Impact case study database
Reducing harm and saving lives in situations of substance misuse
1. Summary of the impact
In 2018, there were 2,917 deaths related to drug misuse in England and Wales, the highest number registered since records began in 1993. The problem is particularly acute in Wales where greater levels of deprivation have contributed to a rate of deaths far higher than in England. Between 2009 and 2020, USW researchers conducted a series of interlinked empirical projects that have helped to minimise drug and alcohol-related harm and save lives. The findings have directly influenced the commissioning and delivery of substance-misuse services in Wales including, the national roll-out of the Take-Home Naloxone Scheme across Wales (naloxone is a drug that reverses a heroin overdose) and important changes to long-standing harm-reduction advice. The research has also helped services to prepare drinkers for the potential unintended negative consequences of Minimum Pricing for Alcohol.
2. Underpinning research
This case study is underpinned by a series of inter-linked projects conducted by University of South Wales (USW) researchers between 2009 and 2020. The projects are linked in their focus on one of the most vulnerable and marginalised groups in society - people with substance (drug/alcohol) use problems. A common thread running through the projects is the goal of minimising health and social harms. As drug-related deaths soar to an all-time high across Wales and the UK, harm reduction has never been more important.
Project 1: In 2009, USW researchers were commissioned by Welsh Government (WG) to evaluate the effectiveness of the Take-Home Naloxone (THN) Demonstration project, which involved training opioid users in the use of naloxone and giving them take-home kits for use in overdose situations. The evaluation employed a quasi-experimental design and mixed-methods approach. With fieldwork support from researchers at Glyndwr University, data were collected using questionnaires (completed by 525 users), observations (of 14 training sessions) and in-depth interviews with eight opioid users and nine providers of substance-misuse treatment services. The study found that users trained in the use of naloxone were able to administer it effectively in real-life overdose events. However, sometimes a single dose was not enough to save lives. The evaluation report (2011) recommended that the Scheme be rolled out beyond the demonstration sites to services across Wales and that the medical arguments for double dosing be reconsidered.
Project 2 aimed to shed light on the ‘dark figure’ of non-fatal overdose (which had been identified in Project 1), through a national survey of injecting opioid users in Wales. The study involved USW researchers and Dr Rhian Hills (Senior Policy Manager in WG) distributing questionnaires to 661 consecutive users of all treatment service-based needle and syringe programmes across Wales over a one-month period in 2013. The questionnaire generated previously unknown data on the prevalence and characteristics of non-fatal overdose in Wales (e.g. the mean number of survived overdoses per person per year). Statistical support was provided by Professor Sheila Bird (University of Cambridge).
Project 3 (2015-2017) added qualitative detail to Project 2 through in-depth interviews, conducted by Holloway (USW) and Hills (WG), with 55 opioid users recruited from prisons and drug treatment services in Wales. The report (2017) identified important ways in which overdose events could be more effectively managed to save lives (e.g. encouraging people to use ‘in sight’ of others and to routinely carry naloxone). May (USW) contributed to an article published in the International Journal of Drug Policy based on these findings.
Project 4 (2018-2019) was commissioned by WG in response to the increasing rate of drug-related deaths involving prescription-only medication. This qualitative study was conducted by USW researchers and Hills, and based on interviews with 60 people with histories of illegal drug use. The research found that drug users often faced barriers to accessing treatment for both substance-use problems and legitimate health problems. The report (2019) recommended the need to speed up access to treatment, to tackle stigma among healthcare professionals, and to capitalise on the helping culture of drug users to help minimise harm and save lives.
Project 5 (2018-2019) was commissioned by WG in response to concerns about potential unintended consequences of introducing Minimum Pricing for Alcohol (MPA) in Wales. This predominantly qualitative study, undertaken by researchers from USW, Glyndwr University and Figure 8 Consultancy, gathered data from service providers and service users through interviews (n=87) and online survey questionnaires (n=193). The research identified several possible harmful consequences including increases in income-generating crime, unplanned alcohol withdrawal and substance switching. The report (2019) recommended dissemination of the findings to service providers across Wales, which would include statutory community-based drug and alcohol teams in each Health Board area as well as the five major substance misuse treatment providers operating in Wales (see Barod, Kaleidoscope, CAIS, WCADA, Change Grow Live). Subsequently, a series of dissemination events (2019/20) was funded by WG, which helped to raise awareness of MPA and prepare services for possible negative effects.
