Topic Report: Drugs and alcohol

Alcohol and drug misuse affects all ages and can impact individuals, families, and children and young people within our communities with devastating consequences. Drug misuse is estimated to cost society £19 billion per year, and alcohol to cost £21 billion.

The health harms arising from drug misuse are diverse and vary according to factors including drug type and administration route (such as injecting, swallowing or inhaling).

• Some drugs such as heroin and tranquilisers have a sedative effect slowing down body and brain functioning. They can produce drowsiness; affect co-ordination making accidents more likely; and can reduce breathing leading to fatal overdose. Naloxone is a life-saving drug that can reverse the effects of opiates if administered during a collapse.
• Stimulant drugs such as amphetamine, cocaine and ecstasy give a feeling of energy and increase alertness. Stimulants can produce panic or anxiety attacks, particularly if taken in large quantities, and are particularly dangerous for people with cardiovascular problems.
• Hallucinogenic drugs such as LSD and ‘magic mushrooms’ (and to a lesser extent cannabis and ecstasy) tend to alter users’ senses and can produce disturbing experiences and erratic or dangerous behaviours.
• Drugs may each also carry specific side effects depending on how they interact with body processes. For instance, heavy regular use of nitrous oxide may lead to vitamin B12 deficiency, which can cause nerve damage.

Injecting drugs as a route of administration carries additional health harms with the risk of infection. Blood borne viruses (BBVs) include hepatitis C and hepatitis B. Injecting drugs can also lead to bacterial infections. Please see the harm reduction section for more information.

Drugs are an increasingly common factor in deaths in England. In 2021 there were 4,532 drug poisoning deaths, with two thirds (63%) classified as a drug misuse death – that is a drug poisoning that is either reported as being due to drug abuse/dependence or involves a substance controlled under the Misuse of Drugs Act (source: Office for National Statistics).

The most recent breakdown of these drug misuse deaths relates to 2020. Nearly three quarters (73%) were in men. The most common age group was 40-49 year olds. Over the past 20 years the number of drug misuse deaths in those aged under 30 has halved (52% reduction), but this has been more than offset by deaths in those aged 30 and over more than doubling (137% increase) (Figure 9).

The most commonly cited drug group across all death certificates in England and Wales is consistently opiates, with 2,170 deaths in 2020. In comparison, cannabis, used by nearly 120 times more people than opiates, was listed on only 30 death certificates. Marked increases in the number of deaths have been seen for opiates, cocaine and benzodiazepines (BZD)/Z drugs over the past 20 years (Figure 10). There has been a decline in the number of deaths linked to paracetamol during this period.

Drug poisoning hospital admissions and drug poisoning deaths are more common in more deprived areas in England – deaths data show that this trend is true for both men and women (Figure 11) (source: Ibid).

Hospital admissions for drug poisoning indicate a higher level of harm. There were 157 admissions in Buckinghamshire in 2020/21 – a rate of 28.7 per 100,000. There has been no clear trend in the drug poisoning admission rate in Buckinghamshire over the past five years, and it has been consistently lower than the national rate (50.2 per 100,000 in 2020/21).

There were 23 drug poisoning deaths and 12 of these were drug misuse deaths in Buckinghamshire in 2021 (source: Office for National Statistics). Drug misuse deaths are drug poisoning deaths for which the underlying cause was recorded as drug abuse or drug dependence, or any of the substances involved are controlled under the Misuse of Drugs Act (1971). This was a fall compared to 34 drug poisoning and 21 drug misuse deaths in Buckinghamshire in 2020, despite a rise in deaths observed nationally. However, taking a longer term view the general trend both locally and nationally is rising drug misuse deaths. The three-year pooled rate has risen from 2.1 to 3.1 per 100,000 in Buckinghamshire, and from 3.0 to 5.1 per 100,000 nationally between 2010-12 and 2019-21 (Figure 12). The most recent local coroner's audit (2017-19) revealed 85% of drug-misuse deaths in Buckinghamshire involved opiates. The next coroners audit of drug related deaths will be conducted in 2023.

