Scottish National Research Framework for Problem Drug Use and Recovery

Themes

Cross-cutting aspects

A number of the issues identified by the steering group and by stakeholders during the consultation process relate to more than one of the key themes. These are grouped below but are also referred to under each theme.

Headline messages relating to the overall research needs for the addictions field in Scotland were:

• Research to better our understanding of the unique Scottish dimension and its associated challenges - in particular, research into the associations between problem drug use, an individual's recovery journey and deprivation and inequality, is a priority as this will provide a platform to design and evaluate more effective interventions of relevance to Scotland.
• There is a need for enhanced national data collection, and access to these data for research, alongside making better use of the data already gathered
• There is a clear need to synthesise and disseminate research findings better, to establish a strong evidence base that can be used to inform planning, practice and delivery of services across Scotland
• We need a clearer understanding of what the positive, and potential negative, impacts of specific interventions/services are, and what factors/context may influence their effectiveness, including cost effectiveness, that can support assessment of what works, or not, and why, and inform intervention, improvement, implementation and delivery

Additional areas which require attention include:

• Research to address the impact of both problem drug use and treatment processes on different subgroups of society and in different settings
• Research into trauma in early or later life - the impact this has on an individual's development of problem drug use and broader life choices
• The needs of older drug users - the health and treatment issues associated with this group
• The visible evidence of recovery (both individuals and community) and the impact on prevention
• It was felt to be helpful to articulate research activity in a way that uses a 'life span approach' - thinking about the evidence base in terms of different populations and across the lifespan
• The need for research into treatment options - why do some individuals drop-out of treatment and how can services adapt to fit the needs of these harder to reach individuals? Also, what are the needs of those who do not engage with services at all?
• Research on ways to improve the effectiveness of psychosocial treatments for addictive disorders

Families

The role of families is a key theme for improved evidence in Scotland. The wider potential impact on the health and lives of close familial contacts of an individual with problematic drug use may be substantial with repercussions in both the short and longer-term. There are also unexplored areas around recovery and the family that would benefit from further research.

A better understanding is needed to identify and assess the scale of the problems that can arise and to design effective prevention and treatment interventions to mitigate these problems. It was felt that a "lifespan" and "whole family approach" would best address the issues identified.

Aim

• To investigate the wider effects of problem drug use on all family members, carers and communities

Objectives

• To improve the well-being of children and families affected by problem drug use and the associated recovery process
• To identify and assess the scale of the problems which can arise within families affected by problem drug use and recovery from problem drug use

Priorities

• To better understand the wider effects of problem drug use on all family members and at all stages of a parent's recovery pathway. This should include research into: the impact on children of a parent's problematic drug use, and of their recovery; the impacts of consequent child removal on a parent or family unit; and the welfare of removed children and impact of their own subsequent substance use
• Examine the needs of vulnerable children affected by problem drug use and the impact this can have at different stages of a child's development
• Research into the relationship between childhood experiences/trauma and subsequent drug use
• Research into the trans-generational transfer of addictions (and recovery)
• There is a useful research evidence-base addressing some aspects of this theme already in place - some generated in association with Scottish partners. There is a need, however, to better disseminate this evidence to ADPs, commissioners and practitioners to influence local practice

Additional areas which require attention include:

• Gendered recovery - women can have a very different experience of, and pathway through, addiction and recovery. Evidence suggests that there are stark differences in the recovery from problem drug use between men and women, however, the factors that influence this are not well understood. Research is required to understand these factors better in order to inform more effective intervention strategies and services. There is also a need for additional research into parenting capacity, including fathers, as much of the current evidence focusses on pregnant women, mothers and mothering
• The relationship between LGBT clients with addiction issues and associated stigma and family impact. With the knowledge that LGBT groups have higher substance misuse problems, does stigma result in lower engagement with services?

Cross-cutting themes

• Understanding the size of the problem - there is a need for better local and national data on the prevalence, and characteristics of, families affected by problem drug use. This will enable better monitoring and assessment of the challenges and impact of services and interventions
• There is a need for further research into effective interventions for families affected by problematic drug use, examining what interventions/service configurations work, or not, and why. This can then inform intervention/service design, improvement and implementation
• The relationships between problem drug use and untreated trauma, mental health and family function (e.g. domestic abuse) are poorly understood Further research in this area is required to better understand the causes and allow for more effective prevention or treatment of problematic drug use

Harms
Reducing drug-related harm, not just those health related harms but also those associated with crime, remains a national priority for Scotland. There is on-going Scottish research considering some of these areas - including drug death and injection-related blood borne virus (BBV) risk. However, these remain major unresolved challenges in Scotland, where drug death rates are one of the highest worldwide.

