Background: In England and Wales, the mortality rate for drug-related deaths has risen each year since 2012 (ONS data 2023). Just under half of the drug poisoning deaths registered in 2023 involved an opiate, and while heroin and morphine were the most frequently mentioned, methadone was implicated in almost a third of opiate deaths. Additionally, the number of deaths involving cocaine has increased in each of the last 12 years.

Study data: A drug-related death review and surveillance system developed in Merseyside in 2015 by the Public Health Institute at Liverpool John Moores University has now been rolled out across the North West of England to cover ten separate coroner jurisdictions, and additionally one coroner area within the West Midlands. This surveillance coverage allows for the investigation of changes in the substances implicated in drug-related deaths both over time and also the differences in reporting between geographic areas of England. This study illustrates differences in the reporting of implicated substances as well as the challenges of interpreting toxicological results for the purpose of determining the cause of death. In particular, this study aims to add context to the increased mention of substances such as methadone and cocaine within drug-related death data for England and Wales. Data from the drug-related death surveillance system is also used to add further context to these deaths including differentials in demographic profiles, and the proportion of individuals in contact with drug treatment services at the time of their death.

Disclosure of Interest Statement: This work was commissioned and funded by the public health teams within 26 Local Authorities covering the UK areas of North West England, and Birmingham & Solihull.

Abstract: Social isolation has become a major issue for Western societies in the 21st century, and this is evident in the number of drug related deaths in which individuals have died alone. When examining coroner data from a number of regions in the north-west of England, in between 70-86% of cases in which a substance was implicated, the individuals had used the substance alone, and in some cases were not found for several days to weeks after the death occurred. While much of the focus on preventing overdose has been around widening access to naloxone, the overdose-reverser is only useful if there is someone there to administer it, leading to one paper being published in 2019 describing "the sad irrelevance of naloxone in the context of solitary opiate use." With the emerging threat from synthetic opioids such as nitazenes, the issue is one of increasing urgency, with several solutions being considered by partnerships such as the use of buddying apps, telehealth technologies and the development of personal safety plans for individuals in treatment for their drug use.

However there are wider societal factors at play which have been amplified by years of austerity and budget cuts which may be out of the control of localities to counter. While naloxone is a valuable tool in keeping people safe, harm reduction has to build on this and provide a range of appropriate interventions including for instance safer settings for drug consumption. After a prolonged focus on recovery in England, the challenge for drug treatment services is to provide a harm reduction approach which is more than just transactional, and supports connections for individuals who are isolated or living in complex and difficult circumstances.

Disclosure of Interest Statement: This work was commissioned and funded by the public health teams within 26 Local Authorities covering the UK areas of North West England, and Birmingham & Solihull.

Background: Nineteen local authorities across the North West of England commission a review process to examine DRDs and wider mortality in drug treatment in order to explore common themes, identify recurring issues and to share findings. The monitoring system was developed by Liverpool John Moores University’s Public Health Institute (PHI) who collate information from various sources through a bespoke online portal (pictured) and who convene regular panels. The process is based on recommendations from the Local Government Association and Public Health England.

Insights from the system:

• Opiate Substitute Therapies (OST) such as methadone are often prescribed at levels below that which is considered therapeutic (60mls for methadone) which means that individuals in treatment continue to use street drugs.
• Access to mental health care is difficult for people who use drugs and alcohol, with barriers hindering access due to perceived inability for meaningful engagement if “intoxicated”.
• There are high levels of prescribing by GPs of medications such as Pregabalin and Gabapentin which might make someone more vulnerable to opiate overdoses.
• People in receipt of high value back payments of benefits they have accrued potentially over a substantial period of time are susceptible to overdose. Cases from the panels have fed into policy development in this area by the UK’s Department of Work and Pensions.
• Individuals in drug treatment are more likely to die from physical health related issues such as COPD but these comorbidities in turn make individuals more susceptible to fatal overdose.
• A substantial proportion of people (57% regionally in 2021) live alone and often use alone – meaning that Naloxone is not useful since there is often no one to administer it in a timely manner.
• Different systems are in place for pharmacies to notify drug treatment providers when someone has missed a pickup for their OST prescription, which might indicate disengagement.
• The period immediately after leaving prison is a time of heightened risk for overdose, particularly if the release date falls on a Friday or prior to a public holiday.
• There is variation in the levels of end of life support between different local authority areas, with potential barriers to individuals accessing appropriate palliative care in specific settings such as hospices or hospitals.
• A substantial minority of individuals who have refused receipt of Naloxone then go on to die from an opiate-related overdose.

Disclosure of Interest Statement: This work was commissioned and funded by the public health teams within 19 Local Authorities covering the UK areas of Cheshire, Merseyside, and Greater Manchester.

Background: The restrictions introduced in response to COVID-19 presented many challenges, particularly for vulnerable and marginalised populations. These included maintaining access to Needle and Syringe Programmes (NSPs) to reduce the harms associated with injecting drugs. NSP effectiveness is coverage dependent, but lockdowns and social distancing during 2020/2021 limited NSP access and availability. Cheshire and Merseyside, a sub-region in the northwest of England has had NSP surveillance in place via the Integrated Monitoring System for three decades which allows for the counting of individuals attending, visits and equipment distributed.

