7. Discussions and conclusions
This study builds our understanding of the use of NPS amongst key vulnerable groups in Scotland. Based on the findings in this study, this section outlines a number of key learning points for further discussion and consideration.
Key learning point 1:
- Database tools such as DAISy should be adapted and in the case of needle exchange data collection, standardised, to include specific questions relating to NPS use, this may include individual NPS names or categories. Training for frontline workers in how best to apply these tools should be incorporated in this process.
The findings from this research suggest use amongst vulnerable populations is likely to be far higher than in the general population, where NPS use is relatively low, although somewhat higher amongst young people. [179,180] However, vulnerable young people and MSM were the more challenging groups to engage in this study. Additionally, access to some rural areas was limited. In order to develop a more detailed picture of NPS use in Scotland, more focused exploration of specific issues within these target groups and regions may be required.
In order to develop robust estimates of NPS use there needs to be an improvement in data collection within services. The new database for drug and alcohol services currently being developed (Drug and Alcohol Integrated System - DAISy) provides an opportunity to collect reliable data provided staff are enabled to undertake thorough initial assessments. Similarly needle exchange data has the potential to provide useful prevalence data, again provided staff are appropriately equipped to encourage accurate disclosure of NPS use.
Any training on data collection tools should focus on how accurate and reliable information can be collected either at initial assessment or subsequently. Part of this will involve reassuring services users that honest responses will not hinder their access to certain services and that honest answers will help ensure the appropriate care package is put together.
7.2 Motives for use
Key learning point 2:
- Motives for use should be identified in assessments and reviews with service users and used to inform care plans undertaken by support services and frontline staff.
This research highlighted that the motives for NPS use varied across the different types of NPS, although it was clear that ease of access, price, curiosity and pleasure were common drivers. This is similar to findings from other literature such as Global Drug Survey. 
A better understanding of these motives for NPS use and how they may vary based on population groups and NPS type can help to inform interventions by services. In particular, there may be benefits to targeted interventions for people who intend to continue using, reduce use and for those who wish to stop using. Approaches such as Motivational Interviewing already include offering clients a menu of options, which would take account of the different goals NPS users may have. 
Perception of harms and health benefits and how these related to motives for using are also useful to consider. For example, use of benzodiazepine-type NPS and experiencing sleep benefits may suggest a particular need to address possible motives such as self-medication.
It was also notable that legal status did not appear to be a key motive for use within this study; this is again in line with findings by the Global Drug Survey.  Taken alongside the findings from Chapter 6, which showed that the majority of respondents to the NPS survey did not anticipate the Act impacting on their NPS use, this suggests that NPS are likely to continue to be a feature of substance use patterns amongst these vulnerable groups.
7.3 Consequences of use
Although some positive consequences for use were identified, harms for NPS use shared similar themes to other existing literature, which identifies a range of mental health, physical health and social harms. 
Mental health harms
Key learning point 3:
- Greater partnership working between substance use and mental health services and a review of care pathways for those with substance use and mental health difficulties should be considered.
Harms to mental health were the most commonly reported consequences of NPS use, and have been the subject of recent research on acute hospital admissions.  With a high proportion of NPS survey respondents in contact with mental health services either currently or in the past, the risks of further exacerbating mental health problems are high and need to be considered within any treatment settings where people are likely to be presenting with both substance use and mental health difficulties. Better collaboration and partnership working between mental health services and drug services will assist in better care of this population.
Furthermore, use of NPS to manage mental health, particularly anxiety, emerged in relation to those using benzodiazepines-type NPS, which may suggest escape coping, or long-term, non-medically supervised use. This highlights the need to better understand the relationship between NPS use and mental health and a potential need for a dedicated treatment response to sustained self-prescribed benzodiazepine use and anxiety. All these areas present a need to develop the care pathways for people with substance use and mental health difficulties.
Physical health harms
Key learning point 4:
- Assessments within key services should ensure they cover a range of physical health areas including sleep management.
