Playing for Keeps
With Scotland experiencing ever-higher numbers of drug deaths, its government is developing a strategy to keep vulnerable older users in treatment. DDN reports.
This summer Scotland once again broke its own bleak record by registering its highest ever number of drug-related deaths (DDN, September, page 4). The 867 fatalities were more than double the figure from a decade ago and make Scotland’s drug-related mortality rate the highest in the EU.
With the median age 41, and nearly a third of the deaths in the Greater Glasgow and Clyde NHS board area, the twin problems of deprivation and an aging cohort of entrenched users are looking more acute than ever. The Scottish Government has since announced an extra £20m funding for treatment as well as an ‘overhaul’ of its drugs strategy (DDN, October, page 4). It’s also developing a framework to engage older users and keep them in treatment, called ‘Seek, Keep and Treat’, as part of which NHS Health Scotland has issued a new report, Drugs-related deaths rapid evidence: keeping people safe (see news, page 5).
‘If you look back over the last 20 years, all of the increases in fatal overdoses have been in the over-35s,’ Scottish Drugs Forum CEO David Liddell – whose organisation is helping with the ‘Seek, Keep and Treat’ strategy – tells DDN. ‘The under 35 deaths have remained fairly static.’
More than 120 current injectors or people who had injected in the last six months were interviewed for SDF’s expert working group report, Older people with drug problems in Scotland (DDN, July/August, page 4), with an average age of 41. ‘So a very similar profile to those who are dying,’ says Liddell. ‘What we found was that they weren’t being held in services and, alongside that, 79 per cent were living alone. There were massive issues of anxiety and depression, all these underlying health issues that weren’t being addressed, housing issues, welfare benefits issues. So the “keep” part of the initiative is very much about ORT and recognising the protective factors of keeping people in treatment.’
While some countries have up to 80 per cent of problem drug users in treatment at any time – and with that treatment sustained over the long term – Scotland’s current rate is around half that. ‘I think there’s an increasing recognition of the need to hold more of that older population in treatment and maybe try to integrate those other health issues, like COPD, within addiction services,’ he says.
Another issue can be the power relationship between users and those ORT services, he points out. ‘I think advocacy is very important for this population to help sustain contact, but also to help them navigate their way through and better assert what their needs are. In too many cases the individual has to fit the service on offer, rather than the other way round. So while we obviously need to put back some of the core funding to services, we also need to look at how that money might potentially be used to change practice on the ground.
‘When you’ve got a service for 3,000 people it’s very hard to deliver the person-centred care,’ he continues. ‘A key part would be that someone is seen by the same person every time to build up a therapeutic relationship. I think there’s broadly a consensus that things have to change, but in terms of the very big services it can be difficult to turn things around. So there are questions about how the new investment is used, and how you then deliver change.’
The Keeping people safe report stresses the effectiveness of harm reduction interventions, and plans for a consumption room in Glasgow appear to be nearing fruition (DDN, July/August, page 4). A key part of addressing individual need is looking at prescribing options, Liddell stresses – ‘matching the substance to the individual’ – and the facility aims to offer heroin-assisted treatment. Is he confident it will happen?
‘I think the heroin-assisted treatment part is probably easier to deliver in terms of legality issues and so on – I’d be very optimistic that it will happen,’ he says. ‘There’s a consensus in Glasgow that heroin-assisted treatment should have been introduced already. Policy only seems to radically change at the point of crisis, unfortunately, but the level of fatal overdose deaths means we’re certainly there now.’
On that note, when the 2015 figures were announced he called it a national tragedy and the ultimate indicator of the country’s health inequalities (DDN, September 2016, page 4). With the numbers up still further, does media and public opinion in Scotland accept that it is a tragedy, or is there a view that ‘they’ve brought it on themselves?’
‘There’s always going to be a mixture, but my experience in doing media work around the safer injecting facility, as well as the closure of the needle exchange in Glasgow Central station, is that by and large they were very supportive. Obviously they tried to find people who were against it, but it seems there’s much more consensus that this is something that’s worth trying. I do get the sense that there is a shift, and that’s also in terms of conversations with the wider public. In the face of so many overdose deaths it becomes harder and harder for people to argue for the status quo.’