From Digital Inclusion to Digital Transformation in the Prevention of Drug-Related Deaths in Scotland: Qualitative Study.

BACKGROUND: Globally, drug-related deaths (DRDs) are increasing, posing a significant challenge. Scotland has the highest DRD rate in Europe and one of the highest globally. The Scottish Government launched the Digital Lifelines Scotland (DLS) program to increase the provision of digital technology in harm reduction services and other support services. Digital technology responses to DRDs can include education through digital platforms, improved access to treatment and support via telehealth and mobile apps, analysis of data to identify risk factors, and the use of digital tools for naloxone distribution. However, digital technology should be integrated into a comprehensive approach that increases access to services and addresses underlying causes. Digital transformation could enhance harm reduction service and support, but challenges must be addressed for successful implementation. The DLS program aims to enhance digital inclusion and improve health outcomes for people who use or are affected by drug use to reduce the risk of DRDs. OBJECTIVE: This study aims to explore the role of digital technology as an enabler and supporter in enhancing existing services and innovating new solutions, rather than being a stand-alone solution. Specifically focusing on individuals who use drugs, the research investigates the potential of digital inclusion and technology provision for preventing DRDs within the context of the DLS program. METHODS: Semistructured interviews were conducted with 47 people: 21 (45%) service users, 14 (30%) service providers, and 12 (26%) program staff who were all involved in DLS. Interviews were audio recorded, transcribed, and then coded. Analysis was done in three phases: (1) thematic analysis of interview data to identify the benefits of digital technologies in this sector; (2) identification of the challenges and enablers of using digital technologies using the Technology, People, Organizations, and Macroenvironment conceptual framework; and (3) mapping digital technology provision to services offered to understand the extent of digital transformation of the field. RESULTS: Participants identified increased connectivity, enhanced access to services, and improved well-being as key benefits. Digital devices facilitated social connections, alleviated loneliness, and fostered a sense of community. Devices enabled engagement with services and support workers, providing better access to resources. In addition, digital technology was perceived as a preventive measure to reduce harmful drug use. Lack of technical knowledge, organizational constraints, and usability challenges, including device preferences and security issues, were identified. CONCLUSIONS: The study found that digital inclusion through the provision of devices and connections has the potential to enhance support in the harm reduction sector. However, it highlighted the limitations of existing digital inclusion programs in achieving comprehensive digital transformation. To progress, there is a need for sustained engagement, cultural change, and economic considerations to overcome barriers.

Using digital technology to reduce drug-related harms: a targeted service users' perspective of the Digital Lifelines Scotland programme.

BACKGROUND: Deaths due to drug overdose are an international issue, causing an estimated 128,000 global deaths in 2019. Scotland has the highest rate of drug-related deaths in Europe, with those in the most deprived areas at greater risk than those in affluent areas. There is a paucity of research on digital solutions, particularly from the perspective of those who use drugs who additionally access harm reduction and homelessness support services. The Digital Lifelines Scotland programme (DLS) provides vulnerable people who use/d drugs with digital devices to connect with services. METHODS: This paper reports on the evaluation of the DLS from the perspective of service users who accessed services for those at risk of drug-related harms. A mixed methods approach was used including an online-survey (n = 19) and semi-structured interviews (n = 21). Survey data were analysed descriptively and interview data through inductive coding, informed by the Technology, People, Organisations and Macroenvironmental factors (TPOM) framework, to investigate the use, access, and availability of devices, and people's experiences and perceptions of them. RESULTS: Most participants lived in social/council housing (63.2%, n = 12), many lived alone (68.4%, n = 13). They were mainly over 40 years old and lived in a city. Participants described a desire for data privacy, knowledge, and education, and placed a nascent social and personal value on digital devices. Participants pointed to the person-centred individuality of the service provision as one of the reasons to routinely engage with services. Service users experienced an increased sense of value and there was a palpable sense of community, connection and belonging developed through the programme, including interaction with services and devices. CONCLUSIONS: This paper presents a unique perspective which documents the experiences of service users on the DLS. Participants illustrated a desire for life improvement and a collective and individual feeling of responsibility towards themselves and digital devices. Digital inclusion has the potential to provide avenues by which service users can safely and constructively access services and society to improve outcomes. This paper provides a foundation to further cultivate the insight of service users on digital solutions in this emerging area.

