Why are drug-related deaths among women increasing in Scotland?
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 scoping project examines potential explanations for this phenomenon and identifies priority areas for future work.
While there are many commonalities between men and women who use drugs, there are a number of key areas where women's experience of substance use and treatment services may differ from men.
This study found that the disproportionate rise in drug-related deaths among women is likely to have a complex answer, involving many interacting factors. Key themes include:
- Ageing among the cohort of women who use drugs
- Increasing prevalence of physical and mental health problems
- Changes to treatment services and wider health and social care
- Changes in the welfare benefits system
- Changes in patterns of substance use
- Changes in relationships and parenting roles
- Ongoing risk among women engaged with drug treatment
- Previous experiences of trauma and adversity
Many of these potential explanations are amenable to change. Treatment services, research, and policy need to adopt gender mainstreaming practices to ensure the needs of both women and men are fully addressed.
Drug-related deaths have been increasing in Scotland in recent years (National Records of Scotland, 2017a). 2016 saw the highest number of deaths ever recorded, at 867 – a 106% increase on the figure from 2006. Although men still account for the majority of these deaths, the proportion of women has increased over time, from 19% in 2002-2006 to 29% in 2012-2016. When comparing the annual average for 2012-2016 with that for 2002-2006, the percentage increase in the number of DRDs was greater for women (169%) than for men (60%).
This paper summarises the findings of a rapid scoping project which was undertaken to examine potential explanations for the rising rate of drug related deaths among women in Scotland, and identifies implications for policy and practice.
Figure 1. Number of drug-related deaths in Scotland 1996-2016, by gender.
Source: National Records for Scotland
This project consisted of four strands:
1. An overview of relevant literature
2. A review of routine data, including: drug-related death registrations, the National Drug-Related Deaths Database, the Scottish Drugs Misuse Database, Drug-Related Hospital Stays data and data from the Needle Exchange Surveillance Initiative
3. Fifteen semi-structured interviews and two focus groups with key stakeholders from statutory services, the third sector, and academia
4. Analysis of transcripts from 28 semi-structured interviews with women over 35 years of age who use drugs, initially undertaken as part of the Older People with Drug Problems project (Matheson et al., 2017).
This scoping study found that the disproportionate rise in drug-related deaths among women is likely to have a complex answer, involving many interacting factors.
The following factors may potentially have contributed to the trend:
- Ageing among a cohort of women who use drugs. This may increase the risk of drug-related deaths through a range of factors, whether individual ( e.g., co-morbidities), clinical ( e.g. polypharmacy), and social ( e.g. bereavements, loss of maternal role). There is some evidence that the ageing trend may be more pronounced among women than men.
- Changes in patterns of substance use, particularly polysubstance use and potential increases in the problem use of specific prescription medications (whether prescribed directly or obtained illicitly). These changes might interact with the ageing phenomenon to further increase risk.
- Increasing prevalence of physical and mental health problems, which appears to be more pronounced among women who use drugs than their male peers; this may be linked to the ageing phenomenon described above.
- Changes in relationships and parenting roles, including social isolation and the potential cumulative impact of multiple child removals.
- Ongoing risk among women engaged with drug treatment services, potentially reflecting failures to meet needs or missed opportunities.
- Changes to treatment services, and wider health and social services, particularly challenges in funding resulting in withdrawal of services, reduced provision, under-staffing or under-skilled staffing, lack of continuity in relationships, or a change in ethos.
- Unintended consequences of a focus on recovery-oriented care, which some stakeholders felt may have adversely affected harm reduction provision and efforts to address broader life circumstances.
- Changes in the welfare benefits system which may particularly impact on women.
- Interaction between factors above and known barriers for women engaging with treatment services, which may be practical (such as caring responsibilities) or psychological/relational (such as stigma, coercion, and fear of losing custody of children)
- Interaction between factors above and previous experiences of trauma and adversity, which affect some women's coping strategies, vulnerability and engagement with services.
Other factors that merit further investigation include:
- A possible population of women at risk who may be older, predominantly using prescription drugs, and not otherwise known to services.
- Potential problems with drug treatment and throughcare for women in the criminal justice system.
Although it was not in the scope of this project to provide comprehensive recommendations, potential implications for policy, practice and research emerged from the stakeholder conversations and overview of the literature. Key themes which have arisen in this study include –
- The policy response 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.
- Adoption of 'gender mainstreaming' practices in substance use policy and practice, involving the 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.
- The need for trauma-informed and psychologically-informed services, which recognise and respond to previous and ongoing experiences of adversity and their influence on people's circumstances and engagement with treatment. Services also need to be responsive to the ongoing risk of abuse and violence, through initiatives for prevention, recognition, support, and onward referral and cognisant of the relatively high prevalence of concurrent mental health conditions among women (and men) who use drugs.
- A more co-ordinated, cross-sectoral and holistic approach across substance use treatment, mental health, physical health, and social support including housing, benefits, employment, legal and financial advice. This is particularly important in the context of mitigating the adverse impacts of welfare reform. 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.
- Adequate provision of and access to low-threshold services and crisis provision, and outreach to support those at especially high risk of drug-related death and those less able to engage with specialist services or recovery-oriented approaches.
- 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, residential treatment services which support family integration, and support for parenting and re-establishing family relationships.
- Enhanced support at specific times of vulnerability, such as bereavements and loss of child custody.
- Addressing stigma and marginalisation, which remains a universal problem among people who use drugs but may be particularly salient for women.
- Involvement of women with lived experience in design and delivery of services and policies.
- With regard to research, more longitudinal work (to better understand changes in the composition, risk factors, and mortality rates of the population at risk) and more in-depth qualitative work (to understand women's experiences and the risk of drug-related death) would be beneficial. In particular, it would be valuable to explore further the relationship between child protection/social work involvement and women's vulnerability to drug-related harms.
How to access background or source data
The data collected for this social research publication:
☒ cannot be made available by Scottish Government for further analysis as Scottish Government is not the data controller.