Sleep problems were one of the most commonly reported physical harms across all NPS. However, people who had taken synthetic cannabinoids and benzodiazepine-type NPS also reported positive, sleep-promoting effects of use. This outlines a challenge for treatment providers in motivating service users to address substance use where it is used to facilitate sleep. Other studies have shown the correlation between sleep and drug use in that sleep problems can be a trigger for drug use and vice versa.  Many treatment services offer support and advice around sleep hygiene as part of a treatment plan, however services often report that there are limited resources and in-house expertise in this area. Whilst specialist clinics exist for sleep, these are rarely available to people who use NPS or indeed other drugs generally unless they meet specific criteria for sleep problems which is separate to their drug use. Accessing dedicated sleep clinics would generally be restricted to people further into recovery given the likelihood that drug use is affecting the sleep problem. The findings in this study suggest that there could be benefits to offering sleep management support earlier to those currently using NPS as a way of trying to deal with their sleep problems which may in turn allow them to stop or reduce substance use. Training for support staff and dedicated group work or clinics and drug specific literature for people who use NPS and are experiencing sleep problems may be of benefit to both educate and guide treatment options for service users.
Loss of co-ordination was another commonly reported physical harm for some types of NPS and highlights a possible greater risk of accidents when under the influence. Seizures and effects on heart rate as identified by some NPS users in this study are also identified in other literature with additional physical harms including cardiovascular, lung and kidney problems.  Given that a substantial proportion of NPS users report not disclosing NPS use, assessments within key services which cover a range of health areas could assist in opening up a dialogue regarding NPS use and related harms and encourage better disclosure of NPS use.
Key learning point 5:
- Multi-agency and flexible working approaches such as assertive outreach should be continued and developed to support people with the range of social harms experienced.
Debt, loss of tenancy and anti-social behavior (which could lead to loss of tenancy) were key harms identified by people who use NPS in this sample, with 22% (n=92) of the NPS survey respondents identifying as already homeless. This highlights the need to include financial and housing support for people who use NPS in the range of services offered.
Given the issue of missed appointments identified in this sample, it is perhaps not surprising that over one third of people who used NPS reported not being in contact with drug services (although this could also be a consequence of the way the sample was recruited). Non-engagement is often a key issue faced by services, and services which are able to provide flexibility in supporting clients such as assertive outreach, longer opening hours, appointment reminder systems or drop in sessions often report higher rates of engagement from vulnerable populations.  Equally, with regards to benefit sanctions, greater awareness of the complexities of problem drug use and the impact of sanctions on these vulnerable groups would be advantageous. Research has identified hardship caused by benefit sanctions in Glasgow including rent arrears, sometimes leading to eviction. 
This constellation of harms - loss of tenancies, missed appointments and benefit sanctions - will undoubtedly lead to a proportion of the population studied being particularly vulnerable. How this group is protected from further harm should be considered by local planners and services. As identified in more detail in treatment responses and improving practice, multi-agency responses and training for staff required to work with a range of complex issues would be beneficial in ensuring people get the interventions required to reduce harms.
7.4 Improving practice
Key learning point 6:
- Provision of basic NPS training for all staff and training in a variety of health based topics and assessment for support staff should be considered by frontline services.
The low levels of NPS users reporting NPS use to the existing treatment providers they are in contact with, and the challenges outlined by frontline staff in keeping up to date, highlights a need for staff to have current knowledge of NPS. Workforce development may benefit from a systems approach, which could involve not only training, but also addressing and embedding NPS in existing workforce development strategies and ensuring adequate support and supervision is provided for staff working with NPS. A minimum requirement in terms of improving practice is the provision of basic NPS training for all staff, and updates on new NPS trends. As this study identified, NPS are most often used in combination with traditional drugs, and up-to-date training on general drug awareness and poly-substance use is likely to be beneficial for front line services. Given that staff identified lack of specialist treatment as a barrier to service utilisation for people who use NPS, more comprehensive training on NPS would be recommended for more specialist services, especially for those services currently or hoping to offer treatment to people who use NPS.
With significant crossover within the vulnerable populations, in particular homeless people, injecting drug users and people in contact with mental health services, and the range of issues articulated by people who use NPS in this sample, training in complementary topics such as mental health, sexual health, chemsex, homelessness, and sleep hygiene in addition to drug awareness would contribute to the development of holistic NPS services. Training in assessment would also assist in being able to identify NPS use and related harms.
7.5 Service developments
Key learning point 7:
- Health board and ADP areas should review possibilities for service developments or adaptations to existing services to respond to NPS users.
