In 2020, the Scottish Drug Deaths Taskforce sought research proposals to contribute to the evidence base on interventions to reduce drug-related deaths and overdose, the experience of people who are most at risk, and the services which support them. As the Taskforce prepares to publish its final report and recommendations this summer, the DRNS is supporting two online events showcasing the work and findings of these Research Fund projects.
The two sessions will take place on the 7th June 10am-12pm, and 21st June 2pm-4pm, and will focus on the broad themes of ‘Reducing Risk’ and ‘Emergency Response’. A full list of each of the presentations and both of the events, including abstracts are available to view below. Register for the sessions via Eventbrite here:
7th June: Presentation Abstracts
Exploring the utility and safety of benzodiazepine prescribing among people receiving Opiate Replacement Therapy in Scotland.
Prof Catriona Matheson & Mr Joe Schofield
Background: Street benzodiazepines (BZD) are a strong feature in Scotland’s escalating drug related deaths. There is increasing pressure on clinicians to prescribe ‘safer’ supplies alongside opiate replacement treatment (ORT) and interim guidance has been developed by the Drug Death Taskforce. Previous research indicates that BZD prescribing among ORT patients is associated with increased harms including mortality, but also improved engagement in care. Some addiction specialists, including GPs, already provide maintenance prescribing to reduce the risks associated with illicit BZD. However, clinical guidance does not currently provide an evidence based framework for this. Evidence of patient safety and other outcomes is sparse and conflicting.
Aim: The aim of this study was to compare the characteristics and outcomes (benefits / harms) for ORT patients prescribed BZDs (exposed) compared with those not prescribed BZDs (unexposed).
Methods: This retrospective observational cohort study used routinely collected administrative data of those prescribed ORT and BZD and a matched cohort prescribed ORT (no BZD). Participants are followed from their first ORT prescription since 01/01/2010 until the time they are known to have died, stopped being prescribed ORT, or until the 31/12/2020. Outcomes studied are: all cause mortality, DRD, hospitalisation, emergency care and retention in treatment. A systematic review was conducted to synthesis the existing international literature.
Results: Data is available on over 7million ORT prescriptions. The full analysis is not complete. Patient demographics, prescribing information (dose and type of ORT) and comparison for the primary outcomes of all-cause mortality will be presented.
Discussion: The presentation will consider initial findings in the context of international evidence and discuss the implications for prescribing practice in Scotland.
Understanding the role and potential of primary care in the prevention of drug-related deaths post COVID-19.
Dr Aileen O’Gorman & Prof Anne Whittaker
Background: Drug-related deaths cluster disproportionally in the most deprived areas of Scotland. Primary care, in particular ‘Deep End’ GP practices serving the 100 most deprived communities in Scotland, are natural hubs of local health systems but represent a small part of the complex system of care of people affected by drug use. This study investigates the current and political role of Primary Care in the prevention of drug-related deaths.
Methods: Underpinned by complex systems thinking and a case study approach, we conducted semi-structure interviews (n=32) and focus groups (n=2) in two Deep End GP practices with patients who use drugs, affected family members, GPs and other health and social care professionals. Each system and model of care was ‘mapped’ using NVivo and Kumu software. Thematic and framework analytical methods were used to identify facilitators and barriers to the quality and delivery of care.
Results: Components of care that ‘worked well’ for patients and professionals included holistic, needs-led, relationship-based care delivered by a multidisciplinary team including Primary Care, supported by strong inter-agency relationships, adequate resources, and pragmatic ‘good practice’ guidance. Care involving GPs was impeded where the model of care and associated services were fragmented, resource-poor, ‘hard to reach’, and guided by policies, goals and ethos that did not prioritise the prevention and care needs of service users. COVID-19 highlighted how a robust ‘shared care’ model is required to reduce drug-related harms and to address the multiple and complex needs of this population.
Conclusion: The design and delivery of care for people who use drugs, and their families should involve GPs, Primary Care teams and their patients, and seek to incorporate key components of care that are likely to work best within local communities and within the context of structural inequalities. Efforts to improve the quality of care for people who use drugs, should focus on overcoming barriers to the involvement of primary care so they can provide a more effective and substantive role in the prevention of drug-related deaths.
