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.

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).

'Why would we not want to keep everybody safe?' The views of family members of people who use drugs on the implementation of drug consumption rooms in Scotland.

BACKGROUND: People who use drugs in Scotland are currently experiencing disproportionately high rates of drug-related deaths. Drug consumption rooms (DCRs) are harm reduction services that offer a safe, hygienic environment where pre-obtained drugs can be consumed under supervision. The aim of this research was to explore family member perspectives on DCR implementation in Scotland in order to inform national policy. METHODS: Scotland-based family members of people who were currently or formerly using drugs were invited to take part in semi-structured interviews to share views on DCRs. An inclusive approach to 'family' was taken, and family members were recruited via local and national networks. A convenience sample of 13 family members were recruited and interviews conducted, audio-recorded, transcribed, and analysed thematically using the Structured Framework Technique. RESULTS: Family members demonstrated varying levels of understanding regarding the existence, role, and function of DCRs. While some expressed concern that DCRs would not prevent continued drug use, all participants were in favour of DCR implementation due to a belief that DCRs could reduce harm, including saving lives, and facilitate future recovery from drug use. Participants highlighted challenges faced by people who use drugs in accessing treatment/services that could meet their needs. They identified that accessible and welcoming DCRs led by trusting and non-judgemental staff could help to meet unmet needs, including signposting to other services. Family members viewed DCRs as safe environments and highlighted how the existence of DCRs could reduce the constant worry that they had of risk of harm to their loved ones. Finally, family members emphasised the challenge of stigma associated with drug use. They believed that introduction of DCRs would help to reduce stigma and provide a signal that people who use drugs deserve safety and care. CONCLUSIONS: Reporting the experience and views of family members makes a novel and valuable contribution to ongoing public debates surrounding DCRs. Their views can be used to inform the implementation of DCRs in Scotland but also relate well to the development of wider responses to drug-related harm and reduction of stigma experienced by people who use drugs in Scotland and beyond.

Drug Consumption Rooms and Public Health Policy: Perspectives of Scottish Strategic Decision-Makers.

There is widespread support for the introduction of Drug Consumption Rooms (DCRs) in Scotland as part of a policy response to record levels of drug-related harm. However, existing legal barriers are made more complex by the division of relevant powers between the UK and Scottish Governments. This paper reports on a national, qualitative study of key decision-makers in both local and national roles across Scotland. It explores views on the political barriers and enablers to the adoption of Drug Consumption Rooms and the potential role of these facilities in the wider treatment system. It also considers approaches to evidence, especially the types of evidence that are considered valuable in supporting decision-making in this area. The study found that Scottish decision-makers are strongly supportive of DCR adoption; however, they remain unclear as to the legal and political mechanisms that would make this possible. They view DCRs as part of a complex treatment and support system rather than a uniquely transformative intervention. They see the case for introduction as sufficient, on the basis of need and available evidence, thus adopting a pragmatic and iterative approach to evidence, in contrast to an appeal to traditional evidence hierarchies more commonly adopted by the UK Government.

'They already operated like it was a crisis, because it always has been a crisis': a qualitative exploration of the response of one homeless service in Scotland to the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has necessitated unprecedented changes in the way that services are delivered to individuals experiencing homelessness and problem substance use. Protecting those at high risk of infection/transmission, whilst addressing the multiple health and social needs of this group, is of utmost importance. The aim of this novel qualitative study was to document how one service in Scotland, the Wellbeing Centre run by The Salvation Army, adapted in response. METHODS: Care was taken to identify methods that did not create additional stress at this pressured time. Semi-structured interviews were conducted with Centre clients (n = 10, in-person and telephone) and staff (n = 5, telephone), and external professionals (n = 5, telephone), during April-August 2020. These were audio-recorded, fully transcribed, and analysed using Framework. Service documents were used to enhance contextual understanding. Analysis was informed by theories of psychologically informed environments and enabling environments. RESULTS: The start of the pandemic was a time of confusion, disruption, and isolation. Centre staff rapidly adapted methods of engagement to provide a range of comprehensive physical and emotional supports, to both existing and new clients, through telephone and online communication and, eventually, socially distanced in-person support. This involved balancing the risks of COVID-19 infection/transmission with the benefits of continuity of support to those highly vulnerable to a range of harms. Whilst the pandemic created many challenges, it also facilitated removal of barriers, particularly concerning provision of harm reduction services which had previously been severely constrained. Clients described the Centre as a 'lifeline', providing stability and safety during a period of profound disruption when other services closed their doors. Strong leadership, intensive team working, support/training for staff, a focus on relationships, and active use of client feedback, enabled responsive adaptation to fast-changing demands and the creation of a 'culture of care'. CONCLUSION: This study provides a unique insight into the pandemic by analysing the response of one homeless service during the height of the pandemic. We present a range of implications that have international relevance for those designing policies, and adapting front-line services, to proactively respond to COVID-19 and the continued public health crises of homelessness and drug-related deaths.