Planning and implementing community-based drug checking services in Scotland: a qualitative exploration using the consolidated framework for implementation research.

BACKGROUND: Drug checking services (DCS) provide harm reduction support and advice to individuals based on chemical analysis of submitted substances of concern. Whilst there are currently no DCS in Scotland, community-based services are being planned in three cities. METHODS: In this paper, we report qualitative findings based on interviews with 43 participants, focused on perceptions of DCS and their implementation. Participants were relevant professionals, those with experience of drug use, and family members of those with experience of drug use. The Consolidated Framework for Implementation Research (CFIR) was used to inform data collection and analysis. We report findings under nine constructs/themes across the five CFIR domains. RESULTS: Participants noted the importance of DCS being implemented in low-threshold, trusted services with a harm reduction ethos, and outlined a range of further service design considerations such as speed of testing, and information provided through the analysis process. In relation to the 'inner setting', a key finding related to the potential value of leveraging existing resources in order to expand both reach and effectiveness of drug trend communication. The approach of local and national police to DCS, and the attitudes of the public and local community, were described as important external factors which could influence the success (or otherwise) of implementation. Bringing together a range of stakeholders in dialogue and developing tailored communication strategies were seen as ways to build support for DCS. Overall, we found high levels of support and perceived need for DCS amongst all stakeholder groups. CONCLUSIONS: Our findings present initial implementation considerations for Scotland which could be further explored as DCS are operationalised. Further, our focus on implementation contexts is relevant to research on DCS more generally, given the minimal consideration of such issues in the literature.

"It would really support the wider harm reduction agenda across the board": A qualitative study of the potential impacts of drug checking service delivery in Scotland.

Drug checking services (DCS) enable individuals to voluntarily submit a small amount of a substance for analysis, providing information about the content of the substance along with tailored harm reduction support and advice. There is some evidence suggesting that DCS may lead to behaviour and system change, with impacts for people who use drugs, staff and services, and public health structures. The evidence base is still relatively nascent, however, and several evidence gaps persist. This paper reports on qualitative interviews with forty-three participants across three Scottish cities where the implementation of community-based DCS is being planned. Participants were drawn from three groups: professional participants; people with experience of drug use; and affected family members. Findings focus on perceived harm reduction impacts of DCS delivery in Scotland, with participants highlighting the potential for drug checking to impact a number of key groups including: individual service users; harm reduction services and staff; drug market monitoring structures and networks; and wider groups of people who use and sell drugs, in shaping their interactions with the drug market. Whilst continued evaluation of individual health behaviour outcomes is crucial to building the evidence base for DCS, the findings highlight the importance of extending evaluation beyond these outcomes. This would include evaluation of processes such as: information sharing across a range of parties; engagement with harm reduction and treatment services; knowledge building; and increased drug literacy. These broader dynamics may be particularly important for evaluations of community-based DCS serving individuals at higher-risk, given the complex relationship between information provision and health behaviour change which may be mediated by mental and physical health, stigma, criminalisation and the risk environment. This paper is of international relevance and adds to existing literature on the potential impact of DCS on individuals, organisations, and public health structures.

'It's not going to be a one size fits all': a qualitative exploration of the potential utility of three drug checking service models in Scotland.

BACKGROUND: Scotland currently has the highest rates of drug-related deaths in Europe, so drug checking services are being explored due to their potential role in reducing these deaths and related harms. Drug checking services allow individuals to submit presumed psychoactive drug samples for analysis, and then receive individualised feedback and counselling. This paper explores participants' views on the advantages and challenges of three hypothetical service models, to inform future service delivery in Scotland. METHODS: Semi-structured interviews were conducted with 43 people: 27 professional stakeholders, 11 people with experience of drug use, and five family members across three cities. Vignettes were used to provide short descriptions of three hypothetical service models during the interviews. Interviews were audio-recorded, transcribed and analysed using thematic analysis. RESULTS: Participants identified advantages and challenges for each of the three potential service models. The third sector (not-for-profit) model was favoured overall by participants, and the NHS substance use treatment service was the least popular. Participants also noted that multiple drug checking sites within one city, along with outreach models would be advantageous, to meet the diverse needs of different groups of people who use drugs. CONCLUSIONS: Drug checking services need to be tailored to local context and needs, with a range of service models being possible, in order to meet the needs of a heterogeneous group of people who use drugs. Addressing issues around stigma, accessibility, and concerns about the potential impact of accessing drug checking on access to and outcomes of drug treatment, are essential for successful service delivery.

'I'm not going to leave someone to die': carriage of naloxone by police in Scotland within a public health framework: a qualitative study of acceptability and experiences.