Feasibility and acceptability of an overdose prevention intervention delivered by community pharmacists for patients prescribed opioids for non-cancer pain
Dr Fiona Mercer & Prof Tessa Parkes
Background: While recent trends illustrate a rise in the prescribing of high strength opioids for chronic non-cancer pain (CNCP) generally, CNCP patients perceive their risk of opioid overdose as low and their overdose knowledge is often poor. Naloxone is not widely distributed within the CNCP population, and this group are also overlooked in wider drugs harm reduction research and practice. Low risk perceptions, poor overdose knowledge, and inadequate intervention provisions make this at-risk group vulnerable to opioid-related harms.
Method: The current study builds on findings from the ‘Prescription Opioid Overdose Risk 1’ study to establish how a bespoke take-home naloxone intervention delivered by community pharmacists for people prescribed high-strength opioids for CNCP would work in practice in Scotland. In total, twelve participants received the intervention. All participants also completed a baseline questionnaire which gathered data on patient demographics, general health, prescription and non-prescription drugs, and alcohol use. A follow up questionnaire was sent to all participants six months after receiving the intervention. CNCP patients (n=7) and community pharmacists (n=4) were interviewed, and a Framework Method approach used to analyse findings.
Results: The intervention increased patient opioid overdose knowledge and opioid overdose risk awareness. Patients developed insight into the value of naloxone for themselves as a member of the CNCP population. Most patients were satisfied with the intervention content and delivery. In follow up questionnaires, all patients ‘strongly agreed’ that they learned what steps to take if they thought they were having an overdose. Pharmacists identified that the reimbursement for the intervention was reasonable and that they enjoyed delivering the intervention, however they stated that they would have liked to have been able to dedicate more time to it.
Conclusions: This intervention attended to a critical gap concerning overdose risk for individuals prescribed opioids for CNCP. Pharmacist perceptions of providing a bespoke naloxone intervention for people prescribed opioids for CNCP were vey positive and indicated that the intervention would be feasible if certain adaptations were made. Whilst the small sample size limits generalisability, the study provides insight into the acceptability and feasibility of the intervention for the CNCP population in Scotland.
Perceptions and attitudes of strategic decision-makers and affected families across Scotland towards Drug Consumption Rooms to prevent drug-related deaths.
Dr Rebecca Foster & Mr Andy Perkins
Drug Consumption Rooms (DCRs) are low threshold settings which allow: supervised consumption of pre-obtained drugs; provision of clean injecting equipment; and immediate intervention by trained staff in the event of an overdose. Some service models also aim to engage those not in formal drug treatment and who may be particularly marginalised and who may not engage with services – for example, for people who are experiencing, or who are at risk of, homelessness. These models involve providing additional health and social support and onward referral to other support and services (e.g. housing, welfare support), as well as referral into structured drug treatment. There are over 100 formally sanctioned DCRs operating internationally, including in Europe, Canada, and Australia. Proposals to implement a DCR in Scotland are currently being discussed. To date, these have been unsupported by the UK government and approval remains a power reserved to Westminster, under The Misuse of Drugs Act 1971. There is a developing evidence base which has explored views towards, and support for, DCRs from the perspective of members of the public and people who inject drugs. However, two groups have so far been overlooked in research: family members of people who use drugs; and strategic decision-makers with workforce responsibilities who would be involved in the development and implementation of DCRs. This study involved semi-structured interviews with family members (n=13), and decision-makers (n=26) across Scotland (October 2020-April 2021). The aim of these interviews was to explore:
- perceptions of DCRs and what factors shape these understandings;
- whether these factors influence decision-making;
- barriers and facilitators to implementation;
- and, for strategic decision-makers specifically, anticipated workforce needs/adjustments within organisations to ensure such factors are addressed in readiness for potential implementation.
Both family members and decision-makers were supportive of DCR implementation. There were high levels of awareness of DCRs among both groups, with decision-makers on the whole more aware of DCR delivery models. Both groups perceived DCRs to be an important intervention to prevent drug-related harm among people who use drugs. Family members and decision-makers identified the stigma of problem drug use as a key barrier to implementation. Scotland’s unique political and legal context was also highlighted by both groups as constituting a barrier to implementation. Both expressed frustration that this legal and political context, alongside a sense of a lack of support, seemed to be delaying implementation. Participants believed that clarity was needed to resolve the uncertainty surrounding the legal framework required to implement DCRs in Scotland. In relation to the stigma associated with problem drug use, family members highlighted the importance of public education initiatives to raise awareness of DCRs and their potential role in reducing drug-related harm, and to challenge problematic and stigmatising perceptions of people who use drugs. Both family members and decision-makers emphasised the importance of community engagement, and decision-makers also commented that any DCR would need to be tailored to suit the community in which it was implemented. Finally, both groups highlighted the importance of DCRs being accessible and appealing to people who use drugs. While the challenges of DCR implementation were acknowledged by both family members and decision-makers, these were not considered to be insurmountable, both family members and decision-makers were clear that the conversation about DCRs needed to swiftly progress to implementation.
