Guidance

National intelligence network on drug health harms briefing: January 2020

Updated 13 January 2020

This briefing is based on a meeting of the national intelligence network (NIN) on the health harms associated with drug use. The NIN is made up of representatives from drug treatment services, local authority public health and commissioning teams and national professional and membership bodies. Network meetings are chaired by Dr Michael Kelleher, consultant addictions specialist and clinical lead for Lambeth Addictions at the South London and Maudsley NHS Foundation Trust.

1. Drug-related deaths in England: findings from latest ONS report

Martin White (PHE Alcohol, Drugs, Tobacco and Justice Division)

The Office for National Statistics (ONS) reported that there were 4,359 deaths due to drug poisonings in England and Wales registered in 2018, a rise of 16% on the previous year. It also reported that 2,917 of these were deaths from drug misuse: an increase of 17% from 2017.

More information is included in the ONS report on deaths related to drug poisoning in England and Wales.

These are the highest numbers on record and part of a continuing trend which goes back to 2012. The trend is primarily driven by heroin deaths, which make up the largest proportion of drug-related deaths and have more than doubled since 2012. Many of these deaths are among people over 40, often with poor physical and mental health.

However, there are also upward trends for other substances, most significantly cocaine, and in age groups under 40. For example, cocaine deaths are up nearly 50% on 2017 and nearly sixfold since 2011. A large proportion of the cocaine deaths are likely to involve crack cocaine, which echoes evidence we reported last year of increasing cocaine and crack availability, purity and use.

Drug-related death rates across the country continue to vary with the highest rate being in the North East and the lowest in London.

There are also increases in other UK countries and a recent report in Scotland highlighted the influence of drug-related deaths (DRDs) in stalling life expectancy in Scotland. Life expectancy has also stalled in England and we are working to understand the role of drug misuse in this, including overdose deaths. We are also trying to estimate the broader impact of drug misuse on other causes of death.

2. Reducing injecting-related harms and barriers to care among marginalised groups

Dr Magdalena Harris (Associate Professor, London School of Hygiene and Tropical Medicine)

Download the reducing injecting-related harms presentation

Skin and soft tissue infections (SSTI) are bacterial infections of the skin, muscles, and connective tissue and can lead to limb amputation, kidney failure and death among people who inject drugs (PWID) in the UK. Up to 60% of PWID in the UK report symptoms of recent or current SSTI and 10% of these report SSTI-related hospital admissions each year.

The Care and Prevent Study aims to promote care of these infections and to prevent AA amyloidosis (a disease which attacks tissues and organs) among PWID. Nearly 4 in every 5 of people taking part in the study experienced street homelessness and half injected heroin and crack in the preceding year.

SSTI are associated with the reuse of uncleaned needles and syringes and the time someone takes to seek medical advice after they first notice a sore or infection.

The risk of SSTI is also increased where the individual:

• is over 45 years old
• has spent over 8 years injecting
• has injected in the last day
• is injecting over 4 times a day
• is injecting into the groin, neck, legs or feet

Severe health harms and care delays are common among PWID, so wound care nurses and outreach services are crucial to tackling SSTI in this group.

Some PWID want to keep their veins healthy, functioning and accessible for injecting into. So they will likely be receptive to safer injecting advice about how to look after their veins.

3. Peer harm reduction in the UK

Mat Southwell, George Charlton and Mick Webb (European Network of People who Use Drugs)

Download the ‘Peer powering up harm reduction in the UK’ presentation

Providing naloxone through drug services to people in treatment is well-established, but peer-to-peer provision can be a necessary and effective way of reaching hard to reach populations, including people who are street homeless and do not have any contact with other services.

The European Network of People who Use Drugs (EuroNPUD) has produced materials including case studies on some pioneering programmes for distributing naloxone. A total of 4 peer-to-peer naloxone pilots are operating across England.

