Observations from a frontline worker in London - in response to the Office of National Statistics on drug deaths of 2024 in England and Wales

By Plinio Ferreira

The recent publication of drug-related deaths by the Office of National Statistics just confirms what we are seeing on the frontline: taking drugs is increasingly dangerous, and the government is doing very little to protect the lives of people who use drugs (PWUD). Nitazenes and fentanyls, strong synthetic opioids which are replacing the low abundance of heroin in the market, are here to stay. Deaths confirmed by nitazenes have increased fourfold compared to 2023, and this number is underestimated, as previous research has shown. Cocaine-related deaths are increasing exponentially: 14.4% compared to 2023, reaching a staggering 1,279 deaths — a figure eleven times higher than in 2011. There have been many articles and posts on social media rightly asking the government to take these figures more seriously and act on new measures such as opening overdose prevention centres across the country, drug checking facilities such as The Loop in Bristol and the newly announced service in Scotland, heroin-assisted therapy as an alternative for people who don’t adhere to current opioid substitution therapies (OST) (methadone or buprenorphine), and other measures that would involve policy change. Unfortunately, the current UK government has shown no interest in changing the current drug policy and also no intent on rethinking the prohibitionist approach, which is the basis for the failed war on drugs.

Here I present a few observations and suggestions where drug policy does not need to be changed, with the aim to reduce harms and, eventually, deaths from drug use. These are based on my personal experience as a frontline drug and alcohol worker in London’s most deprived areas, with high numbers of homeless individuals and PWUD. I acknowledge that some of my observations and suggestions might not correspond to the diversity of the country due to regional differences. The population where these were observed are mostly those facing homelessness, from rough sleepers to unstable temporary accommodation, who are more susceptible to becoming a number in this tragic statistic. All opinions are my own.

Window of opportunity

Local authorities in England have the statutory duty to improve the health of their populations. This includes commissioning services for drug and alcohol misuse prevention, treatment, and recovery support. People who use drugs have the right to access treatment and recovery support services. Whenever someone shows interest in addressing their substance misuse issues, this window of opportunity is taken very seriously. It may take years for a person to realise that their behaviour regarding drug use might be detrimental to their health and that it’s time to try and do something about it. Or they might be enjoying using drugs and living the lifestyle around it, until that certain day when they get exhausted with the hassle involved in feeding a habit and decide to ask for support. It’s our duty as keyworkers to take it very seriously and provide clear and assertive support — and, most importantly, do not let them down again since they have been ignored and living on the margins of society for, maybe, a very long time.

Service providers in boroughs with a high population of opioid users usually have open prescription clinics. These work very well, and service users can receive their opioid replacement therapy on the same day they first walk through the doors. Once engaged, however, if a service user falls off their prescription (not picking up methadone or buprenorphine) for 2 weeks, their prescription for OST is stopped and the dose needs to be reassessed. This mechanism is reasonable because tolerance to opioids can rapidly change, and the dose might need to be readjusted to avoid harms. But, because they are already enrolled at the local drug and alcohol treatment service, they are also not allowed to attend the open prescription clinic drop-in service anymore and need to schedule a session with their assigned keyworker/prescriber. These professionals are overworked due to short staffing across the entire drug and alcohol treatment sector, and it may take weeks for an appointment for OST reassessment. Therefore, the client who was previously engaging and on treatment now has no option but to return to using illicit drugs until their reassessment day. Once back using illicit opiates, it becomes much harder for them to attend appointments and engage with keyworkers. They might be rough sleeping again or involved in anti-social behaviour and minor crimes. Mobile phones come and go incredibly fast, cutting ties with their keyworkers. Therefore, there is a good chance that this person will miss their appointment, and it could take months or even years for them to decide to commit again and engage on a treatment pathway. Buprenorphine prolonged-release injections are effective for a week or a month, depends on the formulation used, and is an effective OST which doesn’t require daily trips to the pharmacy. Its use needs to be more encouraged by treatment providers. 

Attending the local drug and alcohol recovery support service can be a traumatic process for folks in recovery, and some refuse completely to go inside the building — either because they can’t stay in enclosed spaces or because they have already been so many times to that particular place aiming to address their substance misuse and did not succeed, that returning to that very same space again is a way of re-living trauma they might want to avoid.

Although severely understaffed, drug and alcohol treatment services need to rethink these processes and make OST access more agile and flexible. The recovery journey will have many setbacks. A strict booking system for engaging clients in OST is not lifestyle-friendly and has to be changed. Folks in recovery need an even more lenient system to accommodate their needs. Drop-in and open-door approaches are far more effective. Cranstoun’s DEMO (Dynamic Evolving Model of Outreach) service, where service users can get their OST prescribed by outreach workers, is a brilliant example of a progressive community drug treatment model and should be taken into consideration by other local authorities too.