The Buckinghamshire Suicide Audit 2022 covered deaths in calendar years 2017, 2018 and 2019. Of the 141 people who took their own lives during the audit period, 125 (89%) were resident in the Buckinghamshire County Council area at the time of death. Substance misuse at the time of death related to 11 (8%) of cases, with fewer than five cases recorded as being in drug and alcohol support services at the time of death. Alcohol and drug misuse is a known risk factor for suicide (source: Health matters).

Alcohol-related harm is largely determined by the volume of alcohol consumed and the frequency of drinking. In January 2016, the UK Chief Medical Officers issued guidance advising adults not to regularly drink more than 14 units of alcohol per week to keep the risk level low, and to space drinks out over the week.

Alcohol misuse may harm both physical and mental health. In the short term, alcohol may impair judgement leading to accidental injury. Long-term physical consequences include:

- alcoholic liver disease;

- increased risk of cancers such as those of the gastrointestinal tract, breast or lung;

- cardiovascular disease such as stroke and heart disease;

- reduced immunity to infection, raising the risk of pneumonia.

Alcohol use disorders are associated with mental health issues including depression, an increased risk of suicide (up to eight times higher), and an increased risk of dementia (source: Drinkaware: Alcohol and suicidal thoughts).

Alcohol dependence is a cluster of behavioural, cognitive and physiological phenomena that develop after repeated alcohol use, including:

- strong desire to drink alcohol;

- difficulties in controlling its use;

- persistent use in spite of harmful consequences;

- prioritising alcohol over other activities and responsibilities;

- evidence of increased tolerance and sometimes a physical withdrawal state.

Alcohol is related to 12-15% of all Accident and Emergency (A&E) department attendances (source: Emergency Medical Journal). Nationally, there were 318,596 alcohol-specific hospital admissions, that is where the admission is known to be wholly caused by alcohol, in 2020/21 (source: Office for Health Improvement and Disparities). 12% of patients admitted with an alcohol-specific disease are readmitted to hospital within 30 days of discharge (source: Emergency Medical Journal). However, alcohol contributes to far more admissions than those for which it is the sole cause – there were 814,595 alcohol-related admissions in 2020/21 nationally (source: Office for Health Improvement and Disparities).

Alcohol-specific deaths, where deaths are known to be a direct consequence of alcohol misuse, have been rising over the past 20 years to reach 6,984 in 2020. Alcohol contributes to far more deaths than those for which it is the sole cause – there were 20,468 alcohol-related deaths in 2020. Changes to drinking patterns during the COVID-19 pandemic are estimated to result in an additional 1,830 deaths over the next 20 years if behaviours return to pre-pandemic levels in 2022. An estimated 25,192 additional deaths are anticipated if these new drinking patterns continue (source: Institute of Alcohol Studies).

Alcohol misuse in parents can affect the health and wellbeing of children, as well as destabilising families. When parents misuse alcohol their marriages are more likely to end in divorce (source: "Like sugar for adults"). Children of alcohol-dependent parents may also need to care for their parents or siblings – 7% of young carers are looking after someone with a drug or alcohol problem. Amongst these children, 40% missed school or had other issues at school (source: Public Health England).

Children of parents who misuse alcohol are more likely to be obese, have an eating disorder, have attention deficit hyperactivity disorder (ADHD), feel socially isolated, be injured and/or be admitted to hospital (source: NHS Digital). Compared to other children, children of parents who are alcohol dependent are twice as likely to experience difficulties at school, three times more likely to consider suicide and four times more likely to become dependent drinkers themselves (source: Childhood adversity, substance misuse and young people’s mental health).

Alcohol misuse impacts on the economy through absenteeism, unemployment, and premature mortality. A study by the National Social Marketing Centre estimates the costs to employers due to lost productivity, absenteeism and accidents to be £7.3 billion (source: Institute of Alcohol Studies). People with an alcohol use disorder are at twice the risk of moving from employment to unemployment. Drinkers who consume alcohol at higher risk levels are six times more likely not to be employed than low risk drinkers. Nationally, only 21% of adults entering drug treatment are in regular employment (2020/21).

Alcohol-specific deaths, where deaths are known to be direct consequences of alcohol misuse, have been rising over the past 20 years in England (Figure 13). From 2001 to 2019 alcohol-specific deaths rose by an average of 2% per year. Between 2019 and 2020 there was a 20% increase in alcohol-specific deaths to a high of 6,984 deaths. Alcoholic liver disease represents the majority (82%) of alcohol-specific deaths. Again, alcohol contributes to far more deaths than those for which it is the sole cause – there were 20,468 alcohol-related deaths in 2020.

