Drug-related deaths in the UK · 2017. 9. 14. · Drug-related deaths in the UK Alex Stevens...
Transcript of Drug-related deaths in the UK · 2017. 9. 14. · Drug-related deaths in the UK Alex Stevens...
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Drug-related deaths in the UK
Alex Stevens University of Kent
With thanks to Tim Millar, Claudia Wells and Annette Dale-Perera
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This talk
1.Causes of increased deaths 2. Effective responses 3. Conclusion: preventing preventable deaths.
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Potential causes of recent increase
• Probable • An ageing cohort of prematurely ageing heroin users,
with high vulnerability, chronic conditions and health risk behaviours.
– The ageing ‘new heroin users’.
• Possible • Changes in the availability of heroin at street level. • Changes in the commissioning and provision of drug
treatment. • Socio-economic changes, including increasing
deprivation and cuts to support services in deprived areas.
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Age at drug-related death (England and Wales)
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Age at drug-related death (Scotland)
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1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Number of drug-related deaths by age group and year
>25 25-34 35-44 45-54 >54
Source: National Records Scotland
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Changes in the availability of heroin
• In 2010-2012, a shortage of heroin was observed in many European countries.
• Provisionally attributed to: –Poor weather and crop blight in Afghanistan. –Law enforcement on the ‘Balkan’ through Turkey.
• Purity of heroin seized at street level: • 2009: 46% • 2012: 17% • 2014: 36%
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Trends in the type of opiate(s) involved in opiate-related deaths: 1993-2013: England and Wales
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1993
19
94
1995
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1997
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98
1999
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2001
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2003
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2005
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2007
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2009
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10
2011
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12
2013
Heroin/morphine
Methadone
Tramadol
Codeine (excl. compound formulations) Dihydrocodeine
Oxycodone
Fentanyl
Buprenorphine
Other specified opiate
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Socio-economic deprivation
Age standardised mortality rates (drug misuse deaths per 1 million population) by lower super output areas sorted into quintiles of the Index of Multiple Deprivation (1 is the most deprived), 2001-2014.
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72.4680840391
39.9837249448
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62.78137181
36.2559969743
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62.5617227507
34.1082738957
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17.4221755923
10.4997988457
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77.0514581321
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25.4930701827
16.8628211889
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74.3908223145
38.4290383606
24.0951919079
19.6594062576
14.9368107804
68.8199255158
40.6206818677
25.3690476336
15.3719495583
12.8596349012
64.1977748622
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14.9687251911
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Year12345
200172.540.023.018.810.6
200258.736.524.716.211.0
200353.932.218.713.910.1
200459.933.622.515.59.3
200562.836.323.814.711.7
200662.634.119.617.410.5
200766.338.523.017.111.4
200877.142.325.516.913.0
200974.438.424.119.714.9
201068.840.625.415.412.9
201164.234.522.616.511.4
201262.333.621.214.39.1
201370.840.825.119.213.5
201483.147.930.521.315.0
To resize chart data range, drag lower right corner of range.
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Redistribution away from people in poverty
• Welfare cut per working age adult p.a.: Blackpool -£910 Westminster -£820 Knowsley -£800 Liverpool - £700 S. Oxfordshire –£260 Cambridge -£250 City of London -£180
Source: Beatty & Fothergill (2013) Hitting the Poorest Places Hardest
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Cuts in drug treatment funding (England)
• Past: • 30 – 40% cuts in community drug treatment 2008-09
to 2016-17. • Survey of local commissioners:
– Half of commissioners said local substance misuse service are underfunded by 2016.
• Futures: • Local public health grant ringfence removed from
2017/18 • Evidence of predicted cuts of 60% to substance
misuse treatment funding in some areas.
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Changes in commissioning
• Local authorities deal with cuts by re-procuring • High flux in treatment services
– E.g. three year commissioning cycles
• Damage to performance at the area level • Perception that initial dips in service quality take
months to recover… • … just in time for the next commissioning round.
• Damage to the continuity of individual treatment • E.g. arbitrary changes in prescribing and supervision
of consumption.
