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by Dr Roy Robertson
26 August 2015
Increase in drug-related deaths is a warning that our best efforts are not good enough

Increase in drug-related deaths is a warning that our best efforts are not good enough

Deaths from drug use have, in recent years, assumed the status of an inevitable part of the fabric of modern society. Cases of celebrity fatalities and not infrequent and occasional more detailed reflections identify a steady attrition in communities across the country.

Less well publicised are the chronic deaths due to infections acquired from past drug taking or indirect deaths from associated behaviours or disease. Surprise has been replaced by a resignation of the sort previously, sadly, observed in attitudes to cases of suicide and death from alcohol problems.

Paradoxically, irritation and outrage have been replaced by sadness and sympathy. The annual numbers of deaths in Scotland from the consequences of drug taking has moved from a headline to an observation deeper in the media report.

There are reasons why the focus has shifted and the alarm bells have ceased to ring. Human Immunodeficiency Virus is no longer the spectre that worried politicians and the public. Antiviral chemotherapy has revolutionised the treatment of HIV and a better understanding of the transmission risks to lower risk groups has given the impression that the infection is confined to a small group of high risk takers.

The recognition that hepatitis C infection is almost completely confined to those who inject drugs has restricted anxiety about this disease to a smaller number of interested groups and professionals. These diseases seem, in the public discussion, less of a risk to the average person.

There is, for some unsubstantiated reason, a belief that injecting drug use is less of a problem and that a residue of people from a former cohort are all that remains of a problem from several decades ago.

There is a fatigue in the system that tries to mitigate the effects of drug taking which results in nearly 600 deaths in Scotland every year, a figure per number of population higher than almost every other country in Europe.

Perhaps most worrying of all is the possibility that some deaths from illegal drug use is an unintended consequence of a shift in drug policy which has, in the interest of recovery, resulted in a failure to apply the hard learned lesson that the single intervention with a powerful evidence base to support its efficacy in preventing death is medically assisted treatment in the form of methadone, buprenorphine or other opiate prescriptions.

Deaths in Scotland from illegal drug use are predominantly opiate-driven, emphasising the essential value of medically assisted recovery in the form of the opiate substitutes methadone and buprenorphine. There is, unfortunately, a stigma associated with this treatment which is not evident in any other medical intervention.

Recovery should never be seen as separate from medically assisted treatment but part of the same process. All these treatments and interventions should be part of the portfolio of our treatment services and recognising the extraordinarily difficult personal situations that give rise to self-neglect and high risk drug taking has to allow that, for some, support and treatment may be lifelong.

Indeed, extending support to include safe places for people to use drugs and at times heroin assisted treatment remains a striking part of the very effective treatments seen in several parts of Europe where the death rates are significantly lower.

Sometimes observations of others give helpful insight into our own situation. For entirely different reasons, absence or reduction in opiate substitute treatment has resulted in HIV and hepatitis C epidemics in Greece, Romania and Estonia, a pattern seen last in the UK in the east of Scotland when methadone treatment was, catastrophically, suspended in the belief that it inhibited recovery.

Many parts of Asia and Russia and Eastern Europe are experiencing an ideological moratorium on opiate substitute treatment resulting in a dramatic reduction in life expectancy for drug users in these countries. Following a familiar pattern countries like China have responded to a crisis of rising numbers of drug users and epidemic blood borne viruses.

Realising the urgency, they have expanded methadone clinics rapidly. Hepatitis C is almost too prevalent to count but the consequences of this is beginning to be seen in rising numbers of young people with cirrhosis and increasing registrations for liver transplants across Europe.

Drug problems and deaths from drug use concern us all. Sometimes we are closely connected by relationship or friendship with those involved; sometimes it is obvious that more should have been done to prevent the outcome. On a more objective level it should be recognised that there is a large cost to society and the economy.

If a sector of the population is suffering and using emergency and elective treatment services for problems that could have been prevented then ultimately we all suffer from the financial and social costs. We perhaps all share the responsibility of a large drug and alcohol problem in Scotland.

The Scottish Government has allocated considerable time and expense to these problems in an ongoing programme of interventions and investigations. A belief in the value of recovery and progress from dependency to independence from a perceived reliance on treatment is germane to all our interventions. 

There is a complexity to recovery, however, which is well recognised in the current drug strategy. Not all individuals recover from any disease or disorder and treatment has to run its course. Evidence is required to understand the risks and benefits of any therapy.

Harm can be done by treatment and by failure to intervene. Chronic intractable disorders require long-term maintenance treatment. Disorders, which are characterised by remission and relapse, require understanding and persistent attention and most of all recognition of when risks are greatest and what can be done to divert from crisis.

Observing this year’s drug-related deaths figures may have a sense of familiarity and consequently lack the opportunity to respond with conviction and innovation. An increase is a warning, however, that our best efforts are not good enough.

As ever there is no simple solution and interpretation of these figures has to recognise the variability and many factors implicated in causing deaths. We do, however, have a guiding principle enshrined in a set of guidelines and a substantial body of research.

Medically assisted treatment in the form of opiate substitute prescription is effective if it is long term, consistent and supplemented by professional support. Relapse into dangerous drug taking is common and should be prevented or responded to urgently.

Situations which represent an increased risk of overdose are common in the lives of drug dependents and are generated by coercive abstinence while in custody or in medical settings during hospitalisation and when well-intentioned encouragement reduces opiate substitute treatment to levels below a well-researched therapeutic level.

Applying the knowledge we have painfully gained in three decades of harm minimisation should be something we are careful to recognise.

Dr Roy Robertson is an Edinburgh GP and chair of the National Forum on Drug Related Deaths.

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