Development of an intervention to manage benzodiazepine dependence and high-risk use in the context of escalating drug related deaths in Scotland: an application of the MRC framework.

BACKGROUND: Scotland has the highest rate of drug related deaths (DRD) in Europe. These are deaths in people who use drugs such as heroin, cocaine, benzodiazepines and gabapentinoids. It is a feature of deaths in Scotland that people use combinations of drugs which increases the chance of a DRD. Many deaths involve 'street' benzodiazepines, especially a drug called etizolam. Many of the 'street' benzodiazepines are not licensed in the UK so come from illegal sources. People who use opiates can be prescribed a safer replacement medication (e.g., methadone). While guidance on management of benzodiazepines use highlights that there is little evidence to support replacement prescribing, practice and evidence are emerging. AIM: To develop an intervention to address 'street' benzodiazepines use in people who also use opiates. METHODS: The MRC Framework for Complex Interventions was used to inform research design. Co-production of the intervention was achieved through three online workshops with clinicians, academics working in the area of substance use, and people with lived experience (PWLE). Each workshop was followed by a PWLE group meeting. Outputs from workshops were discussed and refined by the PWLE group and then further explored at the next workshop. RESULTS: After these six sessions, a finalised logic model for the intervention was successfully achieved that was acceptable to clinicians and PWLE. Key components of the intervention were: prescribing of diazepam; anxiety management, sleep, and pain; and harm reduction resources (locked box and a range of tips), personal safety conversations, as well as a virtual learning environment. CONCLUSION: A co-produced intervention was developed for next stage clinical feasibility testing.

Overdose Alert and Response Technologies: State-of-the-art Review.

BACKGROUND: Drug overdose deaths, particularly from opioids, are a major global burden, with 128,000 deaths estimated in 2019. Opioid overdoses can be reversed through the timely administration of naloxone but only if responders are able to administer it. There is an emerging body of research and development in technologies that can detect the early signs of an overdose and facilitate timely responses. OBJECTIVE: Our aim was to identify and classify overdose-specific digital technologies being developed, implemented, and evaluated. METHODS: We conducted a "state-of-the-art review." A systematic search was conducted in MEDLINE, Embase, Web of Science, Scopus, ACM, IEEE Xplore, and SciELO. We also searched references from articles and scanned the gray literature. The search included terms related to telehealth and digital technologies, drugs, and overdose and papers published since 2010. We classified our findings by type of technology and its function, year of publication, country of study, study design, and theme. We performed a thematic analysis to classify the papers according to the main subject. RESULTS: Included in the selection were 17 original research papers, 2 proof-of-concept studies, 4 reviews, 3 US government grant registries, and 6 commercial devices that had not been named in peer-reviewed literature. All articles were published between 2017 and 2022, with a marked increase since 2019. All were based in or referred to the United States or Canada and concerned opioid overdose. In total, 39% (9/23) of the papers either evaluated or described devices designed to monitor vital signs and prompt an alert once a certain threshold indicating a potential overdose has been reached. A total of 43% (10/23) of the papers focused on technologies to alert potential responders to overdoses and facilitate response. In total, 48% (11/23) of the papers and 67% (4/6) of the commercial devices described combined alert and response devices. Sensors monitor a range of vital signs, such as oxygen saturation level, respiratory rate, or movement. Response devices are mostly smartphone apps enabling responders to arrive earlier to an overdose site. Closed-loop devices that can detect an overdose through a sensor and automatically administer naloxone without any external intervention are still in the experimental or proof-of-concept phase. The studies were grouped into 4 themes: acceptability (7/23, 30%), efficacy or effectiveness (5/23, 22%), device use and decision-making (3/23, 13%), and description of devices (6/23, 26%). CONCLUSIONS: There has been increasing interest in the research and application of these technologies in recent years. Literature suggests willingness to use these devices by people who use drugs and affected communities. More real-life studies are needed to test the effectiveness of these technologies to adapt them to the different settings and populations that might benefit from them.