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Changes in treatment
• Recovery, not harm reduction? • Pressure on services to produce “drug-
free exits”
• Denigration/disavowal of maintenance in OST:
• “We only do reduction ‘scripts”.
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Effective responses • Opioid substitution treatment (OST)
• Optimal dosage • Optimal duration
• Naloxone • Practitioners • Peers and potential ‘bystanders’ • Intra-nasal and over-the-counter? • Carried by police?
• Heroin assisted treatment (HAT) • Medically supervised drug consumption
rooms (DCR/SIF)
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Opiate substitution treatment
• Findings of systematic reviews: • Increased engagement and retention of problematic
drug users in health services. • Reductions in HIV and other infections. • Reduction in criminal offending.
• Observational studies show reductions in deaths. E.g:
• Introduction of OST in Barcelona associated with an increase of 21 years in the life expectancy of heroin users (Brugal et al 2005).
• Threefold increase in OST in Sweden, 2000-2006, associated with a reduction in opiate deaths of 20-30% (Romelsjö et al 2010)
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Treated Opiate User Cohort: Crude Mortality Rate per 1,000 person-years: In vs. out of treatment (n=151,983 )
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In Treatment Out of treatment
Out of treatment aHR*= 1.72 [1.55, 1.92]
* adjusted for demographic and behavioural covariates
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No naloxone: 8 times higher odds of death from OD
Source: Giglio et al (2015) in Injury Epidemiology, 2:10
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Heroin Assisted Treatment versus optimised oral methadone
% of patients achieving abstinence from street heroin
Source: Strang et al (2010) The Lancet, 375(9729):1885-1895
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Comparing costs
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£14,000
£16,000
Injectable Heroin
Injectable methadone
Oral methadone
Cost of service for 26 weeks
Crime committed Other services Urine tests Case mgt Clinic Drug costs
Source: Byford et al (2013) British Journal of Psychiatry, 203: 342-349
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Medically supervised drug consumption rooms
• Clinics where people can use drugs (purchased elsewhere) under medical supervision.
• Evidence from Vancouver and Sydney: • Reductions in overdoses • Reductions in injecting risk behaviours • Reduced BBV transmission • Reductions in drug-related litter • No evidence of increases in crime or drug use • Reductions in ambulance call-outs and deaths in the
immediate vicinity – Potier et al. 2014
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New dangers to the same people
• Synthetic opioids • E.g. fentanyl, carfentanil • More powerful and kill more quickly than
heroin.
• The solutions? • THE SAME AS FOR HEROIN, BUT MORE SO.
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UK Government response to ACMD report
• On poverty • Welfare changes are increasing poverty
• On OST: • Continued cuts in funding
• On naloxone: • No new national initiatives.
• On heroin-assisted treatment • Will not fund nationally
• On supervised drug consumption rooms • “The Government has no plans to introduce drug
consumption rooms. It is for local areas in the UK to consider, with those responsible for law enforcement, how best to deliver services to meet their local population needs.”
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Preventing overdose deaths in the UK
• We have good evidence for how to reduce these deaths.
• It is clear that the UK government will not take the necessary actions.
• Will Scotland lead the way?
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THE UK’S EUROPEAN UNIVERSITY
www.kent.ac.uk
Drug-related deaths in the UKThis talkPotential causes of recent increaseAge at drug-related death (England and Wales)Age at drug-related death (Scotland)Changes in the availability of heroinTrends in the type of opiate(s) involved in opiate-related deaths: 1993-2013: England and WalesSocio-economic deprivationRedistribution away from people in povertyCuts in drug treatment funding (England)Changes in commissioningChanges in treatmentEffective responsesOpiate substitution treatmentTreated Opiate User Cohort: Crude Mortality Rate per 1,000 person-years: In vs. out of treatment (n=151,983 )No naloxone: 8 times higher odds of death from ODHeroin Assisted Treatment versus optimised oral methadoneComparing costsMedically supervised drug consumption roomsNew dangers to the same peopleUK Government response to ACMD reportPreventing overdose deaths in the UKSlide Number 23