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

4. Emerging implications

4.1 Introduction

"The starting point in developing gender-sensitive drug policy must be to recognise points of similarity and difference between the lives of female and male drug users. Intersectional approaches are useful here which do not assume that gender is the most important factor in shaping the experiences of drug users and provide space to consider the role of other factors - individual, social and cultural - which may be related to drug use. The latter involves recognition that drug users' experiences are shaped, but crucially are not determined by, structured inequalities."

Wincup (2016)

Although it was not within the scope of this project to provide comprehensive recommendations, some potential responses did emerge from the stakeholder conversations and overview of the literature. These are described below as approaches meriting further consideration, for instance through focused evidence reviews or feasibility studies.

Many coincide with the recommendations of other recent reports in this area, including the Older People with Drug Problems project and the ‘Keeping People Safe’ review by NHS Health Scotland (Dickie et al., 2017, Scottish Drugs Forum, 2017). Of note, a significant number relate to the operation and ethos of services: as a recent review of services for women experiencing multiple disadvantage put it, moving beyond merely what is delivered to how it is delivered ( AVA & Agenda, 2017).

A number of areas for further work on this topic are also identified. Much of the research to date has focused on opioid-using women of child-bearing age, with less attention to women who use other drugs or who are older (European Monitoring Centre for Drugs and Drug Addiction, 2017a). Similarly, many efforts at gender-sensitive approaches to drug treatment have focused on women who are pregnant or have young children. In the context of an ageing cohort, additional evidence and different approaches may be required.

It is important to note that both the existing literature and some stakeholders were cautious about the potential unintended consequences of a gendered approach to drug policy and treatment services – for instance, by diverting attention away from men who use drugs, who remain at the highest risk of death. Any responses to the situation at hand should recognise on one hand, the commonalities between men and women who use drugs – particularly in a situation where rates are converging – and on the other, the diversity of experience and needs among women who use drugs. Gender should be considered as a dynamic concept with enmeshed social and biological origins, which interacts with other factors such as socioeconomic position, ethnicity, parenthood, and societal structures. This report therefore advocates a gender-sensitive or gender-informed approach, rather than gender-specific one: indeed, many of the proposals below are likely to be of benefit to both men and women.

4.2 Implications for policy and practice

• Adoption of ‘gender mainstreaming’ practices in substance use policy and practice would contribute towards the gender-sensitive approach described above and as advocated by Wincup (2016). Gender mainstreaming refers to a systematic and meaningful consideration of the implications for both women and men when developing, implementing, and evaluating changes in policy and practice, with a view to promoting gender equality. A number of resources relevant to gender mainstreaming in drugs policy are already available (for example, European Institute for Gender Equality, 2017, United Nations International Crime and Justice Research Institute, 2015, European Monitoring Centre for Drugs and Drug Addiction, 2017b).
• Involvement of women with lived experience in design and delivery of services and policies, recognising that wider efforts to engage service users have not always succeeded in reaching women and that women who use drugs have a diversity of preferences and needs (Hankins, 2008, European Monitoring Centre for Drugs and Drug Addiction, 2017a).
• A more co-ordinated and holistic approach across substance use treatment, mental health, physical health, and social support (including housing, employment, legal and financial advice). This approach has been recommended by recent reports from the Scottish Drugs Forum, the European Monitoring Centre for Drugs and Drug Addiction, and Public Health England. Elements of this approach might range from workforce training, multidisciplinary meetings, and robust referral pathways to a holistic approach to treatment eligibility and thresholds and greater integration of services.
• Trauma-informed and psychologically-informed services, which recognise and respond to previous experiences of adversity and their ongoing influence on people’s circumstances and engagement with treatment. Again, this approach has been endorsed by the European Monitoring Centre for Drugs and Drug Addiction and Scottish Drugs Forum, as well as a range of academic and professional stakeholders (Scottish Drugs Forum, 2016, European Monitoring Centre for Drugs and Drug Addiction, 2017a, Simpson and McNulty, 2008). The key characteristics of this approach are described in the text box below. There is a growing body of literature and practical resources in this area, as well as the related issues of multiple disadvantage and adverse childhood experiences, and ample potential for cross-sectoral collaboration across homelessness, justice, mental health, education, and children’s services.
• Services that are responsive to the ongoing risk of abuse and violence, through initiatives for prevention, recognition, support, and onward referral (Scottish Drugs Forum, 2017, Hankins, 2008, AVA (Against Violence and Abuse) Project, 2013).
• Outreach interventions targeting people who have recently experienced non-fatal overdoses, given that non-fatal overdoses are a key predictor of drug-related death risk: 17% of those of both sexes who died from DRD in Scotland between 2009-2014 had experienced an overdose within three months prior to death. These were mentioned by several stakeholders and expert reports (Advisory Council on the Misuse of Drugs, 2016, Public Health England, 2017, Scottish Drugs Forum, 2016).
• Given the relatively high prevalence of concurrent mental health conditions among women (and men) who use drugs and their association with drug-related death risk, interventions in this area may hold promise. Approaches mentioned in the literature include psychoscial interventions, intensive case management, assertive community treatment and – as described above – greater integration of substance use and mental health treatment services (Brentari, 2011, Luchenski, 2017).
• Ensuring adequate provision of and access to low-threshold services and crisis provision, to support those at especially high risk of drug-related death and those less able to engage with specialist services or recovery-oriented approaches.
• Enhancing the provision of employability, education, training, and volunteering opportunities, to address the boredom, social isolation, and lack of opportunities many women (and men) encounter when attempting to reduce or cease drug use.
• Child- and family-sensitive treatment services, and support for family relationships. Such approaches would recognise the importance of family relationships and parenting to recovery and harm reduction, and might include options which make childcare arrangements easier (for instance through suitable timing and location of appointments, including home visits), residential treatment services which support family integration, and support for parenting and re-establishing family relationships. One such approach cited by stakeholders as an example of best practice was a residential facility permitting women to live with their children whilst undergoing rehabilitation: however, this facility is now closed, apparently due to funding issues. Another example is a recently-initiated home detox programme run by Barnado’s in Fife.
• Enhanced support at specific times of vulnerability, such as bereavements and loss of child custody.
• Additional assistance for individuals with benefits, housing, and legal issues, to help mitigate challenging financial and social circumstances - particularly those associated with welfare reform. These might usefully be delivered through integration or co-location with drug treatment services and in other healthcare settings.
• Exploring the feasibility, evidence base, and preferences for gender-concordant workers and female-specific recovery groups.
• Provision of a broader range of treatment options in drug treatment services; for instance, opioid substitution therapies other than methadone, psychological support.
• Protecting and, where possible, enhancing funding for drug treatment services – particularly harm reduction – and mental health care.
• Developing the potential of impact assessment of changes in the configuration or commissioning of drug services, to ensure that assessments are meaningful, evidence-informed, and sensitive to local context.
• Addressing stigma and marginalisation, which remains a universal problem among people who use drugs but may be particularly salient for women.
• Strengthening efforts to mitigate the adverse impacts of welfare reform, especially among those who may experience disproportionate harms, as well as ensuring sufficient attention to the intersection between gender, substance use, mental health, and other inequalities in the design of Scotland’s new social security system.

