Who owns the drug problem, and who is to be bold?
Professor Roy Robertson, Edinburgh GP and Professor of Addiction Medicine, on how drug deaths stem from institutional neglect at every level
Image credit: Matt Beech
Drug related deaths, occurring in 2018, as reported by the National Records for Scotland on the 16th July have reached a further record high and continue to distinguish Scotland from most other countries where records are recorded.
Faced with the current situation, characterised by leading authorities, Government Ministers and the press as a “public health emergency”, a familiar list of questions are asked and solutions are presented without the necessary resources or leadership to implement change. The value of press statements and “bold” suggestions for solutions is, however, hard to extract from the predictable expressions of horror and dismay and ill defined ambitious strategies.
A recurring theme in coverage and interviews is the political impasse between Holyrood and Westminster over the authority to allow the injecting room facility in Glasgow. This currently resides with the Home Office and UK Government. Sadly, little was said of the plan to open a legal heroin prescribing clinic later this year in central Glasgow. This initiative is ground breaking in itself, should be replicated in most centres as part of a package of NHS care, and will have some impact on a small part of the problem, for those with intractable and damaging injecting problems. It is however an expensive “intensive care” type programme which will have little or no facility for the main opiate using population who require a lower grade harm reduction treatment intervention.
Entering into a cauldron of debate is decriminalisation or legalisation as the other current strategy to solve the problem of drug deaths. This is an attractive and popular course of action and there is likely, in the medium to long term, to be a progressive policy emerging to provide more sensitive and less interventional policing and sentencing for some drug offences. Formalising this in the form of a new Misuse of Drugs Act has to take some account of United Nations Conventions on Drugs, to which the UK is signatory. The Canadian approach of “respectful non compliance” with the UN treaty may pave the way for change but early experimentation with cannabis legalisation in several US states is incremental change rather than revolutionary and currently has not extended to the more serious life threatening opiates.
As a response to the 2018 drug deaths crisis in Scotland these strategic moves have some way to go to impact on the current epidemic of drug deaths and depend upon some seismic changes in ideological positions in high places.
Scotland’s policy for the last decade was an expansive and inclusive set of nonmedical based recovery initiatives aimed at reducing the stigma in institutions and communities, encouraging peer support and lived experience input at all levels. This approach has, in many ways, been well received and has the advantage of being low cost and low risk for politicians.
Recovery for all is an attractive banner to rally round but it means different things to different people and is difficult to define. A convenient concept but an unobtainable reality for many people who use drugs and which diverts attention from the mental health issues, the acutely ill, the chronically disabled and those better defined as in palliative care. This last group as well as being a super high risk of drug related deaths deserve a supportive and considerate environment of health and social care. They don’t have the luxury of recovery. An unintended consequence is to persuade people to reduce treatment and run the risk of relapse or overdose.
Creating an illusionary landscape of alternative treatments, inclusion, aspiration, opportunity and a stigma free approach driven by graduates from adversity, who have had experience of drug dependency, rather than the graduates from specialist training with the experience of an evidenced based guidelines driven and governance controlled, such as specialist trained doctors nurses and pharmacists, is in the realms of fake news and alternative facts. Well meaning attempts to provide better care runs the risk of underestimating the complexity the high relapse rate with the associated risk of overdose and death. Experience and hardship may inform policy but symptoms and consequences of drug use is the gritty and expensive province of specialists and a robust and caring system which understand the interaction between inequalities and health and is equipped (or should be equipped) to deliver care ranging from domestic and community support through investigations and tests to intensive care. The reality otherwise is of distressing mental health and social isolation being mitigated only by self medication and associated with multimorbidity, recurring crises and premature death. i.e. ongoing drug use?
Solutions should clearly lie with frontline clinical services. Our job in community NHS care is in treating symptoms whatever the cause using the best available advice and guidelines in a non judgemental way. The cause of disability in this case is, variously, or more likely, cumulatively, poverty, inequalities, adversity in young people, availability of mind altering drugs and whatever other things are responsible causes self harm and self medication. Treating symptoms is what we do in clinical practice and in the absence of cures and more effective interventions the evidence, from research, points us to our responsibilities for care. Long term drug use is by no means always inevitable but for some planning for a prolonged treatment is humane and essential.
Diversions from adequate clinical services to support those distressed and at risk of death persistently avoid the importance of the evidenced based interventions delivered by psychiatric and general practitioner services with increasing support from nurse and pharmacy prescribing services. These services have been missing from the debate and absent from the advisory structure. Research informs and guides clinical practice and support is required to maintain and develop specific data collection relating to Drug Deaths.
Blame is not helpful, although there are many contenders, serial Ministers with bold words but strange passivity when the questions are hard, the legal system controlling many of the possible innovations and paralysed by the dead hand of national and international conventions, the public who are more inclined to show interest and support for cancer and children’s illnesses and Health Boards, public health and clinicians who have other, more pressing, priorities all contribute to the isolation of people who use drugs.
Deaths are, to use a term usually attributed to infective agents, epidemic in Scotland. Epidemics usually generate a quick reaction. In the recent past outbreaks and clusters of Clostridium and anthrax infection among drug users have generated an urgent response. It maybe that the perception of lack of risk to the non drug using population prevents an urgent response or maybe the belief that the “infection” is contained in communities and of no risk to others. Sadly, there is a human and economic cost to everyone from the damage to families and cost to the criminal justice and police system and the economic burden of health and social care for those affected.
Public health has a proud tradition of protecting us from illness and harms but seems powerless and, until recently, strangely disconnected from policy and delivery of services. Specialist addiction services are, similarly, struggling with cuts in services and Primary Care has a new GP contract which has shifted priorities away from the drugs agenda.
It is clearly time for frontline services to be energised and supported. NHS services are ideally placed to respond to this wave of drug taking. They are located in communities, have a robust structure, and are staffed by a range of professionals with systematic links into all aspects of specialist care. Reactions to this current crisis neglects frontline services at their peril.
Roy Robertson, GP in NW Edinburgh and Professor in Addiction Medicine, University of Edinburgh
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