BACKGROUND: Scotland has one of the highest rates of drug-related deaths (DRDs) per capita in Europe, the majority of which involve opioids. Naloxone is a medication used to reverse opioid-related overdoses. In efforts to tackle escalating DRDs in many countries, naloxone is increasingly being provided to people who are likely first responders in overdose situations. This includes non-healthcare professionals, such as police officers. A pilot exercise to test the carriage and administration of naloxone by police officers was conducted in selected areas of Scotland between March and October 2021. The aim of the study was to explore the acceptability and experiences of naloxone carriage and administration by police in Scotland. METHODS: The study comprised of two stages. Stage 1 involved in-depth one-to-one qualitative interviews with 19 community stakeholders (people with lived experience, family members, support workers). Stage 2 involved a mixture of in-depth one-to-one interviews and focus groups with 41 police officers. Data were analysed thematically, and the findings from the two stages were triangulated to develop overarching themes and subthemes. RESULTS: By the end of the pilot, 808 police officers had been trained in the use of intranasal naloxone. Voluntary uptake of naloxone kits among police officers who completed training was 81%. There were 51 naloxone administration incidents recorded by police officers at suspected opioid-related overdose incidents during the pilot. Most officers shared positive experiences of naloxone administration. Naloxone as a first aid tool suited their role as first responders and their duty and desire to preserve life. Perceived barriers included concerns about police undertaking health-related work, potential legal liabilities and stigmatising attitudes. The majority of participants (and all community stakeholders) were supportive of the pilot and for it to be expanded across Scotland. CONCLUSIONS: Police carriage of naloxone is an acceptable and potentially valuable harm reduction tool to help tackle the DRDs crisis in Scotland. However, it requires appropriate integration with existing health and social care systems. The intervention lies at the intersection between public health and policing and implies a more explicit public health approach to policing.

A Realist Review of How Community-Based Drug Checking Services Could Be Designed and Implemented to Promote Engagement of People Who Use Drugs.

With rising numbers of drug-related deaths in the UK and globally, exploration of interventions that seek to reduce drug-related harm is essential. Drug checking services (DCS) allow people to submit drug samples for chemical analysis and receive feedback about the sample, as well as harm reduction advice. The use of DCS is often linked to festival and/or nightlife settings and to so-called 'recreational' drug use, but research has also shown the potential of community-based DCS as an intervention serving more varied demographics of people who use drugs, including more marginalised individuals and those experiencing drug dependence. Whilst there is a growing evidence base on the effectiveness of drug checking as a harm reduction intervention, there is still limited evidence of the underlying mechanisms and processes within DCS which may aid implementation and subsequent engagement of people who use drugs. This presents a challenge to understanding why engagement differs across types of DCS, and how best to develop and deliver services across different contexts and for different populations. To explore the contexts and mechanisms which impact engagement in community-based DCS, a realist review was undertaken to synthesise the international evidence for the delivery and implementation of DCS. There were 133 sources included in the review. From these sources the underlying contexts, mechanisms, and outcomes relating to DCS implementation and engagement were developed and refined into seven programme theories. The findings of this review are theoretically novel and hold practical relevance for the design of DCS, with implications for optimisation, tailoring, and implementing services to reach individuals in different settings.

Challenges for drug checking services in Scotland: a qualitative exploration of police perceptions.

BACKGROUND: The impact of policing practices on the engagement of people who use drugs (PWUD) with harm reduction services is well evidenced. Although the police have traditionally taken an enforcement role in responding to drug use, it is increasingly clear that they can play an important part in multiagency delivery of harm reduction interventions. Despite this, there have been no studies exploring police officer perceptions of drug checking services (DCS), which provide analytical testing of client drug samples alongside harm reduction support and advice. METHODS: Semi-structured interviews were conducted with 10 police officers to explore the policing and legal challenges which could be encountered in the delivery of DCS in Scotland. RESULTS: Participants expressed general support for DCS and described this support as part of a wider organisational shift towards public health-oriented policing. Participants also discussed different potential approaches to the policing of areas surrounding DCS including: formal limits on police presence around the service and/or stop and search powers in relation to personal possession; the effective decriminalisation of personal possession within a specified boundary around the service; and informal agreements between local divisions and DCS outlining expected policing practices. Any formal limitation on the capacity of police officers to respond to community concerns was viewed as problematic and as having the potential to erode public confidence in policing. Participants also highlighted the potential for frontline officers to utilise discretion in ways which could undermine public health goals. Legislative change, or national strategic guidance from relevant stakeholders, was seen as a means of providing 'cover', enabling local divisions to support the operation of drug checking. CONCLUSIONS: Despite a small sample of participants, this study summarises key challenges to be addressed in the implementation and operation of DCS in Scotland, and more widely. The paper concludes with suggested opportunities to develop approaches to policing that can facilitate rather than impede implementation and operation of these services.

Are risk factors for drug use and offending similar during the teenage years?

BACKGROUND: This paper explores whether at different stages of the developmental cycle of adolescence, drug use and offending are associated with a similar set of risk factors relating to: socio-structural position, informal social control, deviant peer group contexts, and deviant lifestyle behaviours. METHODS: Multivariate regression was used to analyse data from the Edinburgh Study of Youth Transitions and Crime (ESYTC) self-report questionnaire. RESULTS: Early in the teenage years drug use was associated with a similar set of factors to offending. These include weak bonds to parents and teachers, and deviant lifestyle behaviours. However, later in the teenage years there were differences, e.g. drug use was associated with higher socio-economic status and importance of school, and a number of factors which were associated with offending were not associated with drug use, e.g. parent-child conflict, gang membership and hanging around. CONCLUSION: Results show that the factors included here are more appropriate to understanding offending than drug use. Different risk factors are associated with drug use and offending in the older, but not younger teens. It is argued that later in the teenage years drug use should be understood and addressed differently to offending. This is particularly important given the tendency for the 'drugs problem' to increasingly be dealt with as a 'crime problem' (Duke, 2006).