Why are drug-related deaths among women increasing in Scotland? - full report

2. Overview of gender, drug use, and drug-related harms

This section aims to provide a brief overview of the literature retrieved as regards gender and drug use, informed where appropriate with stakeholder input. It is intended to provide a general background to the topic, prior to the consideration of specific explanations for the trend in drug-related deaths among women in the next section.

2.1 Prevalence, motivations, and antecedents of drug use

Data from population surveys consistently find that the lifetime prevalence of drug use is lower among women than men, particularly for intensive and regular use (European Monitoring Centre for Drugs and Drug Addiction, 2017a, Scottish Public Health Observatory, 2017a). This is supported by data from general health care settings and specialist drug treatment services. In Scotland, the estimated prevalence of problem drug use in adults aged 15-64 years in 2012/13 was 2.5% among men and 1.0% among women, such that men accounted for 70% of individuals with problem drug use in Scotland (Information Services Division Scotland, 2014).

There is some evidence that women tend to start using substances at older ages than men (International Narcotics Control Board, 2017, Evans et al., 2015, Scottish Drugs Forum, 2014), and that they are more likely to have partners or family members who use substances (European Monitoring Centre for Drugs and Drug Addiction, 2017a, Clark, 2015, Neale, 2004). Women’s patterns of drug use are often influenced by those of their partner (International Narcotics Control Board, 2017, Neale, 2004, Shand et al., 2011).

There is some evidence to suggest that women are more likely to engage in non-medical use of prescription drugs, though this is not conclusive and may relate to their greater exposure to prescription medications with potential for misuse (International Narcotics Control Board, 2017, Clark, 2015, Tuchman, 2010). One review cited evidence from Ireland that women are more likely to be prescribed medications with the potential for misuse for “non-clinical symptoms”, like stress, grief, and major life changes, and for longer periods (Clark, 2015).

Clark et al reported evidence of gender differences in the motivations for substance use, with women more likely than men to cite the alleviation of physical or emotional pain, social reasons, or having a drug-using partner and men more likely to cite reasons related to pleasure- and novelty-seeking (Clark, 2015). Among women interviewed as part of the OPDP project, several made reference to the role of trauma in precipitating or sustaining drug use, which was often seen as a form of escape. Several participants also described the use of drugs – and in particular diazepam (Valium) – to self-medicate for mental health problems such as anxiety and low mood. These themes are illustrated in the quotations below.

"I think women do it to block out what's happened in their life, like, abusive
relationships, losing their weans [children], whatever, but men do it more
because they want to do it I think and a lot of men don't do it because, a lot has
happened to men and all but there's a different stage in everybody's life, they're
taking it for a different reason I don't know, the way to explain but I know why I
do it. To shut much of life out, but men are, I don't know, men should, I don't
know, I can, maybe I'm being selfish and saying men, they should be stronger
but. I think men just take it more for the fun, women do it to, because they're
hurting from something."

(Interviewee 128)

Interviewer: So what do you do to try and manage your moods, what helps your
moods?

Participant: Do you know what helps, that keeps me on the level, when I take a
Valium, that helps me, I just keep straight.

I: So do you find when you take Valium, that your mood's more even, it's no so
up and down?

P: Aye even, I would say it's more even, aye, it is, because I've been taking
Valium from when I was about 18, because I got prescribed them, but when I
moved through here, the doctors took me off all my medication, but I still like
bought them off the streets, to keep my, to keep me level.

(Interviewee 303)

However, other researchers have argued that motivations are diverse across both genders and that categorisations such as this fail to capture the complexity of women – and men’s – experiences of substance use and misuse (Campbell and Herzberg, 2017).

Previous experience of physical or sexual violence or abuse, childhood neglect, or parental substance use is relatively common among people who use drugs of both genders, though is somewhat higher among women, especially for sexual abuse (Neale, 2004, Pelissier and Jones, 2005, Neale et al., 2014, European Monitoring Centre for Drugs and Drug Addiction, 2006). Ongoing experiences of intimate partner violence among women in drug treatment are also common (Shand et al., 2011, Neale et al., 2014, Tuchman, 2010). Women who use drugs may also have trauma resulting from experiences of sex work (Neale et al., 2014). Both historical and ongoing trauma can sustain or exacerbate drug use, or precipitate relapse (Tuchman, 2010, Shand et al., 2011, Neale, 2004). Traumatic experiences, whether pre-dating or occurring during periods of drug use, were common among the women participating in the OPDP project: several described a direct link between their drug use and these experiences, as illustrated by the quotations below.

"Anxiety, anxiety, because my partners in the past have battered me, and I've
got metal plates in my jaws, and just had bad experiences with guys, so."