Peer Research Initiative: Peer Research and Reducing Risk
Mr Josh Dumbrell & Mr Andy Perkins
People with lived experience (PWLE) of problem substance use have unique insight into how systems work – and where they do not. For this reason, service user involvement continues to make valuable contributions to the design, implementation and evaluation of services and interventions within the substance use field. Beyond just practical contributions, however, peer research methodologies seek to empower individuals with lived experience to effect positive change by giving them the chance to lead research in their own communities. Our 18-month Peer Research Initiative funded by East Renfrewshire’s Alcohol and Drug Partnership aimed to do precisely this.
Peer Researchers (PWLE of problem substance use or affected family) were recruited and trained in the basics of applied social research, before leading a qualitative evaluation into the provision of opioid substitution therapy in East Renfrewshire. Trainees supported study design, co-developed research instruments, collected and analysed data, and took part in the writing-up and dissemination of the study’s findings.
This presentation explores, through the voices of participants, how peer research and the community interest and action it generates served to reduce the risk of drug-related harm. Strengthening arguments supporting peer-led approaches, Peer Researchers developed instant connections with participants. Our work exposed an unmet need for a lived experience presence in the community. Trust between Peer Researchers and participants ensured rich data, while the reported conditions on the ground generated frustration and anger among those with lived experience. Reflective diaries and regular debrief sessions safeguarded the team’s mental health, promoting objectivity and channelling passion into effective research. Joined by a new enthusiastic cohort of trainees, the Peer Researchers remain steadfast in their commitment to effect change in East Renfrewshire. With input from our growing number of Peer Researchers, lead facilitator and Peer Researcher, Josh Dumbrell will be delivering this presentation.
June 21st: Presentation Abstracts
Results from a mixed-methods evaluation of peer-to-peer naloxone training and supply in Scotland
Dr Matthew Smith
Drug related deaths are at their highest since records began, with opioids implicated in the large majority. Naloxone is an opioid antagonist which provides a window of opportunity for emergency services to attend and treat overdoses. In 2017 the Scottish Drugs Forum (SDF) and NHS Greater Glasgow and Clyde (NHS GG&C) developed a peer to peer naloxone distribution programme. This project evaluated the programme using a mixed methods approach, in order to assess success in distribution, and identify strengths, challenges and potential future improvements to the model. We analysed data from the National Naloxone Programme and found it was associated with an increase of 25 kits per week after applying various controls. Our qualitative interviews with facilitators, peers and recipients suggested that strengths of the service were: shared connections between peers and clients resulting in rapid and deep relationship building; ability to avoid barriers associated with stigma and distrust; and other positive influences on clients, such as acting as examples of successful recovery pathways. Challenges included: resistance from stigmatising service providers; risky working environments for peers; self-inflicted pressure within peer roles; and others. This project working with lived experience collaborators also developed potential service improvements as well as 10 recommendations for development of future programmes. The service was shown to be successful, and keys to this success were identified in the evaluation, representing important learning that can be developed across Scotland. The success of the approach is another example of why peer-based interventions must form a core part of the response to continuing rising drug deaths.
‘I can’t stop them from taking again, but I’ve saved a life right there and then’: Evaluating the training, carriage and administration of naloxone in Police Scotland
Dr Peter Hillen
Background: Between March and October 2021 Police Scotland ran a pilot (test of change) of the training, carriage and administration of intranasal naloxone as an emergency first aid measure to persons suspected of experiencing an opioid overdose. The implementation and processes of the pilot were evaluated to allow elements of learning and best practice to be identified and to inform any potential future national roll-out. The evaluation assessed police officers’ attitudes towards people who use drugs, and their knowledge and experiences of drug overdoses and naloxone. It also sought perceptions from community stakeholders.
Methods: This evaluation employed mixed-methods including: pre-training, post-training and follow-up questionnaires; semi-structured interviews; focus groups; and collection of quantitative data regarding uptake and administration of naloxone and the number of overdoses encountered. A total of 346 police officers completed the questionnaires, 41 police officers took part in interviews or focus groups, 19 interviews were carried out with people with lived/living experience of opioid use, family members and support workers; and eight senior strategic stakeholders were interviewed.