Starting OST is just the beginning

Outreach and recovery services are often evaluated by commissioners based on the numbers of people referred into treatment and the number of people who start treatment. Managers are constantly under pressure as these performance indicators are usually impossible to meet and, ultimately, do not reflect the quality of service provided. Once started on treatment, folks need support, follow-up, care, and attention. These are non-quantitative pieces of work that take up a lot of time from keyworkers but are detrimental to prevent relapse and keep people safe. It’s common to see people with substance misuse disorders and facing homelessness with a history of broken relationships and trust issues towards others, which often make them feel like they have no friends, only acquaintances. Creating a bond based on trust with their keyworker, or a sponsor on 12-step programmes such as Alcoholics Anonymous, is very important for their recovery. Recovery is a long-term commitment, and recovery workers need time available to invest in that by doing long-term work with their clients.

Boredom versus progression and training

When actively using drugs, folks can get trapped in a cycle of raising funds, buying drugs, and using. This is a full-time activity and takes up most of their time during the day. Once a client starts on OST and takes their first steps on their recovery journey, they suddenly have more time on their hands. What to do from now on? Boredom kicks in very quickly, and support is crucial at this point. Stigma is very present, and folks usually have such low self-esteem after years of drug use that they can’t see themselves doing anything else. We need society’s support on this. Folks in recovery need better progression and training opportunities, easy access to volunteering jobs, and, very importantly, routes into employment. To avoid relapse, folks need new avenues that will allow new social bonds so they can thrive and not go back to old habits.

Education and training of support staff and keyworkers

Homeless hostel staff turnover is very fast. Keyworkers usually have a background in housing, homelessness, and social care but, if not trained regularly, they won’t keep up with the fast-paced changing environment of the illegal drug supply and its contaminants. Communication between hostel keyworkers and recovery workers is also key because hostel keyworkers know their clients very well. Recovery workers often have 50 clients on their caseload and won’t have time to chase everyone all the time. Feeding them with information helps them and their clients.

Commissioners need to ensure that hostel staff are trained regularly (twice a year, at least) so that everyone working there can recognise signs of overdose, use naloxone, and, even better, offer basic harm reduction advice to clients and do simple needle exchange and distribute drug testing kits. Hostel keyworkers are the ones more likely to witness an overdose as PWUD use inside their accommodation.

Drug Testing Strips

Drug testing strips are a legal and important harm reduction tool. Although it has been shown that they are not always accurate due to: a) false positives — when a test is positive for a substance but that substance is not actually there; b) new psychoactive substances appearing regularly and the tests might not be sensitive enough; c) false negatives — a recent study showed that out of 36 different nitazenes, a common brand of testing strip used in the UK detected 28 of them. However, distributing testing kits is a very good way of opening conversations about illegal drug contamination and the dangers of synthetic opioids in what is sold as heroin. It also increases awareness and, when effective (most of the time), they provide information to the drug user which ultimately leads to a safer way to consume drugs. One of the key concepts in harm reduction is enabling people with tools that allow them to make informed decisions — whether they will carry on and use those drugs or not is up to them, but now they have a bit of information on what might/might not be present.

Sharing information is vital!

Communication is key and often overlooked. Drug and alcohol support services, treatment providers, floating support workers, hostel keyworkers, and local NHS services supporting PWUD need to communicate. Oftentimes, we only receive emails on threads with other local services when someone overdoses or tragically passes away. We need to share information about drug trends in real-time — especially between the local drug and alcohol community treatment provider and drug and alcohol support workers from hostels and homeless day centres. A mailing list or SMS network with emails/phone numbers of all drug and alcohol workers working in a city or borough can easily be established and, ideally, would be managed by the local LDIS (local drug information system). LDIS is another important mechanism created by Public Health England which isn’t very efficient. A quote from a document published in 2016 by Public Health England describing LDISs says: “An agreed local drug information system (LDIS) that uses consistent and efficient processes for sharing and assessing information, and issuing warnings where needed, can help ensure high-quality, effective information rapidly reaches the right people.” Alerts from LDIS sometimes take days to arrive after a suspected or confirmed drug contamination and they are rare. Also, communication between neighbouring boroughs should be established as PWUD buy drugs in different parts of town. Adding to that, keyworkers would ideally be receiving information from drug tests done by Forensics Police in drug busts but at the moment, they are not.

As an example that integration of services is crucial: in March 2025, a nitazene-laced batch of drugs sold as heroin in Camden, North London, was responsible for 33 people needing urgent medical care with 17 needing hospital admission over a few days.  Fortunately, no one passed away due to good communication and joint work between keyworkers, ambulance staff, and police.

In boroughs where drug testing strips are actively distributed, clients are incorporating drug testing into their routine, especially when they get a new batch of drugs or change dealers. Whatever results they obtain, either positive or negative, is very valuable information from a public health perspective. Developing a positive and non-judgemental relationship with clients is very important: if they feel safe, they will feedback this information to keyworkers, who will then be able to pass this information on to other clients and to other keyworkers. With the new wave of synthetic opioids, it’s detrimental for information to be shared to avoid episodes like the one in Camden described above.

