Scotland’s drug deaths: We need to learn lessons from those who die

Policy makers love to speak to survivors of drug use, who tell their story about difficult times and episodes of delayed, intermittent relapses and eventual recovery.

Other people who use drugs, clearly, recover spontaneously and remain beneath the radar of scrutiny and outside any organised figures.

Knowing what we do about the enormous percentage of the population who at some time in their lives use drugs, and survive, it does make one wonder why some people don’t live to tell their story.

Maybe we are listening to the wrong people, who, by the very fact that they are alive, are somehow different.

In my clinic I often say as people leave the room, “be careful”. They usually try to reassure me and say that they are not doing anything too risky. I follow up by saying that I know many people who said the same thing to me but went on to die of a drug-related cause.

Studying those that have died becomes the imperative if we are to design the most useful interventions.

Deaths attributed to drugs fall into various categories. Acute toxicity as a result of one or more drug is the most obvious and event most easily related to drug use. There are, however, many who die indirectly at a later date, sometimes much later.

There is an increasingly large part of the population of people dying of drug causes who are in an older age group.  A cursory study of this older group reveals a startling accumulation of other medical problems.

It isn’t uncommon for medics who were involved with multi-morbid patients to say that there is no surprise that they died and it could have happened at any time.

A study in Edinburgh some years ago asked GPs what they could have done to prevent the death and often they said “nothing, there was an inevitability about the death” and that their patients were at the end of their lives as they had chronic liver disease, longstanding lung or heart problems or crippling mental health issues.

One of my palliative care colleagues said to me once that “if you think that this person might die within the next 12 months then you should consider treatment as palliative care”.

Solutions are hard to find without the fatigue inherent in considering precursors such as adverse childhood experience, inequalities, poverty of spirit, educational failures, and stigma in communities and institutions.

Everyone has a responsibility to address these issues. Governments can increase tax and redirect resources to reduce inequalities. Health, social care and education can examine their own policies and attitudes. We all need to consider our tendency to stigmatise.

In health and social care, however, we are managing symptoms, whatever the cause. The end stage is a drug-related death but the months and years leading to a fragile and vulnerable state is where the prevention might be managed.

Resources, if they are to be effective, must be targeted at the intervention most likely to reduce death.

The Minister says that there is £250million to be spent over a 5 year period. Recovery communities are unlikely to prevent death but money spent on rigorous academic scrutiny of causes and the value of treatment and resources targeted to management of the highest risk cases are more likely to succeed.

How the money is being spent is already unclear and on what evidence it is allocated is equally opaque. The recent report by the taskforce reporting to government reveals that the members of that group need to listen much more carefully to a wider constituency

We need to know more about why people die, we may be making things worse and we have a duty to individuals and families to manage cases in a format familiar with other sectors of health care.

Roy Robertson has been a GP for 40 years in Edinburgh’s Muirhouse and is Professor of Addiction Medicine at the University of Edinburgh.