Prevalence of new drug users)
Do we have data on how many new users there are per year? Also, is there a tool kit for local authorities that can be used to estimate savings through investment in prevention and treatment?
Answer
PHE has previously published prevalence estimates that show prevalence has been falling over the long-term and probably stabilising. We haven’t been able to publish updated prevalence estimates as recently as we would have liked to, but we are planning to later in the year.
In answer to the second question, on toolkits for local use, PHE has produced a range of tools, which can be found on NDTMS.net, for commissioners to look at cost effectiveness and social return on investment. They are quite sophisticated tools with some nationally collected data, but also local areas can add in their own data to really help them increase cost effectiveness and calculate their return on investment.
Question 4 (Ageing heroin users)
I’m particularly interested in the increase in drug misuse deaths being partly attributed to the ageing population of heroin users. Are there things that we can learn from our European colleagues on how they’re facing similar issues?
Answer
We looked at comparisons between the system in England and other countries in our drugs evidence review (An evidence review of the outcomes that can be expected of drug misuse treatment in England) that we published in January. It is actually quite difficult to make direct comparisons, although we continue to have conversations with colleagues abroad about similar issues. There are other countries, particularly Australia, that are facing similar issues with an ageing cohort of heroin users.
Unless something in the system changes, there is likely be an upward trend, because in lots of cases we’re talking about people with relatively frail health. PHE is giving a very clear steer that treatment services need to be taking care to link with other services to make sure that mental and general health care, in particular, are put in place for people, so that their drug treatment isn’t undertaken in isolation, but rather that their deteriorating physical health can be picked up and attended to.
This is also a good opportunity to remind people that the majority of people who died of drug misuse death in recent years had not been in treatment. This means that local authorities have very vulnerable populations of mainly opiate-using people on the margins of services; as a result, attempts to get people into treatment and for them to benefit from the protective factors of being in treatment really should be a priority for localities. We know it’s cost effective.
Question 5 (Multiple prescribed medicines)
As a GP serving a prison population, I routinely see patients coming in who are on multiple sedative drugs, typically mirtazapine, anti-psychotics, and pregabalin. I presume, and I think a lot of other people think, that there are associated risks, with increased risk of overdose, with these medications but there are very few warnings that these drugs can actually cause overdoses, that they’re addictive and that care should be taken when prescribing them. What can we do to reduce the risks and make people aware when they’re prescribing?
Answer
This is something that we’ve noted in our inquiry and it is an increasing trend. The forthcoming updated clinical guidelines on substance misuse management will get into this issue. We’re working with colleagues in the Medicines and Healthcare Products Regulatory Agency (MHRA) to think about clearer labelling and more warnings. PHE is also about to launch RIDR, which is a system for reporting reactions to illicit drugs but also to prescribed drugs used illicitly, to get much better intelligence on adverse health harms and patterns of use.
Question 6 (Availability of naloxone)
My area has a real issue with drug deaths but we have implemented take-home naloxone over the last few years and we’ve done really well, we’ve got over 300 – 400 kits out there, but how can we do that better?
Answer
That is something that we have done some work on already and we will continue to do more in terms of sharing best practice examples as there is a lot of really innovative work going on around the country. People are really trying to get to grips with the most effective, cost effective and relevant ways of getting naloxone to people in their local areas. We have some examples of good practice available to share on the Health Matters page.
Question 7 (Associated long-term conditions)
I have seen a marked difference in cause of death in the last two years where the cause of death has been attributed to everything from heart disease, chronic obstructive pulmonary disease (COPD), chronic liver disease and then heroin toxicity; so what has been done in terms of making links to health services in a more cohesive way?
Answer
We need to be really engaged with NHS clinical commissioning groups and the services they commission, to help them to better understand that sometimes they need to come to where people are. There have been some really creative responses to getting people like respiratory physicians and hepatologists into drug services and we need to be really engaging with them to get them doing this more effectively. Health interventions could work more upstream to improve levels of engagement and prevent premature deaths.
Question 8 (Engaging primary care)
As a GP it seems to me that with the multi-morbidity issue and the huge issue of people dying outside of treatment services, it falls straight into the lap of primary care and general practice. I wonder what suggestions you might have for engaging primary care in what is essentially a holistic management package for an ageing group, with multiple problems, including drug misuse?
Answer
You are quite right about expecting general practice, along with other parts of the NHS system to be engaged with treatment services. We have made a big effort to link drug services with smoking cessation services as a first port of call because, as you know well, most people in drug treatment will probably be smokers as well.
One of the other issues that you touched on is that so many of the people who are dying are outside drug treatment services. These are very vulnerable populations who are on the margins of different kinds of services, and at an exaggerated risk. So we need to be talking to local authorities about how comfortable they are about having large numbers of their drug using population not in treatment. People who are dying outside of treatment will probably be interacting with homelessness services, day centres, hostels, night shelters, soup kitchens, so there is an opportunity there to engage with them.
Question 9 (Measuring outcomes of drug treatment services)
I’m a consultant psychiatrist and my drug treatment service is facing criticism about our relatively low number of successful completions and having people in treatment for a long period of time. I am concerned about people being put off coming into treatment because they are being told to follow a strict programme. What is the strategy with that?
Answer
We can’t pre-empt what the drug strategy is going to say but I do want to be clear that poor practice is what puts people at risk. It is not appropriate to overly focus on a single outcome. The recent evidence review we published was very clear that treatment, because it produces a range of complex outcomes, needs to be assessed through a broad range of outcome measures.
Question 10 (Drug consumption rooms)
The Advisory Council on Misuse of Drugs pointed out that more than half of the people who die are not engaged in treatment at the time. They recommend that we try open access drop-in in order to allow people who collect their needles and syringes, to go somewhere safe and clean and hygienic to inject, and I wonder what you think about that as a possible step towards getting people engaged in treatment?
Answer
There is some evidence that drug consumption rooms can be effective in some very specific set of local circumstances. There is also a government response on its way to the ACMD recommendation. A key issue would be to get the right kind of local stakeholders and partners on board.
Question 11 (Treatment penetration)
What work is being, or could be, done in talking to people who aren’t engaging in treatment? We don’t know much about the experience of people who aren’t accessing treatment. We really need to discover what is preventing people from accessing treatment because we can’t design services unless we know what people are wanting.
Answer
Treatment services need to be attractive and accessible, reaching out to people outside of treatment by using service users, who will have links to them. Service users will be aware of the places in the system where people out of treatment present and we need to be engaging with them and gathering them in to keep them safe.
PHE is working with a consortium of third sector and NHS providers and one of the work streams relates to the issue of access for and engagement with people currently outside of treatment services.
Conclusion
If you have any further questions, the team here at Public Health England will be very pleased to answer them. Please send your questions via email to healthmatters@phe.gov.uk.
Do please keep on sharing your stories about how you have used the Health Matters materials to communicate your messages and to get things done, or if you have ideas for improvements. Just send an email to healthmatters@phe.gov.uk.
Health Matters
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