People who use NPS and frontline staff both identified the provision of specialist treatment for NPS as an important area for improving services. In particular, residential detoxification and rehabilitation were desired services among people who use NPS. This was stated particularly by people who inject drugs, homeless people and people in contact with mental health services, over one third of whom identified residential detox and rehabilitation as an important treatment option. Over a quarter of vulnerable young people identified residential detox and rehabilitation as a treatment need. This suggests a role for Child and Adolescent Mental Health Services ( CAMHS) and youth addiction services to explore how best to provide more targeted services for this population.
Although provision of NPS specialist residential detox and rehabilitation is likely to be unrealistic in the current funding climate, existing treatment centers could be utilised to provide NPS detox options. The most likely NPS to require inpatient detox would be with benzodiazepine-type NPS. Although the expertise for offering general benzodiazepine treatment already exists there are challenges in accessing this level of treatment due to reduced funding for residential services. Clinical guidelines have recently been developed which outline how to respond to acute harms and advise on detoxification. 
NPS specialist staff, whether in existing services or specialist services were seen by both people who use NPS and staff to be a valuable asset to be developed. With limited resource for specialist services, the development and expansion of the remit of established treatment services including dedicated workers within existing services could be useful to explore. Adapting current treatment services to offer residential detox and rehabilitation for NPS users as outlined above would be a cost effective response to NPS use in Scotland.
MSM had low levels of contact, and did not present with the same level of multiple vulnerabilities as other groups. They also favoured harm reduction over other treatments. This highlights merit in considering the rebranding of services to appeal to 'new' service users, perhaps considering moving away from the more traditional branding of drug services such as addiction services or drug problem services and utilising targeted resources and adverts to reach out to particular populations e.g. MSM- and vulnerable young person-specific. Opening hours could be a further consideration with certain aspects of the NPS treatment populations perhaps struggling to access services within the working day hours often offered by services. Evenings and weekends opening could be attractive to vulnerable young people and MSM in particular. Guidance on substance use services responding to MSM recommends the importance of services being available outside normal working hours and highlights example service models including, satellite services or outreach services operating in targeted areas.  Local scoping exercises gaining the views of people who use services and people who would potentially use services would be useful in establishing evidence for these options and would also take account of likely regional varieties.
The findings from this research also suggest that services should consider developing the skills and expertise of one member of staff who can keep up to date with new developments and provide advice and assistance to other staff. Services have utilised a dedicated worker model for other aspects of treatment often in combination with utilising people with lived experience  such as in the mental health or recovery specific services, therefore it would be possible to build on this to develop a similar system of named NPS workers hosted within services. It would be crucial to ensure such workers had the appropriate skills, knowledge and training for these roles, and that the services had appropriate resources to maintain and develop this knowledge. As outlined in this study there is still an information gap in some areas when it comes to NPS resources and basic NPS training. In order for staff to take on a specialist worker role, a higher level of NPS training would also be beneficial to ensure service quality.
7.6 Engaging vulnerable populations
Key learning point 8:
- Multi agency and targeted responses should be explored for the different populations using NPS.
There was considerable cross over between the populations of homeless people, mental health service users and people who inject drugs. This highlights that NPS users often face a range of issues including ill health, homelessness and financial problems. Multi-agency responses are effective for those groups experiencing multiple disadvantages and have been recommended by services responding to 'club drugs' and NPS.  The population-specific harms identified in Chapter 5, and the low levels of engagement with services amongst MSM who responded to the NPS survey suggest that there is a need for specific service developments within key services that MSM are likely to use. This may include sexual health services and targeted gay men's health provision where it exists. Similarly, services for vulnerable young people should explore how best to address NPS and wider substance use among their young people.
Hosting dedicated drug workers within partner organisations including sexual health, mental health and/or emergency care could effectively capture those people who are not in regular drug treatment and may be at greater likelihood of using other services and/or emergency care. This model has been utilised to great success in other parts of the UK such as 56 Dean Street in London which houses sexual health and drugs workers within the service aimed at MSM.
With the majority of NPS survey respondents sourcing information from peers combined with low levels of service contact for NPS use, this may suggest assertive outreach combined with use of peer support could be worthy of exploration. There are various existing models which couple peer support with harm reduction such as the stepped care model used by Crew in Edinburgh or with abstinence based treatment as underpins the therapeutic community model offered by Phoenix Futures Scotland.
Tailored care and relationships with support staff were both identified by NPS users as important, which is confirmed by other studies.  Findings from specialist services suggest treatment is more likely to be accessed by people who would not otherwise seek treatment if it is appropriate to their needs. 