The acceptability of overdose alert and response technologies: introducing the TPOM-ODART framework.

BACKGROUND: Opioids were implicated in approximately 88,000 fatal overdoses (OD) globally. However, in principle all opioid OD are reversible with the timely administration of naloxone hydrochloride. Despite the widespread availability of naloxone among people who use opioids (PWUO), many who suffer fatal OD use alone, without others present to administer the reversal agent. Recognising this key aspect of the challenge calls for innovations, a number of technological approaches have emerged which aim to connect OD victims with naloxone. However, the acceptability of OD response technologies to PWUO is of key concern. METHODS: Drawing on the Technology People Organisations Macroenvironment (TPOM) framework, this study sought to integrate acceptability-related findings in this space with primary research data from PWUO, affected family members and service providers to understand the factors involved in harm reduction technology acceptability. A qualitative study using a focus group methodology was conducted. The participant groups were people with lived experience of problem opioid use, affected family members and service providers. Data analysis followed a multi-stage approach to thematic analysis and utilised both inductive and deductive methods. RESULTS: Thirty individuals participated in one of six focus groups between November 2021 and September 2022. The analysis generated six major themes, three of which are reported in this article-selected for their close relevance to PWUO and their importance to developers of digital technologies for this group. 'Trust-in technologies, systems and people' was a major theme and was closely linked to data security, privacy and confidentiality. 'Balancing harm reduction, safety and ambivalence' reflects the delicate balance technological solutions must achieve to be acceptable to PWUO. Lastly, 'readiness-a double bind' encapsulates the perception shared across participant groups, that those at the highest risk, may be the least able to engage with interventions. CONCLUSION: Effective digital strategies to prevent fatal OD must be sensitive to the complex relationships between technological, social/human, organisational and wider macroenvironmental factors which can enable or impede intervention delivery. Trust, readiness and performance are central to technology acceptability for PWUO. An augmented TPOM was developed (the TPOM-ODART).

The impact of COVID-19 on access to harm reduction, substance use treatment and recovery services in Scotland: a qualitative study.

INTRODUCTION: People who use drugs (PWUD) are considered vulnerable to COVID-19 exposure and the sequelae of infection due to their social circumstances, health conditions, drug purchasing, and substance use. They can depend on access to services that provide harm reduction, substance use treatment, recovery and support, and general healthcare. Social distancing measures and service restrictions posed significant challenges to the health and wellbeing of PWUD. METHODS: Ethical approvals were secured. PWUD were recruited from voluntary sector homeless and housing, harm reduction, and recovery organisations across central Scotland. Data was collected via semi-structured interviews and analysed using the Framework Method. RESULTS: Twenty nine PWUD participated and reported mixed experiences of the impacts of COVID-19 lockdown. Several benefitted from policy and practice developments designed to sustain or increase access to harm reduction services. Some PWUD reported improved access to substitute prescribing and/or appreciated being trusted to manage multiple take-home doses. Others noted the loss of regular in-person contact with treatment providers and dispensers. Access to recovery support was challenging for many, especially those unable to access or uncomfortable with online provision who experienced greater isolation. Lack of access to general healthcare services was common, and especially problematic for PWUD with chronic physical and mental health conditions. CONCLUSIONS: This qualitative research describes the impacts of COVID-19 social and service restrictions on PWUD in Scotland. These impacts were anticipated by policy makers and service providers. Effective and acceptable developments were shown to maintain and even increase service provision for PWUD. Developments were geographically dependent and significant challenges remained for many people. The learning generated can inform responses to increase service access and uptake in post-pandemic times.

An avoidable crisis.

