The lethal burden of drug overdose.

The past fortnight has seen the release of alarming new fi gures about drug overdose in England and Wales, together with a report damning the UK Government’s approaches to drug addiction. Prime Minister David Cameron should take heed. Both legal and illegal drugs cause many deaths in the UK. The National Offi ce for Statistics reports that 2597 people died from overdoses in 2012—1496 cases were related to drug misuse. Opioids are still the biggest killer. Methadone replacement is the most widely used treatment for opioid addiction and reduces harm to patients. However, people enrolled in such programmes are at high risk if they relapse—the combination of methadone and heroin is often a deadly one. Indeed, the 2012 data report 414 overdose deaths involving methadone—the third highest mortality in 20 years and not far short of the 579 deaths involving heroin and morphine. The Coalition Government’s 2010 Drug Strategy noted that too few people progress from methadone replacement programmes and that “This must change”. Instead, the policy emphasised the importance of complete recovery from drug dependence—including from methadone. Complete independence from drugs is a worthy ideal but any new treatments must be as robustly informed by research fi ndings as the pragmatic approaches used at present. Health services should also provide holistic care—beyond simply managing dependence—to address the complex physical health needs of the ageing population of long-term opioid users. The UK Government’s implementation of its drug strategy was criticised in a report by the Centre for Social Justice published last month. The authors of No Quick Fix note that 55% of local authorities have had funding cut for residential rehabilitation schemes whereas methadone replacement remains well supported. The report also notes the ineff ectiveness of selecting services to treat drug and alcohol addiction on a payment-by-results basis. The Government is also struggling to cope with the emergence of novel psychoactive substances—socalled legal highs. The number of deaths caused by drugs such as synthetic cannabinoid receptor agonists and mephedrone leapt from 29 in 2011, to 52 in 2012. Although still far short of the deaths caused by drugs such as heroin and amphetamines, the trend is concerning. Every year dozens of new drugs enter the British market for which the short-term and long-term health eff ects are unknown. Ministers have demanded action to stem their availability and the government has highlighted legal highs as a priority for drug control. However, as noted in a Lancet Editorial earlier this year, the health-care systems and regulatory agencies are still having diffi culty in addressing the issue. In the US, the Obama administration is making progress in countering accidental drug overdose. As in the UK, drug overdoses are a major cause of death in the USA, killing 38 329 people in 2010—more than motor vehicle accidents or homicides. And, like in the UK, opioid overdose is by far the biggest killer. The US faces great diffi culties with misuse of prescription drugs, which are responsible for about 60% of drug overdoses. The prescription culture is endemic, with the US National Center for Health Statistics reporting that 4% of adults—9·6 million people—have recently used a prescription drug to aid sleep. However, the US Government is taking positive steps. Its drug policy—released in April this year—emphasises the importance of an evidence-based strategy. It recognises the futility of a punitive approach, addressing drug addiction, instead, as any other chronic illness. Treatment has been made available under the Aff ordable Care Act and President Barack Obama has requested an additional $1·4 billion to tackle substance misuse. These are large political milestones for America. Tackling drug addiction is a complex, diffi cult task, with many medical, political, judicial, and social factors at play. The UK Government’s drug strategy included laudable aims—targeting prevention strategies to young people, aiming for complete recovery from drug dependence for people with addiction, and recognising the threat of emerging trends in drug misuse. But good intentions alone are not enough. As of April this year, local councils, supported by Public Health England, are responsible for selecting services to treat drug addiction. In realising the Government’s drug strategy, they need to be certain that new measures are based on the best available evidence. They must resist the caprices of party politics. It is these choices that will save, or not, the lives of thousands of people in the coming years. The Lancet For the National Offi ce for Statistics data see http://www. ons.gov.uk/ons/rel/subnationalhealth3/deaths-related-to-drugpoisoning/2012/index.html