National decision makers must wake up to the fact that their approach to addictions services is fuelling the rise in drug-related deaths, says Julia Sinclair
Alison Bedford Russell wrote a moving piece in the BMJ about the tragic death of her son in 2016. He was a young graduate with longstanding anxiety and depression, who became addicted to heroin. He successfully engaged with treatment to tackle his addiction and became drug free. But when he tried to get help for his mental illness, he was turned away from services. Without mental health support, he couldn’t tackle all the root causes of his addiction and slipped back into using heroin.
He was one of the 3,744 people who sadly died from drugs in England and Wales in 2016. But tragically lessons have not been learnt. Since then drugs have contributed to the deaths of 8,115 more people in England and Wales, with 2018 reporting the highest number and highest annual increase (16%) since records began in 1993.
When will national decision makers wake up to the fact that making swingeing cuts to services, disconnecting NHS mental health services from addiction services, and shifting focus away from harm reduction to abstinence-based recovery is destroying lives and fuelling this unprecedented increase in drug related deaths?
Most addiction services are not properly connected to wider health and care teams, so people are bounced between addiction and mental health services or fall between the gaps in both. It’s not uncommon for a patient to be excluded from mental health services due to having drug or alcohol use disorder but not be able to access addiction services because they have an untreated mental illness. This represents a lost opportunity to improve outcomes for patients, reduce the harm to individuals and their families, as well as a staggering waste of limited resources.
Mortality rises when we neglect evidence-based harm reduction strategies and ignore the fact that deaths due to addictions, like many health conditions, are over-represented in the most deprived parts of the country. 
The result is that patients present in crisis to their local acute hospitals; the one place they know will see them. Emergency departments, such as Southampton where I work, are struggling to cope with the additional burden.
In 2017 the Royal College of Psychiatrists laid out three solutions: To use the opportunity of developing sustainability and transformation plans to return to joint NHS and local authority commissioning of addiction services; to reverse cuts to training posts in England; and to halt all further cuts to local authorities’ budgets for these services. These solutions are still as relevant now as in 2017, although we are moving towards integrated care systems in the former.
However, in too many places, addiction and mental health services are not working together and spending on addiction services has been cut to the bone. Since 2013, when addiction services were moved out of the NHS into local authorities, budgets to support people struggling with drug use in England have been cut by £180 million (28%).
The 2017 GMC data shows that between 2009-2017 the number of consultants completing training with a specialist endorsement in addictions has fallen by 63%, and a recent survey of Health Education England (HEE) Heads of Schools shows that outside of London there are fewer than 10 training places in England and Wales available to gain the experience required for a Certificate of Completion of Specialist Training (CCST) endorsement, and at least 3 regions—Thames Valley, Wessex and Peninsula—are not able to offer any higher training opportunities.  How can we have a competent workforce without training?
There is almost no teaching for doctors and nurses on identifying and managing substance use disorders, and many health professionals continue to have ill-informed, even stigmatising, attitudes about people with addictions. There is no magic ‘cure’ for addictions, but there is evidence showing that a range of effective interventions can significantly improve outcomes, if more widely available, better resourced, and joined up.
National decision makers must properly fund services that support the whole person, by integrating addiction services with NHS pathways. The transformation the NHS is gearing up for; the long term plan, could be a key opportunity, but it will require political and medical leadership to see this through.
Julia Sinclair is chair of the Royal College of Psychiatrists’ addictions faculty.
Competing interests: None declared
 Bhui, K., Byrne, P., Goslar, D., & Sinclair, J. (n.d.). Addiction care in crisis: Evidence should drive progressive policy and practice. The British Journal of Psychiatry, 1-2. doi:10.1192/bjp.2019.158
 Current RCPsych training survey, (in preparation)