In Scotland drug policy and consequently the progress of evidence-based treatment options has been struggling for many years. Political inaction is brought about by a complex chain of legal and operational obstructions with local authorities deferring to national Government which in turn is paralysed by international convention. Scotland represents a case study demonstrating the adverse consequences of management by non medical requirements rather than implementation of a clinically proven progressive policy. The difficulty of translating theory and evidence into practice is acknowledged but suggestions are made for pragmatic and humanitarian initiatives.

Assessing the feasibility, acceptability and accessibility of a peer-delivered intervention to reduce harm and improve the well-being of people who experience homelessness with problem substance use: the SHARPS study.

BACKGROUND: For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that the development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. METHODS: The study used mixed methods to assess the feasibility, acceptability and accessibility of a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning, for people experiencing homelessness and problem substance use. Four Peer Navigators were employed to support individuals (n = 68 total, intervention participants). They were based in outreach services and hostels in Scotland and England. Qualitative interviews were conducted with intervention participants, Peer Navigators and staff in services, and observations were conducted in all settings. Quantitative outcomes relating to participants' substance use, physical and mental health, and quality of the Peer Navigator relationship, were measured via a 'holistic health check' with six questionnaires completed at two time-points. RESULTS: The intervention was found to be acceptable to, and feasible and accessible for, participants, Peer Navigators, and service staff. Participants reported improvements to service engagement, and feeling more equipped to access services independently. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling trusting, authentic, and meaningful relationships to be developed. Some challenges were experienced in relation to the 'fit' of the intervention within some settings. Among participants there were reductions in drug use and risky injecting practices. There were increases in the number of participants receiving opioid substitution therapy. Overall, the intervention was positively received, with collective recognition that the intervention was unique and highly valuable. While most of the measures chosen for the holistic health check were found to be suitable for this population, they should be streamlined to avoid duplication and participant burden. CONCLUSIONS: The study established that a peer-delivered, relational harm reduction intervention is acceptable to, and feasible and accessible for, people experiencing homelessness and problem substance use. While the study was not outcomes-focused, participants did experience a range of positive outcomes. A full randomised controlled trial is now required to assess intervention effectiveness. TRIAL REGISTRATION: Study registered with ISRCTN: 15900054.

Why are drug-related deaths among women increasing in Scotland? A mixed-methods analysis of possible explanations.

Drug-related deaths have increased significantly in Scotland in recent years, with a much greater percentage increase in deaths among women than among men. We undertook a mixed-methods project to identify explanations for this trend, comprising three parallel methodological strands: (i) an analysis of available routine data, including drug treatment data, death registrations, and surveys of people using needle exchanges; (ii) thematic analysis of interviews and focus groups with professional stakeholders and (iii) secondary analysis of interviews with women who use drugs. Results indicated that the observed trend is likely to reflect multiple, interacting causes. Potential contributors identified were: ageing; changing patterns of substance use; increasing prevalence of physical and mental health co-morbidities; changing relationships and parenting roles; changes to treatment services and wider health and social care provision; unintended consequences or poor implementation of recovery-oriented practice; and changes in the social security system. Policy responses to rising drug-related death rates require a gender-informed approach, recognising the commonalities and differences between men and women who use drugs; the diversity of experiences within each gender; and the intersections between gender and other forms of inequality, such as poverty.

Quantifying prescribed high dose opioids in the community and risk of overdose.