Methodology: Data was compared during five four-year periods centred on the implementation of restrictions in the UK in mid-March 2020. Weekly averages were compared to allow for public holidays and weekly variation in activity. This data was subsequently compared with activity levels at the end of March 2022, by which time most pandemic restrictions had been lifted.

Results: The restrictions resulted in the number of NSP clients decreasing by 36%. NSP coverage for those injecting psychoactive drugs halved, declining from 14 needles per-week during the 4-weeks to 15th March 2020 to 7 needles per-week by mid-April. While activity was substantially down for most of the succeeding year, it recovered during 2021 and by March 2022 was at 96% of the pre-pandemic level for individuals using psychoactive substances, although there were still 26% fewer individuals using NSP for steroids and other IPEDs.

Conclusion: Though it is unclear if there has been a decline in injecting, the decline in NSP coverage during the early months of the pandemic was so marked that it almost certainly reflects decreased utilisation among those in need, indicating increased equipment reuse and risk. While activity has recovered for the psychoactive injecting population, the reasons for its slower recovery among the steroid and IPED injecting population warrants further investigation.

Disclosure of Interest Statement: This work was commissioned and funded by the public health teams within 9 Local Authorities covering the UK areas of Cheshire, and Merseyside.

Published findings: The initial findings were presented in a short report published in the International Journal of Drug Policy, September 2020. This poster presentation includes an update on NSP coverage in March 2022.

Background: Drug related deaths (DRD) are a major public health issue, and have been increasing in many countries including the UK. In England and Wales, DRD are at their highest level since records began in 1993, with deaths from overdose being prominent. In response, the nineteen local authorities across Cheshire, Merseyside, and Greater Manchester, in the North West England, established a DRD review process in order to explore common themes, identify recurring issues and share findings.

Description of model of care/intervention: The system follows national recommendations for good practice; reviews all deaths of individuals in drug treatment, not just those officially classified as DRD; and engages the coroner and non-treatment agencies in the review process. DRD monitoring is coordinated by the Public Health Institute (PHI), who collate information from sources including: service-led internal reviews; the monitoring of drug treatment (NDTMS), needle and syringe programmes (IMS); social services and coroner records. When a death occurs, it is logged on to the system by either the drug treatment service or the local coroner via PHI.

Effectiveness: Public Health commissioners are automatically alerted that a death has occurred, so that they are able to access the record of the death prior to quarterly stakeholder panels. These panels review and scrutinise the cases and identify learning opportunities. The system has examined over 2,000 cases to date and has informed improvements to patient care, including: the development of new care pathways involving specialist services such as respiratory and palliative care; exploring medicines management; and focusing on disguised compliance, whereby individuals who appear well engaged with addiction treatment may be masking underlying drug use.

Conclusion and next steps: A collaborative system involving multiple local authorities ensures learning across areas and stakeholder sectors and also economies of scale. Synthesis summaries to improve cross-learning are being developed.

Disclosure of Interest Statement: This work was commissioned and funded by the public health teams within 19 Local Authorities covering the UK areas of Cheshire, Merseyside, and Greater Manchester.

Background: The World Health Organization target is to provide at least 200 needles and syringes annually per person who injects drugs in order to control infections. However, there is a paucity of evidence evaluating the monitoring of Needle and Syringe Programme (NSP) delivery in different settings. Data from the NSP monitoring system in Cheshire and Merseyside (Integrated Monitoring System, IMS), together with survey responses from NSP staff, were used to explore how NSP delivery affects the quality of monitoring data and to evaluate factors that could impact on coverage.

Methodology: A questionnaire was distributed to all 110 sites involved in NSP delivery. Topics covered service provision, interaction and engagement with clients, opinions regarding the client groups accessing services, and changes in service use over time. Responses were matched to data captured in IMS.

Results: Responses were received from 64 service providers. Almost three-quarters (72%) felt that clients mostly provided correct or consistent personal identification information when using NSPs. Asked about changes in service usage, less than one-third (29%) of providers recognised the increase in client numbers, observed in the IMS data. Opinions regarding injected substance correlated with the IMS data, and supported distinct patterns of service use by people injecting steroids. The majority of services (91%) implemented at least one restriction on service provision, with 45% placing restrictions on the amount of equipment obtained.

Conclusion: Restrictions on NSP provision may present barriers to service access, and result in less than optimal equipment distribution and coverage. Findings support previous data indicating the substance used impacts the types of NSP accessed. Findings indicate that monitoring data quality is sufficient for assessing coverage. Further research is recommended to ensure services are responsive to the needs of people who inject drugs, and to assess impact of restrictions on harm.

Issue: Drug related deaths (DRD) are a major public health issue, and have been increasing in many countries including the UK. In England and Wales, DRD are at their highest level since records began in 1993, with deaths from overdose being particularly prominent.