3. References to the research
Project 1:
The impact of take-home naloxone distribution and training on opiate overdose knowledge and response: an evaluation of the THN project in Wales
Bennett, T. & Holloway, K. 1 Jan 2012. Drugs: Education, Prevention and Policy. 19, 4, p. 320 – 328, DOI: 10.3109/09687637.2012.658104.
Project 2:
Non-fatal overdose among opiate users in Wales: A national survey
Holloway, K. R., Bennett, T. H. & Hills, R. Oct 2016 In: Journal of Substance Use. 21, 5, p. 471-477, DOI: 10.3109/14659891.2015.1063718
Does take-home naloxone reduce non-fatal overdose?
Bennett, T., Holloway, K. & Bird, S. M. 11 Jan 2014 In: Lancet. 383, 9912, p. 124-125, DOI: 10.1016/S0140-6736(14)60022-2.
Project 3:
- Fatal and non-fatal overdose among opiate users in South Wales: A qualitative study of peer responses. Holloway, K., Hills, R. and May, T. 2018. In: International Journal of Drug Policy, 56: 56-63, DOI: 10.1016/j.drugpo.2018.03.007.
Project 4:
Not what the doctor ordered: motivations for nonmedical prescription drug use among people who use illegal drugs. May, T., Holloway, K., Buhociu, M. and Hills, R. (2020) In: International Journal of Drug Policy, 82, DOI: 10.1016/j.drugpo.2020.102823
Project 5:
Research investigating the potential for substance switching following the introduction of minimum pricing for alcohol in Wales. Holloway, K., May, T., Buhociu, M., Livingston, W., Perkins, A., Madoc-Jones, I. 2019. Welsh Government.
4. Details of the impact
The number of deaths related to drug misuse in England and Wales is at a record high (ONS, 2019). The problem is particularly acute in Wales where the rate of deaths is higher than in England. The causes are complex and include poverty and deprivation (which are greater in Wales than England), insufficient funding of treatment services, increases in prescription drug misuse, and an ageing cohort of vulnerable drug users. Alcohol-related harms, including nearly 500 deaths per year and 15,000 hospital admissions, are also of concern in Wales (Public Health Wales, 2019). Such harms have been linked to excessive consumption of cheap, high-strength, high-volume products, and led Welsh Government to implement Minimum Pricing for Alcohol in March 2020.
Findings from a series of interlinked projects conducted by USW researchers since 2009 have had a significant impact on substance misuse policy and practice in Wales. The research has generated new knowledge that has helped to minimise drug and alcohol-related harm and benefited people with substance misuse problems, their families and friends, and the professionals who treat and support them.
USW research led to the Welsh Government’s National roll-out of the Take-Home Naloxone (THN) Scheme and influenced the switch from single to multiple doses
In the evaluation of the THN Demonstration Project (2009-2011), USW researchers recommended the national roll-out of the THN Scheme to services across Wales and urged Welsh Government to review the potential life-saving benefits of providing more than one dose of naloxone. Roll-out was implemented by WG in November 2011 and the Scheme continues to operate across Wales today. Drug and Alcohol Findings , an online ‘Effectiveness Bank’, founded in 1999 by Alcohol Change UK and the National Addiction Centre (with monthly reads “well over 100,000”), asserts that the evaluation “ found promising results leading to its roll-out as a national programme”. The provision of multiple doses of naloxone (Prenoxad) was piloted in 2015 and rolled out across Wales in 2016. By 2017-18, 99% of THN kits were Prenoxad kits. Between 2014 and 2020, 23,667 THN kits (including single and multiple dose formulations) were issued to 6,096 unique people at risk of overdose. Over that same period, there were 2,702 reported uses of THN with fatalities occurring in approximately 1% of these cases (Public Health Wales, 2020). The THN Scheme has been helping to save lives across Wales since 2009 and throughout the current REF period.