Findings: By the end of the pilot, 808 officers had been trained in the use of naloxone; 87% of the workforce in the pilot areas. Eighty-one per cent of officers chose to carry naloxone following training. There were 51 naloxone administration incidents during the pilot. Both quantitative and qualitative data supported the view that training and equipping police officers in carriage of naloxone produced immediate and short term positive impacts. The consensus among participants was that the training was impactful, with a demonstrable improvement in officers’ attitudes and knowledge of naloxone. The initiative was viewed favourably by community stakeholders. Some barriers were identified, including concerns about the safety of naloxone, concerns about legal liability, opposition from the Scottish Police Federation, stigmatising views about drug users held by some officers, and a concern over whether follow up support would be provided post-naloxone administration.
Conclusions: Police officers are often first responders to drug overdoses and are in a position to offer first aid before ambulance services can attend. Administering naloxone in a timely fashion could help save a person’s life. Police Scotland’s decision to make the training and carriage of naloxone part of routine practice is a progressive step towards reducing drug-related deaths in Scotland. Further work is needed to develop police initiatives to prevent deaths among, and provide sustained support for, people affected by problem drug use. This includes developing training, follow up support initiatives and partnership working.
Evaluating the impact of public health interventions in Scotland’s drug-related death epidemic
Dr Andrew McAuley
Scotland’s drug-related death epidemic is occurring in the midst of a syndemic characterised by historical and recent high rates of HIV infection and continued HCV infection. Linking this syndemic is an at-risk population of individuals who are among the most vulnerable in society and experience extreme health inequalities: people who use drugs. Interventions to prevent health harms for this group are not singular, but instead combine to address these syndemics; including medication-assisted therapy (MAT) and take-home naloxone (THN). Scotland’s syndemic is occurring despite availability of these evidence-based interventions known to reduce the risk of morbidity and mortality related to drug use. Despite the wealth of evidence supporting the effectiveness of MAT in reducing drug-related harms, there have been no recent empirical studies conducted in Scotland to assess its impact on mortality for both those in and out of treatment. Moreover, direct evidence on the benefits of THN programmes on reducing opioid-related deaths at a population level is limited internationally and needs to be strengthened, particularly in Scotland where the NNP is now over a decade old. We will use linked and unlinked administrative data to measure the risks of mortality related to problem drug use in Scotland and determine to what extent specific MAT and THN are protective against drug-related deaths.
Baseline characteristics and treatment of people experiencing homelessness with recent non-fatal drug overdose in the Pharmacist and Homeless Outreach Engagement
Dr Richard Lowrie
Background: There are a lack of integrated health and social care interventions and trials aiming to reduce excess morbidity and mortality (from drug related and other causes) in people experiencing homelessness (PEH) and few data describing their combined health and social care characteristics, limiting research and service delivery to address this growing health inequality.
Objectives: To describe baseline health and social care characteristics of PEH who experienced at least one overdose in the past 6 months, recruited in the PHOENIx (Pharmacy Homeless Outreach Engagement Non medical Independent prescribing Rx) pilot randomised controlled trial.
Methods: Key demographic, clinical, laboratory findings, healthcare utilisation, treatment, patient reported health status, accommodation, welfare benefits, problem drug use, and social activities are reported and compared with those of patients in previous randomised controlled intervention studies involving PEH.
Results: 128 PEH were recruited across 20 different venues in Glasgow. Aged 42(SD 8.4) years, 71% male, homeless for 24 years (IQR 12-30), the majority lived in large congregate homeless hotels with single rooms and none had Housing First accommodation. With 8.5(SD 3.0) health problems per patient, in the past 6 months, patients had 3.2(SD 3.2) non-fatal overdoses, and, in descending order of utilisation, health and social care was accessed through: hospitals (Emergency Departments, wards and clinics); physical health nurses in the specialist homelessness GP service; Addictions nurses; and social care. Two thirds were not known to mental health services yet 117(91%) had at least one mental health problem; half were not receiving any mental health treatment. One quarter either did not know if they were registered with a GP or had none, yet 124(96.9%) had at least one physical health problem and half were not receiving any treatment. All patients had poly-problem drug use, 113(90%) were registered with an addictions team although 77(60%) used heroin and 115(89.8%) were treated with opiate substitution treatment(OST). 112(87.5%) took ‘street Valium’ daily with 13(10.2%) receiving diazepam treatment. 76(59%) used cocaine; none were receiving any specific treatment. A majority were frail or pre-frail, describing maximal levels of psychological distress, anxiety and depression. 58(45.3%) had been recently assaulted; 24(18.8%) felt unsafe; 39(30.5%) had no reported next of kin. 38(30%) scored their health as “worse than death” when rated by the wider population. 20(16.3%) ate no daily meals. 107(83.6%) were in receipt of one or two types of welfare benefits.