One of the pilots in Wiltshire explained how peers carried naloxone to a park where they knew groups met to use heroin and where overdoses had occurred. The scheme was supported by local clinicians, police and ambulance services.

Another of the pilots, in Cleveland, is supported by local police and public health and allows peers to get naloxone kits out into the community.

However, there are still barriers to effective naloxone distribution. For example, it’s common for some people to take kits but not to carry them because they are afraid they will be identified as a heroin user and will experience stigma.

Some areas are seeing younger populations using heroin and there are few experienced users around to tell them about safer injecting, carrying naloxone and other harm reduction practices.

Peers can have a vital role in distributing naloxone because of their unique access to drug-using venues, drug supply routes and networks of drug users. People involved in naloxone distribution also gain the trust of other people who use drugs and understand their lived experience.

4. Public Health England update

Pete Burkinshaw, Steve Taylor, Laura Pechey, Rob Wolstenholme and Claire Edmundson (Public Health England) updated the network on recent PHE activity related to drug-related health harms.

4.1 Report Illicit Drug Reactions (RIDR) and Drug Harms Assessment and Response Team (DHART)

PHE’s pilot of a national system for reporting the unexpected or severe adverse effects of illicit drugs will not be extended beyond the end of this financial year. RIDR was originally only a one-year pilot and after extensions to the pilot period, during which the volume of reports has remained low, future funding has not been agreed.

PHE is committed to supporting a system which can rapidly identify and respond effectively to emerging drug health harms. So we are exploring options to develop a new drug health harms surveillance system to add to existing networks. Existing networks include the NIN, the European Monitoring Centre on Drugs and Drug Addiction and drug alerts systems delivered with providers, PHE centres and local authorities. More information on progress will follow.

Meanwhile the multidisciplinary Drug Harms Assessment and Response Team (DHART) continues to use these networks and ther intelligence sources to better understand emerging drug harms. The latest information for professionals summarised by the DHART is updated and published soon after each quarterly meeting.

4.2 Heroin assisted treatment

PHE has set up a group of clinical and commissioning experts to support it in collating existing evidence and guidance on heroin assisted treatment (HAT). This builds on the latest clinical guidelines and earlier evidence that the guidelines are based on. The new guidance, due in early 2020, will clarify clinical and operational details for setting up a HAT service.

4.3 Unlinked Anonymous Monitoring survey on people who inject drugs

Data tables and a Health Protection Report covering the results of the Unlinked Anonymous Monitoring (UAM) survey of people who inject drugs (PWID) in England, Wales and Northern Ireland have been published.

The main findings for England are:

1. The mean age of people taking part in the survey has increased from 34 in 2008 to 40 in 2018. This is consistent with an ageing group of PWID seen in other data sources nationally and internationally.
2. HIV prevalence in England increased slightly from 0.9% to 1.2%. Almost all (97%) of HIV-positive people (in England, Wales and Northern Ireland) were aware of their status.
3. Hepatitis B prevalence has decreased from 19% in 2008 to 9% in 2018.
4. Hepatitis C prevalence increased from 52% in 2017 to 55% in 2018.
5. Crack injecting increased to 62% among UAM participants from 53% in 2017.
6. The proportion of people who reported being homeless during the last year increased from 34% in 2008 to 47% in 2018 (England, Wales and Northern Ireland).
7. A total of 21% of people who had injected drugs in the last year reported overdosing during that period – an increase from 16% in 2013 (England, Wales and Northern Ireland).
8. A total of 65% of people reported carrying naloxone, an increase from 54% in 2017 (England, Wales and Northern Ireland).

4.4 Prescribed medicines review

PHE’s review of prescribed medicines assesses the scale and distribution of dependence on, or withdrawal from, 5 classes of medicines. It makes recommendations for better monitoring, treatment and support for patients and draws on evidence from prescriptions data, a literature review and reports of patients’ experience.

More information is available in the prescribed medicines review report.