Setting: In response, seven of the nine local authorities within Cheshire and Merseyside region established a review process to examine DRD in order to explore common themes, identify recurring issues and to share findings. The system follows Public Health England recommendations for good practice; reviews all deaths of individuals in drug treatment, not just those officially classified as DRD; and engages the coroner and non-treatment agencies in the review process. A collaborative regional system involving multiple local authorities ensures better opportunities for cross-learning and also economies of scale.

Project: DRD monitoring is coordinated by the Public Health Institute (PHI), who collate information from sources including: service-led internal reviews; the monitoring of drug treatment (NDTMS), needle and syringe programmes (IMS) and criminal justice drug assessment (DIP); social services and coroner records. When a death occurs, it is logged on to the system by either the drug treatment service or the local coroner via PHI. Public Health commissioners are then automatically alerted that a death has occurred, so that they are able to access the record of the death prior to quarterly stakeholder panels. These panels review and scrutinise the cases and identify learning opportunities.

Outcomes: The system has examined over 460 cases to date and has informed improvements to patient care which include: the development of new care pathways involving specialist services in areas such as respiratory and palliative care; exploring medicines management; and focusing on disguised compliance, whereby individuals who appear well engaged with addiction treatment may be masking underlying drug use. Implementation issues will be discussed.

The Integrated Monitoring System (IMS) is commissioned by nine local authorities to collate data from pharmacies and drug& alcohol agencies across Merseyside and Cheshire, a region in the north west of England with a population of 2.4 million. The information collected pertains to interventions related to drug and/or alcohol use outside of care-planned treatment and which does not get reported by existing national systems. Services might include needle and syringe programmes delivered in both a drug team and a pharmacy setting, and by services offering brief interventions to particular groups of individuals such as recovering drug users, sex workers and homeless people.

This poster presentation provides an overview of the Integrated Monitoring System (IMS) which is commissioned by Local Authorities across Merseyside and Cheshire, a region in the North West of England. The service landscape for problematic drug and alcohol users in the region is complex with a high level of low threshold and specialised delivery, including needle and syringe programmes (NSP) which are not monitored at attributable level nationally. IMS enables all alcohol and substance use service providers to record information on presenting clients in a consistent manner, irrespective of their service specific monitoring system.

When a client presents to a service provider or pharmacy, information on the presentation is entered onto the IMS data collection tool, which is then collated and presented to providers, commissioners and public health leads, reporting on both activity and outcomes. The poster highlights the benefits of such an integrated system, including cross matching of data with national datasets to provide a comprehensive overview of the number of individuals presenting to any stage of treatment, allowing commissioners to understand the totality of people in contact with services. Its local development in partnership with commissioners and providers ensures that the system is responsive to local needs and captures information relevant to the local landscape.

The poster also highlights the practical side of its implementation, by using established data collection tools alongside the bespoke system, in order for its reach to be comprehensive, with integrated online mapping allowing commissioners to view data at a detailed level. It also assists in building up a picture of drug related deaths across the region, allowing death review panels to examine evidence supplementing the structured treatment data which may compliment or provide new evidence of an individual’s injecting status or alcohol use prior to their death.

The Integrated Monitoring System (IMS) was recognised as a shortlisted finalist in the ‘Best example of advancing local NHS systems for innovation’ category at the 2015 North West Coast Research and Innovation Awards. The North West Coast Research and Innovation Awards is a collaborative celebration event between the North West Coast Academic Health Science Network, and CRN: North West Coast.

IMS Online is a complete web based solution for services to record activity not covered by the National Drug Treatment Monitoring System (NDTMS) dataset such as brief intervention, recovery support and syringe exchange provision. Developed by a specialist team within Liverpool John Moores University’s Centre for Public Health, it complies with national recommended standards and provides a comprehensive suite of reports which agencies are able to use to monitor performances and activity and which can be accessed in aggregated form by local public health commissioners and other designated professionals.

Types of services currently using IMS:

Needle and Syringe Programmes: IMS Online provides a complete solution to syringe exchange services with an online web based tool for data capture which captures every information field as recommended by the 2014 NICE guidelines including demographics, equipment distributed and returned, wellbeing, outcomes and testing data. With a live visual representation of return rates over the last six months and the lifetime of the client’s contact with your service, prompting for assessments after a specified period of time and a full suite of reports for any given time period – plus the ability to generate an individual client level report. IMS Online is already utilised in numerous syringe exchange services.

Low Threshold Drug and Alcohol Services: IMS Online allows services who deliver low threshold brief interventions or extended brief interventions to service users to record their activity in a similar way to NDTMS but recording details of every intervention, along with demographic information, a TOP-like assessment form and wellbeing information based on the widely used WEMWBS scale. A full suite of reports is available for any given time period including activity, demographics and wellbeing reports – or you can generate an individual client level report with a summary of all information held on the client and any recent activity.

Non-Specific Support Services: IMS has been utilised by services dealing with but not specialising in drug and alcohol use, allowing them to report on client groups potentially affected by drug and alcohol use while not exclusively so – services which offer things like housing support or family help. So long as the client’s attributors (initials, date of birth and gender) are recorded along with the date of any intervention, the tool can be used to record all kinds of activity from different kinds of services.