(Interviewee 308)

"See what's happened from I was, from I was a young age, I sort of like, take
drugs to block all that out, but it doesn't work, it blocks it out for one day and
then when you wake up the next day, it's still there, so you're going to have to
repeat, and repeat, and repeat myself every single day, trying to block this
out."

(Interviewee 303)

There is some evidence that, compared to men, women tend to show a shorter period between initial drug use and subsequent dependence and more severe consequences: a phenomenon known as telescoping (International Narcotics Control Board, 2017, Tuchman, 2010, Simpson and McNulty, 2008). However, it was unclear from this overview of the literature whether this reflects biological or social factors, or both.

Many reviews refer to evidence that women’s response to drugs and recovery is influenced by hormones, menstruation, fertility, pregnancy, breastfeeding, and the menopause (e.g. International Narcotics Control Board, 2017) – however, the studies cited almost exclusively relate to cocaine, and it is unclear whether these findings are meaningful at population level. One review did make reference to the similarity between menopausal symptoms and those of opioid withdrawal, suggesting that women with a history of drug use may find that the menopause is a trigger for relapse, but this link appears to be largely speculative (Tuchman, 2010).

2.2 Physical and mental health

Several sources reported that women who use drugs are somewhat more likely than male peers to have concurrent mental health problems and substance use disorder, though it was unclear from these reports to what extent this reflects higher diagnosed rates of common mental health problems (like depression and anxiety) in women in the general population rather than a phenomenon specific to women who use drugs, or gender differences in help-seeking (International Narcotics Control Board, 2017, Tuchman, 2010, Greenfield et al., 2010, European Monitoring Centre for Drugs and Drug Addiction, 2006). There is some evidence from the UK and US that women who use drugs are more likely to have concurrent physical health problems than men (Wincup, 2016, Evans et al., 2015).

2.3 Engagement with treatment services

The evidence appears to be mixed about whether women are more or less likely to access treatment, though pregnancy and parenthood do often appear to motivate or necessitate help-seeking (European Monitoring Centre for Drugs and Drug Addiction, 2017a). One finding frequently cited in this regard is that women seeking treatment for substance use tend to be younger than men, despite having a similar or later age of onset (European Monitoring Centre for Drugs and Drug Addiction, 2006, Gjersing and Bretteville-Jensen, 2014). Some sources suggest that women may be more likely to seek help from services other than dedicated drug treatment services, such as primary care or mental health (Clark, 2015, European Monitoring Centre for Drugs and Drug Addiction, 2006). Several articles cited evidence that women who do enter treatment have similar or better outcomes to men (Clark, 2015, Evans et al., 2015, Bawor et al., 2015) though published evidence on this point from European settings appears to be limited (European Monitoring Centre for Drugs and Drug Addiction, 2006).

From the literature and our interviews with professional stakeholders and women with lived experience, a number of potential barriers to women accessing or sustaining treatment for drug use or other health problems were identified. These are described below, with some accompanying quotations from the OPDP project interviews.

• Stigma, guilt, and shame. These may be exacerbated by societal gender roles and expectations, as experiences of stigma associated with drug use appear to be greater among women than men (European Monitoring Centre for Drugs and Drug Addiction, 2017a, Clark, 2015, Tuchman, 2010, Wincup, 2016, Ashley et al., 2003). Stigma may be both ‘felt’ (subjectively perceived) and ‘enacted’ (overtly manifest), and sources may include family, friends, staff in services, or wider communities.
• Mental health difficulties (Scottish Drugs Forum, 2014, Bernstein et al., 2015). For instance, among a sample of 54 women with drug problems in North Ayrshire who took part in a peer-led research project, 56% said that their mental health had prevented them from fully benefiting from substance use treatment by affecting their ability to attend appointments or to participate in group work.
• Fear of losing custody of children (Wincup, 2016, European Monitoring Centre for Drugs and Drug Addiction, 2017a, Scottish Drugs Forum, 2014). This may affect women’s willingness to engage with services and their ability to be honest with service providers about their drug use.
• Caring responsibilities. This includes both limited flexibility and accessibility of treatment services for those with caring responsibilities, and difficulties with the availability and affordability of childcare (Wincup, 2016, Clark, 2015, Taplin and Mattick, 2015, Tuchman, 2010). In the study in North Ayrshire cited above, 27% of women interviewed said childcare issues had prevented them accessing treatment (Scottish Drugs Forum, 2014).
• Availability and affordability of transport to treatment sites (Tuchman, 2010).
• Unwanted advances or sexual harassment in treatment settings by other service users (Tuchman, 2010).
• Lack of social support (Tuchman, 2010).
• Being in a relationship with someone who does not wish to seek treatment, or who discourages the woman from doing so (Tuchman, 2010, Scottish Drugs Forum, 2014).
• Experiences of trauma and abuse, which may cause difficulties for forming therapeutic relationships and engaging with services or which may be exacerbated by the process of counselling or recovery (Scottish Drugs Forum, 2014, Tuchman, 2010).
• Concerns about confidentiality, which may be linked to stigma or child protection issues (Tuchman, 2010, Scottish Drugs Forum, 2014).