BACKGROUND: Opioid prescribing for a range of health issues is increasing globally. The risk of fatal and non-fatal overdose is increased among people prescribed strong opioids: in high doses in the context of polypharmacy (the use of multiple medications at the same time), especially with other sedatives; and among people with multiple morbidities including cardiorespiratory, hepatic and renal conditions. This study described and quantified the prescribing of strong opioids, comorbidities and other overdose risk factors among those prescribed strong opioids, and factors associated with high/very high opioid dosage in a regional health authority in Scotland as part of a wider service improvement exercise. METHODS: Participating practices ran searches to identify patients prescribed strong opioids and their characteristics, polypharmacy, and other overdose risk factors. Data were anonymised before being analysed at practice and patient-level. Morphine Equivalent Doses were calculated for patients based on drug/dose information and classed as Low/Medium/High/Very High. Descriptive statistics were generated on the strong opioid patient population and overdose risk factors. The relationship between the prescribing of strong opioids and practice/patient-level factors was investigated using linear and logistic regression models. RESULTS: Eighty-five percent (46/54) of GP practices participated. 12.4% (42,382/341,240) of individuals in participating practices were prescribed opioids and, of these, one third (14,079/42,382) were prescribed strong opioids. The most common comorbidities and overdose risk factors among strong opioid recipients were pain (67.2%), cardiovascular disease (43.2%), and mental health problems (39.3%). There was a positive significant relationship between level of social deprivation among practice caseload and level of strong opioid prescribing (p < 0.001). People prescribed strong opioids tended to be older (mean 59.7 years) and female (8638, 61.4%) and, among a subset of patients, age, gender and opioid drug class were significantly associated with prescribing of High/Very High doses. CONCLUSIONS: Our findings have identified a large population at potential risk of prescription opioid overdose. There is a need to explore pragmatic models of tailored interventions which may reduce the risk of overdose within this group and clinical practice may need to be tightened to minimise overdose risk for individuals prescribed high dose opioids.

Survey modes comparison in contingent valuation: Internet panels and mail surveys.

Stated preferences methods are extensively applied in health economics to elicit preferences. Although mailed surveys were commonly used to collect data, internet panel (IP) surveys are being increasingly used. This raises questions about the validity of responses and estimated willingness-to-pay (WTP) values generated from IP surveys. We conduct the first study in health to compare a contingent valuation IP survey with a mailed survey using the electoral roll. Our IP has a higher response rate and lower item missing response rate. The difference is reduced but remains when restricting comparisons with valid WTPs. Sample characteristics differ, with significant differences between modes for gender, age, income, and attitudes and knowledge. Although difference in WTP values exist, with the IP resulting in higher values, we find limited evidence that such differences are statistically significant. The mail survey has lower initial cost per response; however, once restricting samples to valid WTP responses with nonmissing respondent information, the cost per response across modes is similar. Our results, suggesting that IPs generate valid and cost-effective values, are encouraging as researchers move increasingly to IPs to collect preference data.

Pharmacist services for non-hospitalised patients.

