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Background: Opioid-agonist treatment (OAT) is associated with reduced mortality risk among individuals with opioid dependence compared to those not receiving treatment (Santo Jr. et al., 2021). Use of benzodiazepines (prescribed and non-prescribed) is highly prevalent among people with opioid dependence (Jones et al, 2012). In Scotland, the number of drug-related deaths in which non-prescribed, illicitly produced benzodiazepines are implicated has risen markedly in recent years (National Records Scotland, 2022; McAuley, Matheson & Roberston, 2022). In 2021, these so-called ‘street benzos’ accounted for the majority of drug deaths involving benzodiazepines and are thought to be a driver of Scotland’s ongoing drug deaths epidemic (McAuley, Matheson & Roberston, 2022). Previous research in the UK has shown an association between co-prescribing of benzodiazepines with OAT and increased drug-related mortality risk (McCowan et al., 2009; Macleod et al, 2019). Other sedative/anxiolytic drugs commonly prescribed to OAT clients, such as gabapentinoids and z-drugs, may also have a role in polydrug and mortality trends (Abrahamsson et al., 2017). One descriptive study showed that gabapentinoid prescribing, and co-prescribing with opioids, in Scotland had risen markedly between 2006 and 2016, coinciding with a small increase in reports of their implication in drug-related deaths (Torrance et al., 2020). However, there was no strong evidence of an association between gabapentinoid co-prescription and drug-related mortality in a recent UK primary care study (Macleod et al., 2019). Aims: The aim of this study is to use linked data to quantify the risk of drug-related mortality associated with co-prescribing of benzodiazepines, gabapentinoids and z-drugs with OAT among recipients in Scotland (replicating findings from the rest of the UK; Macleod et al., 2019). We will further explore the impact of self-reported use of illicit benzodiazepines on drug-related mortality risk among this cohort, and how this has changed over time.

Background Public injecting of recreational drugs has been documented in a number of cities worldwide and was a key risk factor in a HIV outbreak in Glasgow, Scotland during 2015. We investigated the characteristics and health needs of people involved in this practice and explored stakeholder attitudes to new harm reduction interventions. Methods We used a tripartite health needs assessment framework, comprising epidemiological, comparative, and corporate approaches. We undertook an analysis of local and national secondary data sources on drug use; a series of rapid literature reviews; and an engagement exercise with people currently injecting in public places, people in recovery from injecting drug use, and staff from relevant health and social services. Results Between 400 and 500 individuals are estimated to regularly inject in public places in Glasgow city centre: most experience a combination of profound social vulnerabilities. Priority health needs comprise addictions care; prevention and treatment of blood-borne viruses; other injecting-related infections and injuries; and overdose and drug-related death. Among people with lived experience and staff from relevant health and social care services, there was widespread – though not unanimous – support for the introduction of safer injecting facilities and heroin-assisted treatment services. Conclusions The environment and context in which drug consumption occurs is a key determinant of harm, and is inextricably linked to upstream social factors. Public injecting therefore requires a multifaceted response. Though evidence-based interventions exist, their implementation internationally is variable: understanding the attitudes of key stakeholders provides important insights into local facilitators and barriers. Following this study, Glasgow plans to establish the world’s first co-located safer injecting facility and heroin-assisted treatment service. Electronic supplementary material The online version of this article (10.1186/s12889-018-5718-9) contains supplementary material, which is available to authorized users.

Background:\ud Whilst injecting drugs in public places is considered a proxy for high risk behaviour among people who inject drugs (PWID), studies quantifying its relationship with multiple drug-related harms are lacking and none have examined this in the context of an ongoing HIV outbreak (located in Glasgow, Scotland). We aimed to: 1) estimate the prevalence of public injecting in Scotland and associated risk factors; and 2) estimate the association between public injecting and HIV, current HCV, overdose, and skin and soft tissue infections (SSTI).\ud \ud Methods:\ud Cross-sectional, bio-behavioural survey (including dried blood spot testing to determine HIV and HCV infection) of 1469 current PWID (injected in last 6 months) recruited by independent interviewers from 139 harm reduction services across Scotland during 2017–18. Primary outcomes were: injecting in a public place (yes/no); HIV infection; current HCV infection; self-reported overdose in the last year (yes/no) and SSTI the last year (yes/no). Multi-variable logistic regression was used to determine factors associated with public injecting and to estimate the association between public injecting and drug-related harms (HIV, current HCV, overdose and SSTI).\ud \ud Results:\ud Prevalence of public injecting was 16% overall in Scotland and 47% in Glasgow city centre. Factors associated with increased odds of public injecting were: recruitment in Glasgow city centre (aOR=5.45, 95% CI 3.48–8.54, p