Alcohol-specific and alcohol-related hospital admissions as well as alcohol-specific and alcohol-related deaths are all more common in more deprived areas in England (Figure 14). This is despite average alcohol consumption being lower in households of lower income and is known as the ‘alcohol harm paradox’. The reasons for this paradox are not clear but could include different drinking patterns, compounding effects with other risk factors such as smoking and differential access and experience of health services.

Alcohol is the leading cause of disability in 15-49 year olds in Buckinghamshire. The Global Burden of Disease study estimates that alcohol use is attributable for 1,083 disability-adjusted life years (DALYs) per 100,000 in Buckinghamshire in 15-49 year olds – higher than any of the other risk factors studied. However, this rate of DALYs is lower in Buckinghamshire (1,079 per 100,000) than nationally (1,500 per 100,000) in 2020/21.

There were 5,831 alcohol-related hospital admissions in Buckinghamshire in 2020/21. This rate of admissions (1,079 per 100,000 in 2020/21) represented a small drop compared to before the COVID-19 pandemic (1,324 per 100,000 in 2019/20) but has otherwise been stable for the past five years. The Buckinghamshire rate of alcohol-related hospital admissions is consistently below the national average (1,500 per 100,000 in 2020/21). However, Buckinghamshire experiences a marginally higher rate of hospital admissions due to alcohol-related unintentional injuries (44.6 versus 43.7 per 100,000 in 2020/21) (source: GBD Compare England Data Visualisation Tool). This rate of injury admissions has been stable both locally and nationally over the last five years.

Alcohol is also the leading cause of death and of years of life lost (a measure of premature deaths) amongst 15-49 year olds in Buckinghamshire. There were an estimated 165 alcohol-related deaths in Buckinghamshire in 2020 (source: Office for Health Improvement and Disparity). This mortality rate is lower than the national average (30.4 per 100,000 compared to 37.8 per 100,000) but has been rising faster in Buckinghamshire than nationally – since 2016 there has been a 23% rise locally, compared to a 4% rise nationally (Figure 15).

Given the early nature of many alcohol-related deaths, it has been estimated that alcohol-related conditions were responsible for 2,088 potential years of life lost (PYLL) in men, and 1,187 PYLL in women in Buckinghamshire in 2020 (source: Office for Health Improvement and Disparity). However, these are lower rates than nationally (816 compared to 1,116 PYLL per 100,000 in men; 430 compared to 500 PYLL per 100,000 in women).

Between 2017/18 and 2021/22 3% of recorded crime was flagged as being alcohol-related in Buckinghamshire. These crime figures rely on individual officers selecting the relevant qualifier when recording crimes – but this is not a mandatory question and therefore likely to be subject to under-recording. However, this rises to 5% of domestic abuse offences, 6% of serious violence offences (excluding domestic abuse) and 8% of serious violence offences flagged as also being domestic abuse. Alcohol-flagged crime is more dissipated across the county than drugs offences, with less than one quarter (24%) of alcohol-flagged crime recorded in the two main town centres of Aylesbury and High Wycombe.

The National Combating Drugs Outcomes Framework has identified a reduction in drug-related neighbourhood crimes and drug-related homicides as being key metrics to measure success of the national drugs strategy locally. Drug-related neighbourhood crime includes domestic burglary, personal robbery, vehicle offences and theft from the person. The number of occurrences in Buckinghamshire has remained relatively stable over the past two years at an average of 217 per month and representing 6% of such occurrences across the Thames Valley (Figure 16). Very few neighbourhood crimes are recorded as being related to drugs and/or alcohol at 0.3% of crimes in Buckinghamshire and 0.5% of crimes in the Thames Valley over this period – this is felt to most likely represent under-recording.

Drug-related homicide is defined as any homicide that involves drug users, drug dealers or is known related to drugs in any way. There have been two drug-related homicides in Buckinghamshire in the last two years (October 2020 – September 2022). For comparison, the Thames Valley as a whole has seen 9 such homicides over this period.