Aim

• To explore and test how to reduce the range of harms associated with problem drug use

Objectives

• To reduce the level of drug related deaths
• To reduce the harms associated with injecting drug use (injuries/infections etc.)
• Reduce the level of non-health related harms affecting the life opportunities of individuals and their families

Priorities

• The need for a coordinated research dissemination programme around drug related deaths to ensure evidence is effectively disseminated and appropriately put into practice across the country, but also to capitalise on new approaches aimed specifically at reducing our drug death rate
• Capitalise on opportunities to link with on-going Scottish BBV (hepatitis and HIV) research programmes - to ensure that people who inject drugs can consistently access evidence-based prevention and treatment opportunities across Scotland
• Research into the effects of long term ORT use and the alternatives to methadone
• Research into the problems faced by the older drug taking cohort and associated co-morbidities
• Non-health harms affecting the life opportunities of individuals and their families (relating to the family/community, training or employment, housing or criminal activity) must be more robustly researched - requiring closer collaboration across the field. There should be consideration of how to use data-linkage opportunities, capitalising on existing Scottish initiatives in this area may provide opportunities to better understand the wider harms of problematic drug use

Additional areas which require attention include:

• What are the long term effects of different forms of drug use and also of the treatments received?
• What are the effects of drugs on young people and adolescent brains?
• Do we sufficiently understand the needs of problematic drug users across the age range?
• Better monitor and understand the emergence of new drugs in addition to the changes in the ways drugs are used (e.g. NPS, anabolic steroids, chem sex)
• Research into healthcare delivery in a range of justice settings is needed
• The relationship between mental ill health and drug use - both as a causative factor and as a symptom of problem drug use

Cross-cutting themes

• The Scottish Effect - why, when compared with other countries, does Scotland experience worse health impacts, more deaths etc.?

• What are the effects of early life trauma on (risky) decision making?

Prevention
Increased prevention of drug use was a key aim of the Road to Recovery strategy. It was acknowledged that there is inconclusive evidence on the potential impact of much of the prevention activity delivered, particularly for young people in schools.

Aim

• To explore and test how people will be less likely to develop a substance misuse problem

Objectives

• Reduce vulnerabilities of our most at risk populations
• Reduce prevalence of problem drug use

Priorities

• There is an international move towards more generic delivery of prevention techniques, addressing multi-risk behaviours and resilience in prevention efforts. Research programmes are required to determine what - if any - of these approaches are effective in the Scottish context
• Investigate the links between socio-economic disadvantage, deprivation, health inequalities and the progression towards problem drug use

• Develop research to better understand the impacts of prevention techniques within, and outwith, schools. Which aspects of these interventions had a specific impact?

Additional areas which require attention include:

• The approach used to progress our knowledge in this area is likely to be crucial. There is a need to consider 'bottom up' solutions rather than have a "one size fits all" intervention imposed in all areas (different needs for different backgrounds)
• The need to understand current prevention activity within Scotland
• Secondary prevention, such as those focussed on prevention of BBV, should also be considered within this theme.

Cross-cutting themes

• Research the impact of visible recovery (both individuals and communities) on prevention

Recovery
Since the publication in 2008 of 'The Road to Recovery' Scotland has been one of the leading countries in the world in this area. However, there remain many unanswered questions in a Scottish context relating to long-term changes to sustained recovery, the role of treatment and other forms of community intervention and engagement.

Those working in the recovery field have also highlighted the need for a shift in focus with regards the research around recovery. Placing an emphasis on examining the reasons why an individual got better, rather than on how they got ill, will assist others to get better.

Aim

• To explore and test how people receive support which helps them to recover from problem drug use

Objectives

• Increase the number of people attaining recovery from problem drug use
• Better understand what individuals want from treatment and what the best methods are to achieve this
• Reduce the stigma associated with problem drug use and people's recovery from it

Priorities

• Investigate the role of peer-based recovery support - what impact is it having and how can treatment and support services best capitalise on it
• Research into how many people seek to be abstinent from drug use and what factors help to achieve it
• Research into how communities work to promote recovery
• Investigate what are effective interventions at different stages of an individual's recovery journey
• What is the natural history of progression of problematic drug use? How do different factors impact on an individual's use of drugs? Why do some develop problems and what impacts on the outcome of their recovery process?

Additional areas which require attention include:

• How can we better engage people with their recovery process and how do we help them maintain their progress?
• Research into effectiveness of community and residential rehabilitation
• There is a need for robust Scottish research which identifies opportunities to intervene to prevent progression towards problematic drug use, develop resilience and promote personal recovery and prevent relapse

Cross-cutting themes

• How to reduce the stigma (in the media and public perceptions) attached to drug use and recovery from problem drug use?
• The role of the family in recovery - what is the role of mutual aid in family support? How many treatment services are inclusive, provide support or look at the treatment of the client and their recovery holistically as a whole family phenomenon?