A different way

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Stopping the rise of drug-related deaths needs an innovative approach – such as paying drug users to stop using, says Neil McKeganey.

The recent report of record number of deaths amongst drug users in Scotland (see news, page 4) is likely to lead to a fundamental review of how we are tackling Scotland’s drugs problem. At the present time Scotland spends well in excess of £100m a year tackling a drugs problem that has been estimated to cost the country £3.5bn a year. The fact that Scotland has seen a persistent rise in drug deaths over the last ten years shows however that in services are failing to meet the needs of drug users, especially with regard to identifying those at greatest risk of dying.

The growing proportion of deaths linked to methadone presents an additional serious concern. While a proportion of deaths involve individuals who have purchased their methadone illegally, in other instances the death has occurred in an individual prescribed the medication by their doctor. These deaths give rise to questions about why prescribing services had been unable to identify the individuals as being at heightened risk and whether services were aware of the other drugs the individual had been using at the time they were being prescribed methadone.

Within the context of the steadily rising number of drug-related deaths it is inevitable that these questions will be asked and attention will be given as to whether in Scotland we have the right services working in the right way or whether we need a fundamental reconfiguration of services. One initiative that should be given attention is that of encouraging drug users to cease or reduce their drug use by providing a financial incentive for them to do so.

The practice of rewarding individuals for positive changes in their health-related behaviour is by no means new. Termed ‘contingency management’, this practice has been positively evaluated by the UK National Institute for Health and Clinical Excellence (NICE). One example of contingency management is that of providing a financial incentive to pregnant women as a way of encouraging them to stop smoking.

The opportunities for using contingency management, however, go far beyond the use of financial inducement by existing services. For example, we could substantially expand contingency management initiatives by redirecting around half of our current drug treatment budget towards the provision of such financial incentives to drug users themselves. Any such scheme would need to be coupled with a programme of drug testing to ensure that participants were indeed ceasing their drug use.

The immediate response to such a suggestion might be that it simply would not work because the individ­uals involved are ‘addicted’. In fact, however, research undertaken by Professor Carl Hart in the US showed that individuals who were dependent upon a variety of drugs were more inclined to accept the offer of a small financial sum than the provision of the drug they had become addicted to. Hart’s research demonstrated that individuals who are addicted can still exercise some choice if they are offered attractive alternatives to the drugs they have become dependent upon.

‘The practice of rewarding individuals
for positive changes in their health-
related behaviour is nothing new.’

Redirecting a large part of the current drug treatment budget in this way would be controversial. Many of those who are currently running drug treatment services might object that this would substantially reduce their budgets and the effectiveness of their services. However, we do not actually know whether the effectiveness of services would reduce in this way if contingency management approaches were applied on a much larger scale. Indeed it may well be that drug users who are offered a financial incentive would be willing to initiate much greater changes in their drug using behaviours than is occurring at present.

While not all drug users might be interested in participating in such a scheme, there may be enough who would volunteer for such a programme to enable services to start to work in a different way with their clients. Instead of directing effort and energy to encouraging drug users to reduce their drug consumption, services could direct much more effort towards rehabilitative support – enabling drug users to learn skills that might increase their likelihood of securing employment once they have moved on from engaging with drug treatment services. Equally, by reducing actual levels of concurrent drug use, the wider effectiveness of treatment services might be enhanced.

Paying drug users money to remain drug free may be rejected on the basis that it involves coercing individuals who are hugely vulnerable. If such an approach were seen to work (as it has in other areas of health-related behaviour change) then it may be that the ends justify the means.

What is certainly the case however is that faced with the rising number of drug deaths in Scotland and England we should be prepared to try alternatives in both the way services are working and in the types of services we are providing. Simply carrying on doing what we have been doing for years may keep many drug workers in employment but it may not actually meet the needs of their clients.

Prof Neil McKeganey is director of the Centre for Substance Use Research, Glasgow