In the context of rising drug-related deaths, and an increasingly vulnerable ageing cohort of people with drug problems, what does the evidence tell us about keeping people safe?

This was the question posed for a rapid evidence review by NHS Scotland2 to inform a conference held by the Scottish Government along with the Partnership for Action on Drugs in Scotland (PADS) in July 2017 entitled ‘Drug Policy through a Health Lens’.

Methodology

The report provided a combination of findings from the evidence based on the critical appraisal of systematic reviews and grey literature reports.

Findings

The evidence was divided into three categories listed as follows:

Seek — engagement and access to services

Keep — characteristics of treatment and support

Treat — benefits of treatment

1. Seek — engagement and access to services

Many complex barriers exist preventing older people seeking and maintaining support for a drug problem, including financial restrictions, negative perceptions of services, feelings of shame and stigma, loneliness and isolation, and having multiple health issues due to their long-term drug use. The vulnerable nature of this group means that they are not accessing services and, when they do, they are frequently dropping out. In order to support individuals to access services and treatments, these psychological and social barriers need to be addressed. In response to this, the evidence from the review found that using a more holistic approach tailored to the individual improves effectiveness of interventions, increases motivation, and prevents dropout.

The review found that blood-borne viruses and risk behaviours are reduced when individuals engage with treatment and harm reduction services.3,4 In addition, the likelihood of recovery from overdose is increased by the use and awareness of take-home naloxone programmes. Providing training and education to users and their families and peers on recognising signs of overdose and how to intervene enables them to intervene and potentially save a life.5,6 Before and upon release from prison is a critical time for providing support to drug users, and the evidence demonstrates that drug-related deaths can be prevented if prison staff are sufficiently trained in harm reduction practices and risks of overdose. Pre-release education on overdose risks and prevention, liaising with addiction services upon release, and training for prisoners with a history of drug abuse and their families on overdose awareness and naloxone use were indicators of good practice.

2. Keep — characteristics of treatment and support

The first four weeks of treatment and the first four weeks upon leaving treatment have been identified as periods of high-risk for drug-related deaths and, as such, are critical intervention points to prevent such deaths.7 Having clear re-engagement processes and procedures for those moving through treatment and for those who have disengaged are an important factor in engagement. The review data indicate that medications should not be viewed as a ‘one size fits all’ and each individual should be considered as an individual. Regularly involving users and their families in drug prescribing and treatment options is important. Updating and reviewing care plans and adjusting drug dosage depending on effectiveness have been highlighted as good practice indicators along with strategies and processes to engage and maintain continuity of care.8

For those with opioid dependence, the most positive outcomes for remaining in treatment and for benefits from treatment (e.g. reduced drug use) were seen when a person-centred, holistic approach, including psychosocial interventions,9 is delivered in conjunction with medication-assisted treatment.10 There is limited but growing evidence that contingency management11 is effective in increasing treatment retention and promoting abstinence from drugs.

Awareness of and subsequent staff training for age-specific issues12 was identified as having a positive impact on treatment outcomes for older drug users. A distinction has been made between early onset and late onset of drug problem use with important implications for treatment and recovery approaches. Age-appropriate support for this group is important, including involvement of multidisciplinary health professionals (due to complex mental and physical ill-health), the importance of understanding polydrug use to reduce drug-related harms, and ensuring that treatment plans are pragmatic and tailored to their multiple issues.

There is limited evidence available for identifying gender, ethnicity or social class differences in effectiveness of outcomes. 

3. Treat — benefits of treatment

The mortality risk of people with opioid dependence is reduced when in substitution treatment.7 Finding the balance between optimal dosage and remaining in treatment tends to have the most positive impact on outcomes. Medication-focused approaches were found to have better retention rates (compared to placebo or no medication), but medications should be modified according to the individual’s requirements with consideration for the needs of vulnerable older users. Evidence suggests that where previous treatments have been unsuccessful, older entrenched heroin users may find that heroin-assisted approaches may be more appropriate.

2  Dickie E, Arnot J and Reid G (2017) Drugs-related deaths rapid evidence review: keeping people safe. Edinburgh: NHS Health Scotland. Available online at http://www.healthscotland.scot/media/1609/drugs-related-deaths-rapid-evidence-review.pdf

3  Harm reduction services include needle and syringe programmes, supervised drug consumption clinics, and methadone maintenance.

4  Fernandes RM, Cary M, Duarte G, et al. (2017) Effectiveness of needle and syringe programmes in people who inject drugs – an overview of systematic reviews. BMC Public Health, 17(1): 309.

5  Giglio RE, Li G and DiMaggio CJ (2015) Effectiveness of bystander naloxone administration and overdose education programs: a meta-analysis. Inj Epidemiol, 2(1): 10.

6  McDonald R and Strang J (2016) Are take‐home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria. Addiction, 111(7): 1177–87.

7  Sordo L, Barrio G, Bravo MJ, et al. (2017) Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ, 357: J1550.

8  Timko C, Schultz NR, Cucciare MA, et al. (2016) Retention in medication-assisted treatment for opiate dependence: a systematic review. J Addict Dis, 35(1): 22–35.

9  Psychosocial interventions include contingency management, cognitive behavioural therapy (CBT), motivational interviewing, counselling, mutual aid, and telephone/web-based support.

10   Dugosh K, Abraham A, Seymour B, et al. (2016) A systematic review on the use of psychosocial interventions in conjunction with medications for the treatment of opioid addiction. J Addict Med, 10(2): 91–101.

11   Contingency management involves giving patients tangible rewards to reinforce positive behaviours such as abstinence.

12   Age-specific issues were reported as having comorbidities (physical and mental health); polydrug use; increased social exclusion; feelings of moral failing; fear of judgement within services; and stigmas due to mental health issues, thus preventing older drug users from accessing services.