Background Although public injecting is considered a proxy for high-risk behaviour among people who inject drugs (PWID), studies quantifying its relationship with multiple drug-related harms are lacking. Furthermore, none have hitherto examined this issue in the context of an HIV outbreak, which has been ongoing in Glasgow, Scotland since 2015. We aimed to estimate the prevalence of public injecting in Scotland and associated risk factors; and estimate the association between public injecting and HIV, active HCV, overdose, and skin and soft tissue infections (SSTI). Methods A cross-sectional, bio-behavioural survey (including dried-blood spot testing to determine HIV and HCV) of PWID recruited by independent interviewers from 139 harm reduction services across Scotland was done between July 7, 2017, and Oct 1, 2018. Participants were eligible if they had a history of injecting drug use. Only current PWID (ie, in the past 6 months) were included in the analysis. Primary outcomes were injecting in a public place (yes or no; used both as outcome and exposure); HIV infection; active HCV infection; self-reported overdose in the past year (yes or no), and SSTI the past year (yes or no). Multivariable logistic regression was used to determine factors associated with public injecting and to estimate the association between public injecting and related harms (HIV, active HCV, overdose, and SSTI). Findings 1469 eligible PWID were included in the study. Prevalence of public injecting among PWID was 16% [95% CI 15–18] overall in Scotland and 47% [40–53] in Glasgow city centre. Factors associated with public injecting were recruitment in Glasgow city centre (adjusted odds ratio 5·45 [95% CI 3·48–8·54], p Interpretation In the context of UK policy debates about the provision of safer drug consumption facilities, these findings highlight the need to address the additional harms evident among people injecting in public places. Funding Health Protection Scotland.

Literature review search strategies and results. Describes the search strategies and number of results for the literature review element of the project. (DOCX 37 kb)

Question schedules for engagement exercise. Provides the interview schedule, focus group topic guide, and content of online survey used in the stakeholder engagement element of the project. (DOCX 24 kb)

Background The growth of novel psychoactive substances (NPS) over the last decade, both in terms of availability and consumption, is of increasing public health concern. Despite recent increases in related mortality, the circumstances surrounding and characteristics of individuals involved in NPS deaths at a population level remain relatively unknown. Methods The Scottish National Drug Related Death Database (NDRDD) collects a wide-range of data relating to the nature and circumstances of individuals who have died a drug-related death (DRD). We conducted exploratory descriptive analysis of DRDs involving NPS recorded by the NDRDD in 2012. Statistical testing of differences between sub-groups was also conducted where appropriate. Results In 2012, we found 36 DRDs in Scotland to have NPS recorded within post-mortem toxicology. However, in only 23 of these cases were NPS deemed by the reporting pathologist to be implicated in the actual cause of death. The majority of NPS-implicated DRDs involved Benzodiazepine-type drugs (13), mainly Phenazepam (12). The remaining 10 NPS-implicated deaths featured a range of different Stimulant-type drugs. The majority of these NPS-implicated deaths involved males and consumption of more than one drug was recorded by toxicology in all except one case. NPS-implicated deaths involving Benzodiazepine-type NPS drugs appeared to involve older individuals known to be using drugs for a considerable period of time, many of whom had been in prison at some point in their lives. They also typically involved combinations of opioids and benzodiazepines; no stimulant drugs were co-implicated. Deaths where stimulant-type NPS drugs were implicated appeared to be a younger group in comparison, all consuming two or more Stimulant-type drugs in combination. Conclusion This exploratory study provides an important insight into the circumstances surrounding and characteristics of individuals involved in NPS deaths at a population level. It identifies important issues for policy and practice, not least the prominent role of unlicensed benzodiazepines in drug-related mortality, but also the need for a range of harm reduction strategies to prevent future deaths.