7.7 Information on NPS to people who use NPS
Key learning point 9:
- Information resources in a variety of formats are required to reach the different populations who use NPS.
Both NPS and staff survey respondents highlighted information needs. With around a third of NPS survey respondents sourcing information from peers, and 40% of staff identifying dedicated NPS resources such as leaflets as being something they would like to offer, there is potential to look at leaflet resources for the different target populations. Additional and targeted resources could build on the Know the Score resource aimed at young people, which would be more accessible and marketable to vulnerable populations.
Consideration of new formats for sharing information including 'apps' may also be of benefit for certain populations in order to make information more accessible. NHS Tayside currently provide the Cool2talk service which utilises an online portal to inform young people about a range of health issues including drugs. Equally, film resources specific to NPS may be of benefit for populations who may not be able to access traditional mediums such as leaflets and where demonstration elements would be useful in preventing BBV harms such as safer injecting. With people who use NPS citing documentaries as a source of information, and use of resources such as cartoons  piloted by other treatment providers such as Lifeline, there is an opportunity to explore use of film media as a resource to reach NPS using groups. Use of film has been piloted in the prison population for NPS in Scotland but a more formal pilot with evaluation of effectiveness would be required to gauge the usefulness of this approach. 
7.8 Psychoactive Substances Act
Key learning point 10:
- Monitoring of the impact of the PSA on vulnerable populations should be undertaken by ADPs, health boards and services with a particular focus on increased overdose risk.
The Psychoactive Substances Act ( PSA) came into effect during survey data collection on 26 th May 2016. Unintended consequences of the PSA were anticipated by study participants to include diverted modes of purchase to more underground means, and returning or transitioning to traditional drug use. Therefore there is potential for increased harms for some people who use NPS related to adulterants in street purchases and a possible need for greater resources and funding in both treatment and criminal justice settings to respond to emerging developments, such as around access and criminality, following on from enforcement of the Psychoactive Substances Act.
It will be important to track the impact of the PSA particularly regarding the impact of changes in supply routes of NPS that might have particular impacts on vulnerable populations who use NPS.
Transitioning back to traditional drug use was flagged up by respondents in both surveys as an anticipated outcome of the PSA coming into force. It was further flagged up in focus groups in relation to opiate users moving back from NPS use (in particular mephedrone and ethylphenidate) to heroin use. For those people who use both NPS and heroin and other opioids, the risks of transitioning back to use or heavier use of heroin is high, especially where access to NPS may be more difficult either through availability or increased price. With overdose risk increasing significantly where people may have a reduced tolerance for opioids, provision of Naloxone is a crucial part of the treatment response. Alcohol and Drug Partnerships and Naloxone co-ordinators should be alerted to the potential for increased overdose risk so that appropriate action can be taken, including supply of Naloxone to vulnerable populations. In addition to Naloxone provision, an effective response may involve an element of staff training in order to raise awareness in non-drug specialist settings.
7.9 Study limitations
Estimating prevalence of NPS use amongst vulnerable populations was not possible, due to the under-reporting of NPS use by vulnerable populations to services, combined with limited existing data within services and availability of national data sets effectively capturing NPS use. What the study does provide is an insight into patterns of use amongst vulnerable groups, including motives and consequences of use in the Scottish context.
Given the challenges of gathering robust data on the prevalence of 'traditional' drug use, a focus on harms and motivations amongst specific populations would likely be the most useful focus for further research in developing more effective prevention and treatment responses.
Similarly to other data sets in Scotland, this study relied on self-reported data. Given the confusion of what constitutes an NPS, this may have affected who opted in or out of the study.
This study extends our knowledge of some of the potential harms experienced from NPS use, although it should be acknowledged that given the high rates of poly-drug use within this sample, exact causation of harms cannot be determined.
With the implementation of the Psychoactive Substances Act coming in during the study, responses on the forthcoming ban were anticipatory rather than experiential.
7.10 Closing remarks
NPS use amongst these groups is complex and results in a number of harms and specific treatment needs. This research is important because but it provides a tentative first understanding of patterns of NPS use, alongside motives and consequences of use amongst vulnerable groups in Scotland.
With many factors likely to influence trends within NPS in Scotland, including the PSA, which came into force during data collection, more information is needed to gather a fuller picture of the emerging NPS landscape in Scotland.