BACKGROUND: This review focuses on non-dispensing services from pharmacists, i.e. pharmacists in community, primary or ambulatory-care settings, to non-hospitalised patients, and is an update of a previously-published Cochrane Review. OBJECTIVES: To examine the effect of pharmacists' non-dispensing services on non-hospitalised patient outcomes. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, two other databases and two trial registers in March 2015, together with reference checking and contact with study authors to identify additional studies. We included non-English language publications. We ran top-up searches in January 2018 and have added potentially eligible studies to 'Studies awaiting classification'. SELECTION CRITERIA: Randomised trials of pharmacist services compared with the delivery of usual care or equivalent/similar services with the same objective delivered by other health professionals. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures of Cochrane and the Effective Practice and Organisation of Care Group. Two review authors independently checked studies for inclusion, extracted data and assessed risks of bias. We evaluated the overall certainty of evidence using GRADE. MAIN RESULTS: We included 116 trials comprising 111 trials (39,729 participants) comparing pharmacist interventions with usual care and five trials (2122 participants) comparing pharmacist services with services from other healthcare professionals. Of the 116 trials, 76 were included in meta-analyses. The 40 remaining trials were not included in the meta-analyses because they each reported unique outcome measures which could not be combined. Most trials targeted chronic conditions and were conducted in a range of settings, mostly community pharmacies and hospital outpatient clinics, and were mainly but not exclusively conducted in high-income countries. Most trials had a low risk of reporting bias and about 25%-30% were at high risk of bias for performance, detection, and attrition. Selection bias was unclear for about half of the included studies.Compared with usual care, we are uncertain whether pharmacist services reduce the percentage of patients outside the glycated haemoglobin target range (5 trials, N = 558, odds ratio (OR) 0.29, 95% confidence interval (CI) 0.04 to 2.22; very low-certainty evidence). Pharmacist services may reduce the percentage of patients whose blood pressure is outside the target range (18 trials, N = 4107, OR 0.40, 95% CI 0.29 to 0.55; low-certainty evidence) and probably lead to little or no difference in hospital attendance or admissions (14 trials, N = 3631, OR 0.85, 95% CI 0.65 to 1.11; moderate-certainty evidence). Pharmacist services may make little or no difference to adverse drug effects (3 trials, N = 590, OR 1.65, 95% CI 0.84 to 3.24) and may slightly improve physical functioning (7 trials, N = 1329, mean difference (MD) 5.84, 95% CI 1.21 to 10.48; low-certainty evidence). Pharmacist services may make little or no difference to mortality (9 trials, N = 1980, OR 0.79, 95% CI 0.56 to 1.12, low-certaintly evidence).Of the five studies that compared services delivered by pharmacists with other health professionals, no studies evaluated the impact of the intervention on the percentage of patients outside blood pressure or glycated haemoglobin target range, hospital attendance and admission, adverse drug effects, or physical functioning. AUTHORS' CONCLUSIONS: The results demonstrate that pharmacist services have varying effects on patient outcomes compared with usual care. We found no studies comparing services delivered by pharmacists with other healthcare professionals that evaluated the impact of the intervention on the six main outcome measures. The results need to be interpreted cautiously because there was major heterogeneity in study populations, types of interventions delivered and reported outcomes.There was considerable heterogeneity within many of the meta-analyses, as well as considerable variation in the risks of bias.

'You are still a human being, you still have needs, you still have wants': a qualitative exploration of patients' experiences and views of HIV support.

Background: The importance of patient involvement in service redesign is gaining increasing recognition, particularly for chronic conditions. This study explored the experience, views and needs of people living with HIV to identify areas for improvement and service development. Methods: Face-to-face, semi-structured interviews were conducted with people living with HIV being treated in two clinics in Grampian, Scotland. The topic guide was developed, based on a proposed care pathway, which emphasized support systems. Thematic analysis was undertaken. Results: A total of 14 people living with HIV participated, with time since diagnosis ranging from <1 to >15 years. Most were males, white British and were men who had sex with men. Interviewees highlighted the need for different types of support throughout different stages of the HIV journey, including timely provision of information, post-diagnosis follow-up support, peer support, family support, and support regarding employment, benefits and housing. Many interviewees expressed a preference for support to be provided by people with knowledge or experience of HIV but had mixed feelings towards group support. Interviewees reported concerns with confidentiality and potential stigmatization. Conclusions: Support services should be tailored to reflect changing needs throughout the HIV journey with particular emphasis on maximizing confidentiality whilst minimizing stigma.

Engaging the citizenship of the homeless-a qualitative study of specialist primary care providers.

BACKGROUND: Homeless patients have complex health needs. They also often describe difficulty accessing and maintaining access to clinical services. Although engagement with health care has been explored from the patient perspective, little is known about how health care professionals conceptualize, assess and promote engagement with health care among homeless persons. AIM: To examine how health professionals working in services for homeless persons view their patients' engagement with health care and explore how these views influence their practice. METHODS: Semi-structured phone interviews were conducted with health professionals who had experience working with homeless patients. Purposive sampling aimed to cover a range of location, practice type and duration of professional experience. Thematic analysis was undertaken on interview transcripts. RESULTS: Thirteen interviews were conducted. Four themes were explored relating to engagement of homeless persons with health care: (i) systematic barriers to engagement; (ii) difficulties engaging with professionals; (iii) system approaches to facilitate engagement and (iv) relationship approaches to facilitate engagement. In addition, a fifth theme emerged relating to the interaction between practices and networks of homeless persons in which practices were perceived as a key resource for a citizenship of the homeless. CONCLUSION: Primary care practices providing services for homeless people aim to promote engagement with health care by maximizing flexibility and fostering relationships between patients and the clinical team. In doing so they produce a paradox, whereby they function as a key hub within a citizenship of homeless persons while simultaneously aiming to help people move out of homelessness into a more settled state.

