Roy Robertson: Warning best efforts aren’t enough

Methadone, used to treat heroin addiction. Picture: Dan Phillips

Surprise has been replaced by a resignation of the sort previously, sadly, observed in attitudes to cases of suicide and death from alcohol problems. 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 confined anxiety about this disease to a smaller number of interested groups and professionals.

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 problems 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 opiate substitute treatment in the form of methadone, buprenorphine or other opiate prescriptions.

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 East Scotland when methadone treatment was 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.

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 then maybe this could have been prevented. Ultimately we all suffer from the financial or social costs of drug taking.

The Scottish Government has allocated considerable time and expense to these problems in an on going programme of interventions and investigations. A belief in the value of recovery, and progress from dependency to independence from 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 professional guidelines and a substantial body of research. Opiate substitute treatment is effective if it is long term, consistent and supplemented by professional support. Relapse is common and should be prevented or responded to urgently. Situations that 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.