Introduction and Aims.Specialist services have increased their capacity considerably in recent years to initiate and/or provide ongoing treatment for drug misuse. Consequently, methadone prescribing has substantially increased and over 17 000 patients are currently receiving methadone. Clinical guidance promotes consumption on the premises (COP) initially to ensure patients take medication as prescribed and also to prevent diversion. Diversion poses two risks: the patient may remain under-treated and continue illicit heroin use; diverted drugs put others at risk. However, COP can be restrictive. Current UK guidance is vague and not evidence-based recommending ‘around three months subject to assessment of compliance and individual circumstances’. The overall aim of this study was to describe clinical practice regarding prescribing methadone under COP in Scotland, and reasons for this. Design and Methods.A structured, postal questionnaire was sent to all lead clinicians in specialist drug treatment centres in Scotland in 2009 (n = 42). The questionnaire explored current practice, influence of supervision on retention, views of best practice and contingency management. Results.The response rate was 76% (n = 32). Clinicians usually supervise for a minimum of three months with patient-centred criteria used to determine when to reduce or stop COP. Employment, clinical stability, family support and concerns for the safety of children in the home influenced decision making. Contingency management approaches to supervision were widely used (62%). Discussion and Conclusion.In Scotland, clinicians' practice is variable and individualised to patients, but generally cautious regarding relaxing supervision conditions. This may reflect the lack of evidence-based guidance.[Anthony GB, Matheson CI, Holland R, Bond C, Roberts K, Mac Rae A, Whitelaw E, Priyadarshi S. Methadone prescribing under supervised consumption on premises: A Scottish clinician's perspective on prescribing practice. Drug Alcohol Rev 2011]

Specialist services have increased their capacity considerably in recent years to initiate and/or provide ongoing treatment for drug misuse. Consequently, methadone prescribing has substantially increased and over 17,000 patients are currently receiving methadone. Clinical guidance promotes consumption on the premises (COP) initially to ensure patients take medication as prescribed and also to prevent diversion. Diversion poses two risks: the patient may remain under-treated and continue illicit heroin use; diverted drugs put others at risk. However, COP can be restrictive. Current UK guidance is vague and not evidence-based recommending 'around three months subject to assessment of compliance and individual circumstances'. The overall aim of this study was to describe clinical practice regarding prescribing methadone under COP in Scotland, and reasons for this. Design and Methods. A structured, postal questionnaire was sent to all lead clinicians in specialist drug treatment centres in Scotland in 2009 (n=42). The questionnaire explored current practice, influence of supervision on retention, views of best practice and contingency management.The response rate was 76% (n=32). Clinicians usually supervise for a minimum of three months with patient-centred criteria used to determine when to reduce or stop COP. Employment, clinical stability, family support and concerns for the safety of children in the home influenced decision making. Contingency management approaches to supervision were widely used (62%).In Scotland, clinicians' practice is variable and individualised to patients, but generally cautious regarding relaxing supervision conditions. This may reflect the lack of evidence-based guidance.

Estimating the prevalence of public injecting. Estimating the prevalence of public injecting. (DOCX 13 kb)

Estimating the prevalence of public injecting. Estimating the prevalence of public injecting. (DOCX 13 kb)

Scope and quality of existing service provision. Provides additional qualitative and quantitative data on the nature of existing service provision in Glasgow for the population of interest. (DOCX 17 kb)

Scope and quality of existing service provision. Provides additional qualitative and quantitative data on the nature of existing service provision in Glasgow for the population of interest. (DOCX 17 kb)

BACKGROUND:\ud To address rising drug-related harms (including significant transmission of HIV) among people who inject drugs (PWID) in Glasgow, officials have proposed the introduction of the UK's first drug consumption room (DCR) in Glasgow city centre. Using a nationally representative sample, this study aimed to determine willingness to use a DCR among PWID nationally, in Glasgow city centre (the proposed DCR location), other Scottish city centres (excluding Glasgow) and the rest of Scotland (excluding city centres).\ud \ud METHODS:\ud Bio-behavioural survey, of 1469 current PWID (injected in last 6 months) across Scotland during 2017-18. Willingness to use DCRs was examined by drug-related risk behaviours and harms overall in Scotland, and then stratified by Glasgow city centre (n = 219), other Scottish city centres (n = 226) and the rest of Scotland (n = 1024).\ud \ud RESULTS:\ud The majority of PWID overall in Scotland (75%) were willing to use a DCR; willingness was higher among those recruited in Glasgow city centre (83%) and other Scottish city centres (83%), compared to the rest of Scotland (72%) (p < 0.001). Willingness was greater among PWID who reported (compared to those who did not report) injecting heroin (76%, p = 0.002), cocaine injecting (79%, p = 0.014), homelessness (86%, p < 0.001), public injecting (87%, p < 0.001) and an overdose (80%, p = 0.026). Willingness was found to be associated with a cumulative multiple risk variable: increased from 66% among those with a score of zero to 85% with a score of at least three (p < 0.001).\ud \ud CONCLUSIONS:\ud The vast majority of PWID at greatest risk of drug-related harm in Glasgow and elsewhere in Scotland would be willing to use a DCR, supporting proposals for the introduction of DCRs nationally.