The evolution of pharmaceutical care for drug misusers.

BACKGROUND: In the last 20 years, pharmaceutical care has evolved as a modus operandi for community pharmacy. This article tracks the development of pharmaceutical care for drug misusers since 1995 and considers the implications for pharmacy engagement with the wider care team. OBJECTIVE: To survey current community pharmacy service provision for drug misusers, past training and future training needs and compare with data from previous years (1995, 2000 and 2006). METHOD: A cross-sectional postal questionnaire of pharmacy managers in Scotland (n = 1246), and telephone interviews with non-respondents. Results were compared with previous surveys. RESULTS: The response rate was 70% (873) including 13.2% (164) by telephone. More pharmacies dispensed methadone in 2014 (88.5%) than previously, a significant increase across all time points (1995, 2000 and 2006) (P < 0.001). Most pharmacies (88.1%) had some drug misusers registered for the minor ailment scheme. In 2014, 43.4% of pharmacists always reported a drug misuser's non-attendance for opiate replacement treatment (ORT) to the prescriber (36.6% in 2006). If patient intoxication was suspected, medication was always withheld by 47.9% (27.5% in 2006). Pharmacists undertaking training in drug misuse and blood-borne diseases increased significantly since 1995, to 78.6% and 48.7%, respectively, in 2014 (P < 0.001). The preferred topic for future training was communication/engagement with other services. CONCLUSION: Pharmaceutical care for drug misusers has evolved from ORT supply to a more clinical approach. Pharmacists actively monitored ORT patients, managed their minor ailments and increasingly engaged with the wider care team.

Reducing drug related deaths: a pre-implementation assessment of knowledge, barriers and enablers for naloxone distribution through general practice.

BACKGROUND: The Scottish Naloxone Programme aims to reduce Scotland's high number of drug-related deaths (DRDs) caused by opiate overdose. It is currently implemented through specialist drug services but General Practitioners (GPs) are likely to have contact with drug using patients and their families and are therefore in an ideal position to direct them to naloxone schemes, or provide it themselves. This research gathered baseline data on GP's knowledge of and willingness to be involved in DRD prevention, including naloxone administration, prior to the implementation of primary care based delivery. METHODS: Mixed methods were used comprising a quantitative, postal survey and qualitative telephone interviews. A questionnaire was sent to 500 GPs across Scotland. An initial mailing was followed by a reminder. A shortened questionnaire containing seven key questions was posted as a final reminder. Telephone interviews were conducted with 17 GPs covering a range of demographic characteristics and drug user experience. RESULTS: A response rate of 55% (240/439) was achieved. There was some awareness of the naloxone programme but little involvement (3.3%), 9% currently provided routine overdose prevention, there was little involvement in displaying overdose prevention information (<20%). Knowledge of DRD risk was mixed. There was tentative willingness to be involved in naloxone prescribing with half of respondents willing to provide this to drug users or friends/family. However half were uncertain GP based naloxone provision was essential to reduce DRDs.Factors enabling naloxone distribution were: evidence of effectiveness, appropriate training, and adding to the local formulary. Interviewees had limited awareness of what naloxone distribution in primary care may involve and considered naloxone supply as a specialist service rather than a core GP role. Wider attitudinal barriers to involvement with this group were expressed. CONCLUSIONS: There was poor awareness of the Scottish National Naloxone Programme in participants. Results indicated GPs did not currently feel sufficiently skilled or knowledgeable to be involved in naloxone provision. Appropriate training was identified as a key requirement.

Compared implementation of the long-acting buprenorphine treatment buvidal in four European countries.

