“The lessons of a failing national policy need to be learnt,” is the conclusion experts drew this week about the surge in drug deaths.
Between 2012 and 2015, these deaths in England and Wales increased by nearly two thirds. Deaths from heroin or morphine more than doubled to 1,201 in 2015 - the highest since records began in 1993. Public health officials have said this was partly because Britain’s drug users are growing older and frailer, making them more vulnerable to purer drugs or droughts in supply. More than half of those who died used opiates, like heroin, and had had no recent contact with drugs services. This week, a British Medical Journal (BMJ) editorial said part of the reason was “massive changes in national policy” since 2010, when the national drugs strategy moved the emphasis from harm reduction to drugs abstinence. This change created the incentive for drugs services to get people off treatment when they are not ready, the BMJ article says.
As experts here debate the cause of the rise in deaths, there is an example of a life-saving, misery-ending drug policy in Europe that Britain helped inspire, but then failed to follow. Switzerland saved lives when it began its radical experiment with giving heroin addicts a place to inject it under supervision. In the late 1980s, the country had the highest HIV infection rate in Europe. Police shepherded drug users into public parks to keep an eye on users, creating so-called “needle parks” in Swiss cities. There were a growing number of addicts who had become resistant to methadone, the drug more commonly prescribed to stave off their withdrawal symptoms. In 1989, the Swiss began to look at experimenting with heroin prescription. Prof Prof Ambros Uchtenhagen, of Zurich University, set the terms of the project.
He and other Swiss delegates travelled to meet the patients of Dr John Marks, a psychiatrist in Widnes in Cheshire, where he had begun prescribing patients smokeable heroin, something Britain has done in different forms and at fluctuating levels since 1926, and ended up being called ‘the British system’. Britain was unique in that it resisted complete prohibition of the drug. The Swiss were impressed at the low level of HIV injection in the area and the positive police response, but they were wary with giving their addicts heroin to take home. The Swiss experiment changed the system. Theirs was a comprehensive treatment programme - people could only inject under supervision in a clinic. Everyone taking part had to register with the government.
Prof Uchtenhagen quotes a British expert’s take on how the UK influenced Switzerland’s effort. “The Swiss borrowed a corrugated knife from the British. We got back a Swiss Army Knife,” he says. Switzerland’s experiment began with three arms: 700 patients receiving either injectable morphine, methadone or diamorphine, the medical name for heroin.
But patients on morphine and methadone soon reported painful side effects. The experiment shifted to focus on diamorphine. The first results were visible within the first month: the addicts became healthier. “Those people had neglected their health for years, when they started to participate in the programme, they got all the medical help they needed,” Prof Uchtenhagen says.
Deaths by overdose fell by half. HIV infection fell by 65%. More than half of addicts given heroin were off it within three years. Crime fell. The project expanded - more than 1,200 addicts were receiving it by 2007. In 2002, health insurance started covering heroin treatment. In 2008, the Swiss voted for a change to national laws to provide the legal basis for the project.
Prof Uchtenhagen believes Britain would see the similar benefits if it embraced the same model. The Swiss model has been experimented with in Britain. In 2010, the Random Injectable Opiate Treatment Trial (RIOTT), which was on a smaller scale, reported encouraging results. It had enrolled 127 patients who had failed to respond to more conventional treatments and randomly allocated them injectable heroin, injectable methadone or oral methadone. It found letting people inject heroin under clinical supervision led, within six weeks, to “significantly lower use of street heroin” than either type of methadone.
“UK Government proposals should be rolled out to support the positive response that can be achieved with heroin maintenance treatment for previously unresponsive chronic heroin addicts,” concluded Prof Sir John Strang a world-renowned expert in treating addiction at King’s College London, in his paper on the results.
Prof Strang said funding continued for the three clinics involved in RIOTT for around four years but then “ran aground because of further severe cuts” to treatment services.
“Personally, I don’t see the logic,” he told The Scottish Drugs Forum last month. “This is an evidence-based treatment which is then found to be cost effective, with essentially, better bang for buck than the ordinary treatments... It’s cost inefficient to be putting [the most chronic addicts] into a treatment that fails.”
Professor Sir John Strang discusses the RIOTT trial
Prof Uchtenhagen hoped Britain could follow the evidence the way Switzerland did and was disappointed when Britain did not roll out supervised heroin injections on the same scale. “I was very much disappointed because England was such a pioneer... I couldn’t understand,” he says.
Running clinics where hundreds of addicts have to be monitored every day is not cheap, but he says it saves more money than it costs. “These higher costs are more than compensated by the benefits,” he says, saying a study of Switzerland’s success identified that the money saved in improved health, fewer addicts winding up in hospitals and less police time spent monitoring and chasing addicts was double the cost. Prof Unchtenhagen adds: “The number [of people using heroin illegally] is so down, it’s comparable to the numbers we had in the 70s, before the great boom of heroin arriving here.”
Prof John Middleton, president of the Public Health Faculty and one of the authors of this week’s BMJ article, fears the UK government shift in drugs strategy has contributed to the rise in deaths. Pushing for abstinence is at odds with longer-term - often called “maintenance” - prescriptions, on methadone or diamorphine, he says.
“You wouldn’t want people to be on [prescriptions] forever,” he says. “But also you wouldn’t make it the problem that people who support an abstinence approach seem to make of it.” The BMJ article notes drug users receiving medical treatment through drugs are half as likely to die than those on abstinence regimens.
Prof Middleton says part of the Government’s change in policy was to change the key indicator of drug policy success to be the number of people discharged from treatment who were free from all drugs, including prescriptions, and did not return for at least six months. Prof Middleton says this creates “pressures on services to get people out of treatment and off the books”.
He is concerned at the number of people dying who have no contact with drugs services. “The fact that so many opiate deaths are people who haven’t gone to the service, or haven’t found anything of value in the service, is a concern.”
Close clinical supervision, of the sort in Switzerland and the RIOTT trial, could help Britain’s drug users in particular, Prof Middleton says, noting their habits could be masking symptoms of conditions if they take drugs alone. Having spent decades “smoking anything they can get their hands on”, they could be suffering breathing problems that opiates, as a depressant, would mask.
“Controlled prescribing does allow for people not to be reliant on those fluctuating quality and strengths of street heroin,” he says. “An aging addict might suddenly stop breathing [but this] ought to be less likely if they did it by using a drug consumption room, [where] somebody who stopped breathing ought to be resuscitated more easily.”
Prof Middleton says the 2010 drugs strategy was “very much the philosophy in keeping with the new Coalition Government”.
“The reality is, there’s no evidence base for reducing doses of methadone and reducing substitute opiates, whereas there’s very strong evidence about [maintaining] methadone and heroin substitution regimes.”
Diamorphine prescriptions should be “part of the prescribing toolkit,” the BMJ article authors say. Prof Middleton says national guidelines on prescribing opiates, which advocate such maintenance prescriptions, read like an “ironic” comment on the 2010 new strategy. “There was a degree of contradiction about what the scientists were saying, based on the evidence, and what the politicians they wanted the strategy to look like.”
In the final paragraph, the BMJ article says: “The approach of harm reduction was born—under a Conservative government—in response to the threat of HIV. It saved countless lives. When focus shifted away from harm reduction, deaths began to rise...
“If death rates are an accepted measure of system performance, the current trend is surely evidence of system failure.”
The Department of Health had not responded to a request for comment when this story went live.