“I feel, I get pretty paranoid at times, my sister is bi-polar, it runs, so is my cousins and my aunties. My mum’s been wanting me to go to the doctor for a while, but na, you see and I was worried what that would, because I had to sign an agreement wi’ the social work, so if I go to my doctor they get to see everything.”

(Interviewee 508)

“Because I’m no getting any sleep, so it’s making me moody and it’s making me exhausted, moody, eh, [puff out of air], it’s starting to make my depression worse, because I’m nae getting nae blooming help because o’ the stigma, probably the doctors just looked at me and knowing I was an ex-addict, just looked and when ach, ken [know] what I mean, just gie [give] her that.”

(Interviewee 106)

"Aye but as I say [name] I was coming out [of counselling] and using, I thought I'd dealt wi' stuff, fae [from] years back, she was taking me right back to when I was in care, when I was a young lassie and talking about all that and I mean it was all in my heid [head] when I was coming out o' the office. My heid was bursting and I was like oh, straight to a dealer, coming back, using. And I telt [told] her, I was honest wi' her, I said to her I don't know if this is right for me the now. I says, I've, it's bringing up stuff I didn't think we were going to be speaking about and, I'm just, I've no been able, I don't know to deal wi' it and cope wi' it, the noo. I'm no good at dealing wi' my emotions, I've never, I've been runnin' away fae I was a wee lassie. That's one o' the main things I need to learn how to do, is feelings and emotions like anybody else. I just cannae deal wi' it, do you know what I mean, I was to just shut down and, you know."

(Interviewee 126)

Many of the issues described above may pose challenges for women in their efforts to achieve recovery, though many of these are common also to men (Neale et al., 2014). Conversely, women who use drugs often have a number of assets which can contribute to their ‘recovery capital’, including more practical and emotional support from family members, a more stable housing situation, and greater ease in establishing new social relationships unrelated to drug use compared to men who use drugs (Neale, 2004).

2.4 Life circumstances and family relationships

Several studies have found that women who use drugs are more likely to have stable accommodation than their male peers, though this is not a universal finding in the literature and may fail to capture hidden forms of homelessness or living situations contingent on an abusive relationship (Neale, 2004, Wincup, 2016). Some reviews found that women who use drugs are less likely to be employed and tend to have a lower household income than their male peers (Pelissier and Jones, 2005, European Monitoring Centre for Drugs and Drug Addiction, 2006, Evans et al., 2015), though research in the UK has found that women often fare slightly better than men in this respect due to material support from family and greater access to resources like social housing (Neale et al., 2014). Women who use drugs are less likely than men to depend on criminal activity for their income and to have been arrested or imprisoned (Neale et al., 2014, Bird et al., 2003, Shand et al., 2011, Bawor et al., 2015).

A number of studies, including several in Scotland, have found that women who use drugs are more likely to be parents and to have childcare responsibilities than men who use drugs (European Monitoring Centre for Drugs and Drug Addiction, 2006, Neale et al., 2014, Simpson and McNulty, 2008, Bird et al., 2003). The challenges of this unequal responsibility were highlighted by one woman in the OPDP project, as per the quotation below. Conversely, children were also felt to be a positive influence, providing company, a routine, and a motivation for recovery.

"Some of them help to bring the weans [children] up, some don't, some don't care, do you know what I mean, so that's a bigger issue for us. If you've got that, trying to look after weans, also, trying to address their drug problem, going into a chemist every day, do you know what I mean."

(Interviewee 131)

"Get up, take the dog for a walk, go to the chemist, come back, get the bairn's stuff ready that she needs, cos she canna cook, she canna iron, she canna do nothing, at 17 years old, so she says anyway"

(Interviewee 511)

One potential source of trauma among women who use drugs is the loss of child custody due to child protection concerns (Broadhurst and Mason, 2013, Kenny et al., 2015). Some authors have hypothesised that the emotional impact of child removal is exacerbated by its profound stigma, in ‘disenfranchised grief’ that cannot be acknowledged or shared with others (Broadhurst and Mason, 2013). There is emerging research evidence to support front-line reports that child removal often results in worsening mental health, social functioning, and substance use among mothers (e.g. Kenny et al., 2015, Wall-Wieler et al., 2017). These themes were supported by interviews with participants in the OPDP project and with professional stakeholders. Several women described regret and guilt at the effect of their drug use on their children, and the impact of (actual or threatened) child removals on their mental health and drug use. Loss of child custody appeared to be a time of considerable vulnerability: one woman explicitly linked this event to a relapse and another to plans for an intentional overdose.