The core components of a gender sensitive service for women experiencing multiple disadvantage: adapted from AVA & Agenda
(2017)

• High-quality relationships built on trust – e.g. non-judgemental attitudes by staff,
  meaningful listening, dignity and respect, directed by women's needs and at own pace
• Continuity and persistence – e.g. cases not being closed but "shelved", so service is
  available for as long as required; 'stickiness' of support
• Ethos of service – sense of hope, faith in individuals, belonging
• Trauma-informed care – trauma awareness; establishing safety, trustworthiness, choice &
  collaboration; building of strength and skills; integrated counselling
• Strengths-based, empowerment models based on collaboration and choice (not control by
  staff)
• Holistic services
  • assigned keyworker and individual casework approach
  • access to range of services relating to health, social care, housing, welfare rights,
    immigration
  • immediate crisis support
  • parenting support, childcare, support around social service involvement
  • structured activities to reduce social isolation
  • opportunities for education and training, incl. voluntary work
• Focus on physical and emotional safety

4.3 Implications for future analysis and research

• Gender mainstreaming should apply with regard to research and evaluation, as well as policy development. For instance, potential differential impacts by gender should be considered when planning the evaluability assessment for the drug treatment strategy refresh.
• Many of the potential responses above are likely to require further investigation for feasibility and impact, prior to their adoption: this may involve focused literature reviews or bespoke analyses of existing data.
• Much of the analysis here is based on cross-sectional data from treatment settings, or about people who have died from drug-related causes. More information from population-based cohort analyses would be beneficial in order to better understand changes in the composition, risk factors, and mortality rates of the population at risk and to test hypotheses relating to trends. Data linkage methods may be particularly valuable to this end.
• More in-depth qualitative work to understand women’s experiences and the risk of drug-related death would also be beneficial, particularly in relation to:
  • The intersection between gender, substance use, and welfare reform
  • Missed opportunities or unmet needs in treatment services
  • The impact of changes to drug treatment services, and wider health and social care services
  • Gender aspects of naloxone supply and administration
• Additional analysis may be warranted in order to understand the prevalence and role in deaths of inappropriate or illicit use of prescription drugs, and in particular of polysubstance use, and how this may differ by gender. This could draw on data from SDMD, NDRDD, NRS, and the Prescribing Information System, as well as insights from dedicated qualitative work.
• Further investigation of the possibility of ‘hidden’ populations of people who use drugs, through both quantitative and qualitative methods.
• Further investigation of the relationship between child protection/social work involvement and women’s vulnerability to drug-related harms. Some work is already ongoing on this topic in Scotland, including a mixed-methods project at the University of Glasgow due to report initial results later this year (Russell, 2018). Further work might encompass detailed analysis of routine social work statistics, data available on parenthood from the National Drug-Related Deaths Database, evidence review, and/or bespoke qualitative work.