BACKGROUND: Buvidal is the only depot buprenorphine currently available in Europe. Buvidal offers a new treatment paradigm, which may require some adjustment in the national regulatory frameworks for opioid agonist treatments (OATs), as well as the national care systems. RESEARCH DESIGN AND METHODS: Data on the national dissemination of Buvidal, types of populations treated, and the national regulatory framework and care organization system through which Buvidal has been implemented were compared between the UK, Finland, Spain, and France, using a qualitative survey. RESULTS: In 2022, the proportion of people on OAT who received Buvidal was 2.1% in the UK, 60-65% in Finland, 1% in Spain, and 0.3% in France. In both Finland and the UK, the cost of the medication is covered by the national health system, whereas, in Spain and France, Buvidal is accessible only in specialized centers, which must carry its cost. Other national features may explain the gaps in Buvidal use, including the baseline level of OAT coverage, which was high in both France and Spain. CONCLUSIONS: Important national discrepancies are found regarding Buvidal dissemination among people on OAT.

Clinical Outcomes of Benzodiazepine Prescribing for People Receiving Opioid Agonist Treatment: A Systematic Review of the Evidence.

Many countries are experiencing an increased use of unregulated benzodiazepines in combination with opioids and other drugs, which contributes to drug-related harm. This descriptive review identifies and synthesises the outcomes of studies co-prescribing benzodiazepines and opioids. A systematic review was undertaken in Medline, CINAHL, PsychInfo, Embase, and the Cochrane databases covering publications from 1 January 1991 to 18 November 2021. Inclusion criteria were peer reviewed, English language studies of adults prescribed opioid agonist treatment (OAT) and a concurrent benzodiazepine, and reporting outcome data. Of the 4370 titles screened, 18 papers were included. The main outcomes identified covered all-cause mortality (ACM) (n = 5); overdose death (n = 3); retention in treatment (n = 7); and hospitalisation/emergency department encounters (n = 2). Other outcomes included QTc interval, cognitive function, illicit drug use, and mental health. The prescription of benzodiazepines alongside OAT increased the ACM by 75-90%, while evidence on overdose death was less robust but indicative of increased risk (40-334%). There was an indicative positive effect on treatment retention, with increased retention in those prescribed a benzodiazepine with OAT compared to those not prescribed or taking non-prescribed benzodiazepines. In conclusion, methodologically robust epidemiological studies found increased ACM and overdose death but possibly improved retention. However confounders (e.g., psychiatric comorbidity) exist, so a trial is recommended.

Association between benzodiazepine coprescription and mortality in people on opioid replacement therapy: a population-based cohort study.

OBJECTIVE: To investigate the association between opioid replacement therapy (ORT) and benzodiazepine (BZD) coprescription and all-cause mortality compared with the prescription of ORT alone. DESIGN: Population-based cohort study. SETTING: Scotland, UK. PARTICIPANTS: Participants were people prescribed ORT between January 2010 and end of December 2020 aged 18 years or above. MAIN OUTCOME MEASURES: All-cause mortality, drug-related deaths and non-drug related deaths. SECONDARY OUTCOME: ORT continuous treatment duration. ANALYSIS: Cox regression with time-varying covariates. RESULTS: During follow-up, 5776 of 46 899 participants died: 1398 while on coprescription and 4378 while on ORT only. The mortality per 100 person years was 3.11 during coprescription and 2.34 on ORT only. The adjusted HR for all-cause mortality was 1.17 (1.10 to 1.24). The adjusted HR for drug-related death was 1.14 (95% CI, 1.04 to 1.24) and the hazard for death not classified as drug-related was 1.19 (95% CI, 1.09 to 1.30). CONCLUSION: Coprescription of BZDs in ORT was associated with an increased risk of all-cause mortality, although with a small effect size than the international literature. Coprescribing was also associated with longer retention in treatment. Risk from BZD coprescription needs to be balanced against the risk from illicit BZDs and unplanned treatment discontinuation. A randomised controlled trial is urgently needed to provide a clear clinical direction. TRIAL REGISTRATION NUMBER: NCT04622995.