Drug-related deaths: a shared approach to a public health crisis

As part of our Policy Thinking series, we hear from Toby Seddon, Professor of Social Science at University College London and head of the UCL Social Research Institute, on the rising tide of drug-related deaths in the UK, and why a new joined-up approach that focuses on mobilising community public health could help tackle the crisis for individuals and communities.

A public health crisis

Whilst media attention has tended to focus on the deadly North American opioid crisis, latest figures show the UK is experiencing its highest rate of drug-related deaths since records began. Indeed, Scotland is the very worst affected country in the whole of Europe. The UK problem, as with the rest of Europe, has so far remained linked primarily to heroin, however, there are growing and worrying signs that synthetic opioids are now entering UK drug markets. As well as fentanyl, another class of synthetic opioids, nitazenes, have recently been found in the drug supply. The increasing potency of these substances is stark: whilst fentanyl is up to 50 times stronger than heroin, some nitazenes can be a staggering 500 times more potent. We need urgent, targeted and evidence-based action, if we are to avoid potentially being overwhelmed by a serious public health crisis.

What are the causes?

Opioids are potentially deadly because they can lead to ‘fatal respiratory depression’ - that is, they can cause people to stop breathing. More potent opioids increase this risk. Why, though, has there been an increasingly severe opioid deaths crisis in the last two decades? The causes of the crisis are complex and difficult to disentangle, and there are different stories for different parts of the world, but for the UK the situation is partly rooted in disinvestment in drug treatment and harm reduction. Changing patterns of socio-economic disadvantage and increasing polysubstance use (taking two or more drugs together) have also been cited as factors. An additional concern currently is the potential impact on European and UK heroin markets of the ban on opium poppy cultivation instituted by Taliban authorities in Afghanistan in 2022. There is evidence from the US that synthetic opioids can very rapidly supplant heroin within a market and that this may not be easily reversible. If the UK’s heroin problem becomes a fentanyl and nitazenes problem, we will be in a highly challenging situation

What does the research tell us we should do?

There is no single silver-bullet solution to this complex problem. Research suggests that a multi-faceted approach focused on impacting in the short-term (saving lives), medium-term (helping people get better) and long-term (tackling root causes) offers the best way of addressing the crisis.

Short term

There are three evidence-based interventions for immediate impact on mortality. First, establishing Overdose Prevention Centres (OPCs) in areas with street injecting problems. OPCs are safe spaces for supervised consumption where people can also be given advice, brief interventions and referrals to other services. There is evidence they can reduce overdose risk, needle-sharing and negative neighbourhood impacts (related to street injecting, litter etc), and also facilitate access to treatment. Second, expanding the distribution of naloxone (an opioid antagonist which is highly effective as an emergency treatment to reverse overdoses). Ensuring naloxone is available to opiate users, their peers and family members, and to relevant professionals (first responders, hostel workers, pharmacists, outreach workers etc) has been shown to reduce deaths. Third, drug checking services (e.g. ultra-portable NIR devices and fentanyl test strips) can help opiate users to be better informed about what they are consuming and there is some evidence they can be a useful component within overdose prevention strategies.

Medium term

Bridging from short-term emergency interventions, there is strong evidence that providing rapid low-barrier access to Opioid Substitution Treatment (OST) can be effective as an immediate form of life-saving ‘safe supply’ and can then become a pathway to longer-term recovery. To be fully effective, it is important that OST provision follows the evidence base in terms of optimal dosage, provision of wraparound support and flexible access. There is also good evidence that for individuals for whom OST has not worked, who may be at higher risk of overdose, Heroin Assisted Treatment (HAT) is an effective alternative. There is in addition a case for exploring the potential to make HAT accessible to a wider client group. Broader investment in high-quality evidence-based drug treatment and recovery services is also critical as part of a prevention strategy aimed at supporting opiate users to get out of addiction and into sustained recovery.

Long term

In the longer-term, it is essential to deal with the underlying problems of socio-economic disadvantage that we know drive initiation into opiate use, prolong addiction ‘careers’ and exacerbate harms. Social policy which addresses housing needs, tackles homelessness, supports people into paid employment and provides a safety net for those who need it, will lay the foundations for the sustained prevention of serious opioid problems in society. There is also good evidence that the decriminalisation of drug possession would potentially be beneficial for public health, by reducing the barriers to accessing treatment and recovery services that are created by stigmatisation.

Keeping ahead of the curve

An integrated multi-dimensional strategy offers our best chance for averting a public health crisis, built on a combination of emergency measures and longer-term prevention which we know is so key to many of our health challenges. One thing we know is that drug markets do not stand still and market futures are very hard to predict. For this reason, it is essential to invest in ongoing monitoring and evaluation of all the components of the strategy, to ensure we continue to build learning about what works and can adjust course as new evidence emerges. We also need to build capacity in Early Warning Systems and our use of advanced data science and modelling tools so that in the future we are better able to see what is coming over the hill before it is right in front of us.

Toby Seddon is Professor of Social Science at University College London, Head of the UCL Social Research Institute and Chair of Release.