Drug dependence: The challenges facing a neglected service landscape
Daniel Mogford is more than qualified to be talking about drug dependence – he is currently the Medical Director for the UK and Ireland at Camurus. Here, he talks us through the fatal consequences that will follow if services continue to be neglected and how we can help.
Drug dependence can impact all aspects of a person’s life, including their health, social engagements, relationships, and overall wellbeing. Their needs are therefore complex – particularly among younger patients. To help individuals navigate towards recovery and stability, compassionate and holistic interventions are required. This includes specialist treatment as well as broader health and social care services. Families impacted by drug dependence also require support services of their own.
Social care is fundamental to delivering optimal Addiction Services. Unfortunately, these services, primarily funded through the NHS and local authorities, have experienced long-term underinvestment. Combined with regional inconsistencies, this has resulted in increasingly high caseloads across services and a reduction in patient care quality. Data from the Dame Carol Black Review showed that there were only 0.38 social workers for every 1,000 people in treatment for drug dependence.
The burden of drug dependence on society is high. Government data shows globally, the UK had the highest rate of opioid consumption in 2019, with around 300,000 people living with heroin and crack cocaine dependence in England alone. What’s more, research from the British Journal of Pain illustrates Opioid-related deaths have increased by 388% since 1993. The use of illicit drugs currently costs society over £19 billion a year, of which over 80% is associated with opioids and crack cocaine. Regional variations compound this challenge further. For example, the North of England generally has a much higher rate of opioid and crack cocaine usage than other parts of the country.
From Harm to hope – admirable ambition, challenges with implementation
In response to Dame Carol Black’s Review, the previous government published its 10-year drug strategy, From Harm to Hope, in 2021 to enhance support and investment in Addiction Services. The strategy includes the goal to ‘deliver a world-class treatment and recovery system.’ Aside from a commitment to include local authority officials with social care expertise within a proposed strategic partnership in England, and to ensure that outcomes frameworks, commissioning quality standards, and workforce development initiatives enable local areas to meet the needs of families and young people, there was no reference to expanding or improving social care and services.
This sentiment was reiterated in the first annual report for the strategy (2022-23), where the government simply pointed to general increases in workforce numbers, a programme to test the impact of targeted housing support interventions on recovery outcomes, and the introduction of new Individual Placement and Support (IPS) teams in 26 additional local authorities.
A complex social landscape: Women in the spotlight
The social impact of drug dependence covers issues around employment, social integration, access to accommodation, homelessness, and mental health. Marginalised communities are acutely affected by this.
For example, the dynamics around childcare present unique social barriers for women accessing treatment. Around 27% of women have reported either living with a child or being a parent when they started treatment, compared to 16% of men. Women with childcare responsibilities are less likely to engage with community treatment services than those without children, as they fear that their children will be taken away. Mothers engaged in drug and alcohol treatment are up to six times more likely to have a child removed from their care than fathers.
A lack of support to navigate complex safeguarding processes can make it difficult for women to keep their children at home or have them returned to their custody. For instance, women may need to provide weekly drug tests to their social work team, but the drug treatment provider may not have the capacity to provide important clinical interpretation or an assessment of the wider clinical context. When a child is permanently removed, mental health support is not always routinely available to parents to help them grieve their loss.
There are currently very few mechanisms to accommodate the specific needs of women in Addiction Services. The government’s strategy alludes to improving outcomes for underserved communities like women, but it is unclear how this is being delivered in practice.
A complex social landscape: Socioeconomics and stigma
Deprivation is a core theme in drug dependence across the UK, with research showing a clear correlation between socioeconomic status, social exclusion and substance-related harm. Those living in the most deprived areas are experiencing the greatest risk of harm. Research from the Dame Carol Black Review unfortunately showcases this point as she found almost 50% of all people who die while in treatment for drug dependence are from communities within the most deprived quintile of the country.
Stigma and discrimination associated with drug dependence represent significant barriers to treatment access, recovery and reintegration into society. Negative stereotypes and myths reinforce the inaccurate concept that drug dependence is a choice as opposed to a complex medical condition with biological, social and psychological dimensions. According to a government drug advisory report, adverse childhood events, genetic variations and environmental and social factors are all pre-disposing factors which contribute to a person experiencing drug dependence. Better education is needed to improve public and professional awareness, and drive a more empathetic approach.
A positive future is within reach
Treating drug dependence and ensuring continuity of care, requires a combination of medical management, behavioural therapy and social support, involving specialist services, including psychiatrists, psychologists and nurses; GPs; pharmacies; and community organisations. Driving this multidisciplinary, integrated approach is challenging but achievable.
The new government must build on the UK’s commitment to fund and prioritise investment across all areas of the treatment system. A focus on individualised care will ensure treatment is accessible and adaptable to diverse needs, aspirations, and socioeconomic circumstances. More training is required to boost the number of social care professionals with expertise in the management of drug dependence and the workforce needs the support to tackle challenges with retention. Significant work is required to better ensure continuity of care, particularly for those from underserved communities.
To better support women, for instance, the planning of Combatting Drug Partnerships (CDPs) needs to include family-first approaches for working with families where drug use is present. Examples include training social work teams to set achievable goals, implementing suitable safeguarding processes for women while ensuring children’s safety, and guaranteeing mental health support for women whose children are removed from their custody. Automatic referrals to social services should not be the default policy when a drug dependent mother accesses treatment; referrals should only be made when triggers are met or where there is a positive, supportive role for social work input. The Chief Social Workers should provide national guidance to local authorities on reasonable triggers to invoke safeguarding measures, as well as the right for mothers to respond to their referrals.
Innovation in medical management can improve outcomes through reducing exposure to physical and psychological harm. When delivered well, treatment reduces illicit use, the risk of overdose, exposure to and transmission of blood-borne viruses and contact with the criminal justice system. More recent treatment options give patients the opportunity, where appropriate, to stabilise their lives through eliminating the barrier of daily dosing.
Ultimately, service provision for drug dependence is under significant pressure. Concerted and coordinated effort to improve the sector has the potential to deliver significant individual and societal benefits. For patients not engaged and then retained in treatment, the risk of death is substantially elevated as is the socioeconomic burden for the wider community. We have a moral imperative to treat drug dependence the same way as any other health conditions and provide people with every opportunity to have a better quality of life and fulfil their potential.
Daniel has been working at Camurus, a Swedish research-based pharmaceutical and biotechnology company, since August 2021.
Images: Daniel Mogford and Myriam Zilles
More features:
Battle for safety: How can we keep our healthcare workforce safe?