Blog: Lack of access to treatment and prescribing practice contribute to drug death figures

On the 16th of July 2019 , it was announced that 1,187 people had died of a drug overdose in Scotland in 2018.

Scottish Drugs Forum’s CEO, David Liddell, published a piece that day in The Herald newspaper which sought to highlight the damage caused by stigma towards people who have a drug problem, and also to the medication that seeks to assist them regain stability within their lives.

“Scotland prides itself in having an equalities and rights-based approach to policy and service provision.  But the latest drug deaths statistics again suggest that Scotland’s sense of itself as  inclusive may be dangerous self-delusion.

NHS patients are receiving treatment that does not meet standards laid out in national and international good practice guidance.  With any other patient group, this would rightly be regarded as both scandalous and a national priority for action.

These figures raise serious concerns about the response we are making to people who have a problem involving heroin or other opiates. Of particular concern is the extent of deaths involving methadone.  The figures released today show that 560 (47%) of the deaths involved methadone.

The latest statistics, from 2016, showed that 33% of patients were prescribed a dose lower than the minimum dose recommended in national clinical guidance and by the World Health Organisation.  Now, we are hearing that this figure may be considerably higher –  closer to 50% in some areas.   We have to ask ourselves why that is.  If people are not getting the substitute medication dose they require then it is no wonder they ‘top up’ with street drugs and get involved in polydrug use – which is a huge feature in these figures accounting for the vast majority of deaths.

The obvious question we need to ask is why are NHS patients being treated in ways that are clearly contrary to the good practice recommended in the guidelines?  Why is this being allowed to continue?  Recently doctors in Tayside were criticised when it was found they were prescribing cancer chemotherapy drugs in doses that were below the minimum doses recommended in guidelines.  Within 72 hours the Scottish Government’s Chief Medical Officer commissioned an Immediate Review Group and within a fortnight the review was complete, recommendations made and the practice discontinued.

The reaction to years of this same practice occurring in drug treatment services has been that this is a local clinical matter.  This cannot be allowed to continue.

To understand the root of this problem we have to ask –  what drives under-prescribing?  There seem to be two key drivers.  Firstly, many people believe that the less medication they are on, the ‘better’ they are doing.  This is far from true.  Actually, they are failing in treatment and not enjoying the protection that it affords,  The other misperception lies within the treatment services themselves.  Too many treatment providers believe that the lower dose a person is on, the better they, and their service, are doing – that they are somehow ‘ delivering recovery’.  This belief flies in the face of all research evidence accumulated over many decades.

This situation results from the stigma we have created in Scotland around the World Health Organisation’s recommended treatment for heroin dependence – opiate substitution therapy (OST) and specifically methadone.  We have stigmatised drug use and people with a drug problem and also a life-saving pharmaceutical treatment.  We need a concerted effort to address this stigma and achieve a consensus that allows us to join the rest of Europe and the world in recognising that OST is part of an evidence-based response to opiate drug use and that the quality of the services that deliver this is crucial.  Otherwise, we will continue to see people die needless and preventable deaths.  The Government and politicians, the NHS, drug services, the media and wider society have a part to play in this.

At the same time we need to address service quality. In particular we need to see improvements in access to OST.  In some areas we seeing waits of 6 months to get on OST. There are also issues of retention for the most vulnerable with significant drop out rates.  There is a need for assertive outreach to ensure people are not allowed to just ‘disappear from services’.

We can prevent drug deaths – as stakeholders we all need to do what we can to reverse this national scandal  –  that responsibility lies with us all.”

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