As another example, there has been an increase in xylazine being detected in urine drug screening and testing strips from opiate users in East London. Following the situation observed in the United States, xylazine is now being added to drugs sold as heroin in the UK too. Xylazine, when used chronically, provokes wounds that can lead to a necrotic process. Therefore, we contacted the local wound care NHS specialist service, which works in partnership with local drug services, and informed them about it. At first, they were not aware of it and, therefore, they can now prepare to identify and provide the best care for patients, in case they present with these dangerous and characteristic wounds. They will also be able to incorporate this into their regular training of drug and alcohol keyworkers — it’s a full circle process that ultimately benefits the clients.

Better participation of NHS

Once the client starts on their recovery journey, they start to pay more attention to their health. Historically, marginalised communities such as PWUD have less access to health services. The health system needs to make an effort to reach them. Lung specialists, wound care services, eye specialists, and, very importantly, mental health services need to be present as drop-ins at treatment providers and local homeless day centres.

Mental health services often refuse to engage with a person who is regularly using drugs, with the argument that they first need to be fully engaged with the local drug and alcohol recovery support centre to then be offered mental health support. This is another outdated approach which must be reviewed systemically. The waiting lists for mental health services are sometimes months long. And if a client needs to first be abstinent to then receive mental health support, chances are they will not be able to see a therapist soon.

In my experience, I have never interacted with someone actively dependent on drugs who hasn’t experienced childhood trauma. The great majority of people I’ve supported come from foster care or had very difficult childhoods due to poor parenting. Women have almost always been victims of sexual abuse, many times in their childhood, or are currently involved in sex work. For this population, drug misuse is a way of coping with their flashbacks and numbing them from negative memories. Keyworkers with minimal mental health professional training often take the role of a therapist when speaking with their clients about past and present issues. Ideally, substance misuse disorders and mental health issues should be treated together in partnership between community mental health services and recovery and support services

We need to talk about (crack) cocaine!

Cocaine use in the UK is disseminated through every social environment and occasion, 7 days of the week, 24 hours a day. Londoners are one text or phone call away from a quick delivery of the white powder. Mortality rates for cocaine are rising faster than any other drug. In my view, cocaine use is abnormally normalised through British society when it should be taken more seriously. Cocaine has a high environmental and social impact in countries responsible for its production and transport costing thousands of innocent lives from marginalised communities living in areas where criminality due to cocaine trafficking is present at the expense of the war on drugs. If we disagree with decades of prohibitionism and want to see a fairer and more peaceful society, we need to work together to diminish cocaine use around our social circles. It’s only produced (at this scale) because people are buying the powder and using - simple as that. Traditional use of the coca leaf in Latin America has a different approach and it should be kept that way. So go on, talk to your friends and family who might be doing the odd line here and there. It’s not uncommon to see people facing difficult life situations and their (initially) recreational use spiralling into an everyday habit. Cocaine has a short acting stimulant effect and users’ re-dose many times in a session. It’s also commonly used in the workplace where professionals do long hours. A next day depressed hangover is common, and users frequently have another line of coke to cope with it and go on through their days. This is a dangerous cycle which can lead to dependency.  Drug Education in schools and academies also plays an important role in preventing substance misuse and the DSM Foundation is doing a great job with our young ones.

Although opioids topped the list for drug-related deaths in 2024, crack cocaine is the main driver of the lifestyle around homelessness and drug use. Heroin is a lot cheaper than crack cocaine and can be lethal, therefore a heroin binge is much different than a crack binge. A dependent heroin user might re-dose, on average, in 2 to 6 hours. If you consider that one bag of heroin contains 2-3 hits, even a highly tolerant opioid user will spend a maximum of £50 of heroin in a day. It’s very difficult to generalise, but in my experience, they usually spend less - around £20-30 per day. As discussed above, OST works very well and, frequently, opiate users stay on a maintenance level of methadone to avoid withdrawal symptoms but keep using heroin a few times a day on top of it. That reduces the cost of their habit, although it still is a dangerous practice. 

Crack cocaine, on the other hand, costs around £10 for 0.2g and finishes very quickly. The effects last 5-10 minutes and folks usually want another hit straight after that. If being careless, folks can spend £150-200 on a day just on crack cocaine. I’ve seen countless times folks spending all their money received on payday within 2 or 3 days in crack binges. Given that there is no alternative or replacement for it, keyworkers often feel empty handed and it’s very difficult to tackle, given the compulsive behaviour around it. 

Conclusions

If we are aiming for a fairer and safer society, we need to start paying more attention to marginalised people that we come across daily in our lives. Drug related deaths are preventable most of the times and these increasing number on drug deaths prove that the government is failing to provide essential care to its citizens. One thing I can firmly assure: most people that I’ve come across working on charities and health services supporting marginalised communities have strong compassion and are doing brilliant jobs, whilst underpaid and overworked. I hope none of the suggestions that I’ve done above are seen as direct criticism of them but should be seen as progressive solutions to certain aspects to the drug and alcohol recovery sector.