Changes to harm-reduction advice provided by Welsh Government and Public Health Wales were influenced by USW research
Building on a national survey that investigated the dark figure of non-fatal overdose, USW researchers conducted qualitative research (2015-17) that identified new ways in which overdose events could be more effectively managed to save lives (e.g. using ‘in sight’ of others). The importance of not using or injecting out of sight of others is now widely recognised among practitioners as a critical piece of harm-reduction advice, which sits alongside the traditional ‘do not use alone’ message. Leaflets (S1, S2) incorporating this message were produced by Welsh Government (2017) and, more recently by Public Health Wales (2020), for distribution to treatment services across Wales, which would include the needle and syringe programmes operating in 57 specialist statutory/voluntary organisation sites across Wales ( Public Health Wales, 2020). The findings have featured in evidence presented by Public Health Wales to the UK Government’s Advisory Council on the Misuse of Drugs (27/07/20) and the Welsh Government’s National Implementation Board for Drug Poisoning Prevention (31/07/2020).
The Head of Substance Misuse Policy and Finance, Welsh Government, confirms in a testimonial that the findings have been “ of benefit to Welsh Government both in terms of policy and operational practice” and have contributed to “ ongoing work to tackle drug related deaths and of course implement our Substance Misuse Delivery Plan” (S3).
The Head of Substance Misuse at Public Health Wales has said: “ Based upon the findings of the 2018 qualitative study of fatal and non-fatal overdose among opiate users in South Wales, Public Health Wales undertook to develop national messaging for use on all injecting related paraphernalia (single injecting kit packs and sharps/safe disposal bins) including those key harm reduction messages developed with the work of Professor Katy Holloway. These messages included ‘Stay in sight, stay alive, avoid using alone’ and ‘Carry it, use it, call for -help – Naloxone – be the difference’. These messages and associated graphics are being finalised by Public Health Wales will be used across Wales from January 2021. I feel confident in acknowledging that the harm reduction messaging was clearly informed by their evidence, and can confirm that this messaging and harm reduction approach has been shared with other key stakeholders via the Advisory Council on the Misuse of Drugs, the National Implementation Board for Drug Poisoning Prevention (NIBDPP) and European Monitoring Centre for Drugs and Drug Addiction” (S4).
Additionally, the Campaigns and Communications Lead at Barod, a Wales-based charity that provides support and guidance to anyone affected by drug or alcohol use, has said: ” Many of these recommendations [in Holloway’s research] have subsequently been put into practice, including changing the terminology of ‘do not use alone’ to ‘do not use out of sight of others’, when using substances. The change in terminology of this specific harm reduction message has been pivotal. This can be evidenced none more so, than in recent months. In light of the Covid-19 pandemic, we have been able to adapt our advice to those undertaking high risk substance use behaviour, around this specific message. By saying ‘do not use out of sight of others’ has enabled the recipient to better understand and more realistically put this into practice, due to a wider scope of interpretation, compared to ‘do not use alone’” (S5).
These changes in harm reduction advice by service providers have helped to save lives
An experienced Harm Reduction Worker within Gwent Drug and Alcohol Service (GDAS), which provides direct support and intervention for service users and their families across the Gwent region, has confirmed that the recommendations made by USW researchers, such as the change in terminology and the need for a wider provision of THN, amongst others have had a major impact. He specifically attributes the research to the following:
Letters were sent out to every GP in Gwent, Wales, giving clear pathway advice in accessing Naloxone to concerned others
Every hostel in NPT [Newport] has been provided with training to administer this intervention and have on premises at least five Naloxone packs
During pandemic lockdown, 15 self-contained living Pods for street homeless PWUD [people who use drugs] in a secure area called the Mission, “designated as a high risk” now interact weekly with outreach workers (all the security are trained in the use of administering Naloxone and have prevented death by overdose in at least one incident by keeping 5 naloxone on site as harm reduction preventative measure)
He also states that: “ As an ex-opiate dependent service user for 15 years with first-hand experience of overdose prior to working in this field, I would testify that this research on overdose has made it easier for service providers and service users alike to communicate in a frank way without the fear of reprisals in relation to continuing treatment. Highlighting the importance of saving lives through the promotion and education of service providers and service users alike on the prevention of overdose.