“Aye, sorry, I think it’s just one of them weeks, I used to sit for days and shut myself away for days, before I had the youngest two, but oh god that just gives [father of child] ammunition to take the bairns [children] off me, and oh god, I don’t want to lose the bairns again, so I was if I could just make it to the end of the day, and get to my bed, tomorrow will be a new day, but at times like now, I just think tomorrow is never coming, sorry.”

(Interviewee 213)

“Well my last time I was clean I got, I came down, got reduced and I came off it, and it wasna until I got my children taken away from me last year that I went back.”

(Interviewee 508)

"I mean I think I would have stopped wi' the methadone if there hadn't been so many up and downs with the children getting taken off me and such, and there's been so much, and then, I went through. My kids got taken off me, beatings from the ex, so, Women's Aid people were involved, come up to talk to me, things like that. So there had been a lot of things that, not made me take drugs but, I chose to take them to help. But then it doesn't help. It doesn't seem to force away the things from your head."

(Interviewee 402)

2.5 Rates of drug-related death and risk factors

With regard to drug-related death, cohort studies of people who use drugs (including studies undertaken in Scotland) consistently find a higher crude or absolute risk of death for men compared to women (European Monitoring Centre for Drugs and Drug Addiction, 2017a, Merrall et al., 2012). However, relative rates of drug-related death (such as standardised mortality rates) tend to be higher for women, reflecting lower female mortality in the general population (Gjersing and Bretteville-Jensen, 2014, Aldridge et al., 2017).

The reasons for higher rates of drug-related death among men are uncertain. Some of the difference may be explained by different exposure to behavioural and contextual risks: for instance, among opioid users, men are more likely to inject and to experience episodes of imprisonment, both significant risk factors for drug-related death (European Monitoring Centre for Drugs and Drug Addiction, 2006, Bird et al., 2003, Shand et al., 2011). However, one recent cohort study of people accessing structured treatment for opioid dependence in England found that the risk of fatal drug-related poisoning remained about 30% lower in women than men even after adjusting for age, injecting status, and other substance use (Pierce et al., 2016).

There is also some evidence that the impact of known risk factors and protective factors varies by gender. For instance, periods spent out of treatment are a known risk factor for DRD, but this association appears to be weaker among women than it is among men, such that women are less at risk of DRD during out-of-treatment episodes than men (Pierce et al., 2016). Increasing age is also an important risk factor for DRD, but this effect appears to be especially pronounced among women. For instance, studies in Scotland, England and Wales, and Finland have found that the gender gap in risk of drug-related death narrows significantly with increasing age (Pierce et al., 2016, Pierce et al., 2015, Onyeka et al., 2014, King et al., 2013). The explanation for this phenomenon is not clear. In one recent analysis of opioid dependent people in England & Wales, it was still observed after adjusting for self-reported risk behaviour, injecting, and problem use of alcohol or benzodiazepines (Pierce et al., 2015). It has been speculated that it may represent a selection effect: since women tend to cease drug use at a younger age than men, ongoing use at older ages among women may be a marker for more severe dependence or more challenging life circumstances.

A number of previous studies have found that the substances implicated in drug-related deaths in Scotland can differ by gender. Drug-related deaths among women are more likely to involve methadone, and less likely to involve heroin alone, than among men (McAuley and Best, 2012, Information Services Division Scotland, 2016a, National Records of Scotland, 2017a). Among a cohort of people receiving prescribed methadone in Scotland between 2009 and 2013, women and men had similar rates of deaths in which both heroin and methadone were found (heroin/methadone-associated), and methadone but not heroin or buprenorphine was found (methadone-specific) (Gao et al., 2016). The risk of methadone-specific death among the cohort was almost twice that of heroin/methadone-associated death, and was particularly pronounced among those aged 35 years or more, though there was no significant interaction in risk between age and gender.

Potential explanations for this steeper age-related effect for methadone-specific death might include age-related increases in the risk of cardiac complications of methadone (due to comorbidities or co-prescribing), or a greater severity or chronicity of opioid dependence among older methadone users. One of the risk factors for cardiac complications of methadone treatment - QTc prolongation - is more common among women, which has been hypothesised as a reason why rates of methadone-specific death among women and men are similar, in contrast with most other types of drug-related death (Gao et al., 2016).

With regard to drugs other than heroin or methadone, deaths among women are more likely to involve dihydrocodeine or codeine, or antidepressants, than deaths among men, which are more likely to involve ecstasy-type drugs, cocaine, or amphetamines (National Records of Scotland, 2017a). The proportion of deaths involving benzodiazepines is generally similar between men and women (National Records of Scotland, 2017a).