Drug-related deaths have increased significantly in Scotland in recent years. Although men still account for the majority of cases, over the last 10 years the percentage increase in deaths among women has been much greater than among men.
This report draws on routine data, published research, conversations with professional stakeholders, and interviews with women with lived experience of problem drug use to examine potential explanations for this phenomenon, and to identify priority areas for future work.
The evidence reviewed as part of this project indicates that the observed trend is likely to reflect multiple, interacting causes.
Most data sources indicate that the number of women in Scotland with problem drug use is declining, suggesting the increase in deaths is unlikely to be due to an increase in the size of the population at risk. However, some concerns were raised about a potential group of people at risk who may be less likely to be identified through existing routine data sources and by clinical services, particularly older women using prescription drugs: this possibility may merit further investigation.
The same data sources indicate that the average age of people who use drugs in Scotland is increasing, and there is some evidence that this trend might be more marked among women than men. Some studies have found that the increase in drug-related death risk associated with increasing age may be more pronounced among women than among men, which may contribute to the rising rates of deaths observed.
However, ageing effects are unlikely to fully explain the observed trends, since drug-related death rates among women have increased or remained stable within all age groups over the last fifteen years. Furthermore, age should be understood not as an explanation in itself but as a proxy for multiple factors which may affect drug-related death risk, such as physical co-morbidities, social isolation, multiple compulsory child removals, and polypharmacy.
With regard to the patterns of substance used, the increase in heroin availability in recent years following a shortage may have played a role in the trend observed, though there have also been increases in the number of deaths associated with methadone, benzodiazepines, gabapentinoids, codeine, dihydrocodeine, and anti-depressants. Polysubstance use is more commonly implicated in women’s deaths, and appears to account for a growing proportion of deaths over time. Stakeholders identified this as a particular concern in the context of an ageing population with increasing prevalence of co-morbidities and perhaps loss of physiological reserve. It is however unclear from these data whether gender differences in this regard reflect differences in patterns of polysubstance use or vulnerability to their effects.
There is some evidence from routine data that the prevalence of physical and mental health problems has increased in recent years to a greater extent among women who use drugs than their male counterparts, which may contribute to an increasing risk of drug-related death.
Published reports and stakeholder input suggest that women who use drugs are likely to be particularly affected by the adverse impacts of welfare reform and public sector austerity measures. These changes may interact with other risk factors such as abusive or coercive relationships, commercial sex work, experiences of trauma, mental health issues, and changes in drug treatment services.
Stakeholders also highlighted recent changes to drug treatment services in Scotland, as well as in the wider health and social care landscape, which may have particularly affected women. Cuts in funding were felt to have resulted in the withdrawal of services, reduced provision, reductions in staffing levels and skill-mix, lack of continuity in relationships, and changes in ethos. Women were also felt by some informants to be more vulnerable to some of the potential adverse impacts of recovery-oriented systems of care.
Some informants highlighted the potential role of poor drug treatment practices and insufficient throughcare support for women in the criminal justice system: this is an area which may warrant further investigation.
Based on the stakeholder conversations and literature overview, a number of potential responses are identified for policy and practice, as well as priorities for further research and analysis. Such responses should recognise the commonalities between men and women who use drugs as well as the differences; the diversity of experiences within each gender; and the intersections between gender and other axes of inequality, such as deprivation. Many of the areas identified offer the potential for cross-sectoral collaboration and policy synergy – for instance, with mental health, social security, justice, community cohesion, housing and homelessness, and the equalities agenda more broadly.