Conclusions: The extreme levels of ill health and low levels of uptake of physical and mental health treatments with persistent overdose despite near maximal levels of OST for frail, vulnerable chronically homeless lone adults, compounds their multiple disadvantages suffered as a result of being homeless in a high income country. Stronger, assertive, integrated primary health and care outreach by generalists who can prescribe for physical and mental health problems and homelessness experts, may shift the balance of health care utilisation and reduce emergency care demand. The extent of the problem of homelessness worldwide requires generalizable, robust evidence of change to the status quo through randomised controlled trial evidence to determine effectiveness, efficiency and reach. The PHOENIx after overdose is a reproducible NHS prescribing pharmacist led assertive outreach intervention involving NHS pharmacists and third sector homeless charities offering wraparound care weekly over 6 months. Findings from an ongoing pilot randomised controlled trial will be available in November 2022 to inform practice and research.
Ambulance callouts to non-fatal overdose pathways
Prof Niamh Fitzgerald
Psychosocial factors associated with risk of drug-related overdose among people who use drugs
Dr Amy Malaguti & Prof Fabio Sani
Background: Global estimates of drug-related deaths are increasing annually, with most involving opioids. Scotland presents amongst the highest rates of fatal overdose worldwide. Demographic risk factors have been identified in the literature, however evidence is lacking on psychosocial factors associated with overdose which could inform targeted harm reduction interventions. Two studies, a systematic review of the international evidence and a qualitative study on the lived experience of overdose among people who use drugs in Dundee, were conducted to identify potential target of behaviour change to design an intervention to reduce risk of overdose.
Methods: Systematic searches were conducted in Medline, Embase, PsycINFO and Cinahl. Google Scholar was searched for grey literature. Reference lists of selected papers were searched manually. Data were extracted by two reviewers. The data were thematically analysed and results presented as a narrative synthesis.
Results: Twenty-two studies were included in the systematic review, with a total of 185,442 participants. Most studies were conducted in North America (n=17). In most studies poly-drug use was reported (4 did not report). Factors (n=92) were extracted from the studies, and thematically analysed, resulting in 13 themes grouped under 7 overarching themes. The themes explored a variety of psychosocial factors associated with increased risks of overdose: demographic factors influencing behaviour, incarceration, traumatic experiences, overdose experience and risk perception, healthcare engagement, drug use behaviour, and social network characteristics.
Methods: Semi-structured interviews were conducted by two peer researchers with 20 adults who used drugs and had experienced at least one non-fatal overdose in the previous six months. The interviews took place in two injecting equipment provision sites in Dundee. Data was analysed using thematic analysis, using a mainly inductive approach with experiential and essentialist orientation.
Results: Five themes were identified: 1) Social context, which included risk associated with living in the city and knowing other drug users, distrusting others, feeling pressured by peers to buy substances and by the self to use more than others; 2) Personal risk-taking triggers, both automatic associations in the form of paydays, and emotional triggers such as feeling emotionally overwhelmed or suicidal; 3) Planned and impulsive consumption, with associated reflective motivation and personality traits; 4) Risk perception, including general awareness of own and other’s risk and low awareness of tolerance; 5) Reversing overdose, presenting experience of receiving Naloxone to reverse an opioid-related overdose and the acceptability of the use of Naloxone on anyone in need.
Conclusions: A complex interplay of internal and external, and past and present influences emerged from the systematic review and the qualitative interviews. Social and physical environments played a significant role on individuals’ capability to use substances safely. Given the extensive personal and vicarious experience of overdose, the high perception of susceptibility to overdose events, and the high acceptability of Naloxone administration, interventions on overdose risk reduction should investigate mechanisms of individual behaviour change to respond to environmental factors and shift to target the interpersonal skills involved in drug using behaviours which lead to increased risk of overdose.