In the last three years I have administered a Naloxone intervention twice in a social setting outside of working hours, where the availability of Naloxone was key in saving lives. Prior to this important research, the availability of Naloxone was scant at best. The harm reduction advice given by service providers to PWUD and concerned others around not using alone, and the escalation of Naloxone training for all service users entering OST [opioid substitution treatment] has been key in preventing opiate overdose” (S6).
USW research has influenced the Welsh Government Substance Misuse Delivery Plans and helped improve access to treatment
Qualitative research investigating the misuse of prescription-only medication among illegal drug users (2018-19) found that it was common practice for people to share their prescription medication to help those facing barriers to legitimate sources of treatment (e.g. through stigma and disbelief among healthcare professionals and/or long waiting lists for treatment). These findings formed the basis of a BBC One Wales documentary (25/01/20), which within three months (27/04/20) had achieved more than 27,000 views on the BBC website and 4,990 impressions and 202 engagements on Twitter. Findings from the research were also shared on BBC Radio Wales (25/02/20) Breakfast with Oliver Hides (average audience of 62,000). A testimonial from the Head of Substance Misuse Policy and Finance, Welsh Government, confirms that the research findings have been “reflected in our new Substance Misuse delivery plan 2020-22” and “disseminated to partners to ensure they are … taking on board the recommendations” (S7). Additionally, the Head of Substance Misuse at Public Health Wales reiterates that “ this work also informed the Welsh Government Substance Misuse Delivery Plan 2019-22” (S4).
USW research helped drinkers cope with Minimum Pricing for Alcohol (MPA)
Research investigating the potential unintended consequences of introducing MPA in Wales (2018-19) highlighted a general lack of awareness of the legislation and identified widespread concern that some drinkers might engage in harmful behaviours to facilitate their continued consumption of alcohol. To help services prepare for these potential negative consequences, the findings were shared in a series of workshops held across Wales (December 2019 to February 2020). The events were facilitated by USW researchers and attended by 112 representatives from: third-sector organisations, NHS, licensing, trading standards, police, and Area Planning Boards. A post-event feedback survey, completed by 45% of attendees (n=50), showed significant improvements in awareness. Furthermore, nearly three-quarters of respondents indicated that they would now ‘do something new’ to help service users cope with MPA (S8). The Substance Misuse Development Officer for the Huggard (a charity set up in 1998 to provide practical help to people sleeping rough on the streets of Cardiff) attended the workshop in December 2019 and confirmed that it had enabled him to tailor interventions with clients to support them and that “ as a result” an increase in unplanned, life-threatening alcohol withdrawal was largely avoided (S9). On 17/02/2020 findings from the study were shared by USW researchers on ITV's Sharp End current affairs show ( average audience of 29,000), which generated 1870 impressions and 138 engagements on Twitter.
5. Sources to corroborate the impact
S1 Welsh Government harm reduction leaflet
S2 Public Health Wales harm reduction leaflet
S3 Testimonial from the Head of Substance Misuse Policy and Finance, Welsh Government on the impact of overdose research
S4 Testimonial from Head of Substance Misuse, Public Health Wales
S5 Testimonial from Campaigns and Communications Lead, Barod
S6 Testimonial from Harm Reduction Worker, Gwent Drug and Alcohol Service
S7 Testimonial from Head of Substance Misuse Policy and Finance, Welsh Government on the impact of prescription drug misuse research
S8 Post-event feedback survey results
S9 Testimonial from Substance Misuse Development Officer for the Huggard charity
Additional contextual information
Grant funding
Grant number | Value of grant |
---|---|
C68/2009/10 | £49,750 |
20-07-84-54 | £21,880 |
N/A | £10,000 |
C086/2018/2019 | £60,823 |