Policy responses to drug-related deaths: Using a Social Determinants of Health framework analysis to inform policy
Background: Scotland has the highest rate of drug-related deaths (DRD) in Europe. Deaths cluster in areas of deprivation and are contextualised by high levels of social and health inequalities. Policy responses focus on technocratic and clinical solutions to address the substances implicated in deaths and modify risk behaviours. Broader social, structural and systemic factors are largely unaddressed.
Methods: A ‘social autopsy’ methodology traced the lived experience of young people and their interactions with services and state agencies prior to their drug-related death. A social determinants of health (SDH) conceptual framework (Dahlgren and Whitehead, 1991) informed a thematic analysis of all available data (both paper and electronic) from health, social care, police, and post-mortem records for a cohort of young drug-related deaths in a Scottish region (n=22).
Results: The study found a high level of mental and physical ill health among the young people and that they had experienced a series of social and structural challenges under each of the SDH categories. For example, in the category ‘socioeconomic, cultural, and environmental conditions’ many of the young people had experienced school suspensions & expulsions, un(der)employment, financial stress, and precarious housing /homelessness. They had few supportive ‘Social & Community Networks’ and experienced high levels of parental separation and state/kinship care; familial mental illness and alcohol/drug problems; and experiences of violence. At the ‘Individual lifestyle’ level, the young people had engaged in early, regular, and high risk polydrug use; and episodes of self-harm, suicide ideation and non-fatal overdoses. ‘Healthcare services’ data indicated a dysfunctional referral system; an incapacity to address co-occurring mental health and substance use; a focus on behavioural change and abstinence recovery; and a system of care that was hard to reach and quick to discharge for non-attendance and compliance. In contrast, there was frequent contact with criminal justice services and a high level of imprisonment.
Conclusions: Using a Social Determinants of Health framework provides an informative analysis that highlights the complex unmet needs that underpin drug-related deaths. These findings have implications for policy and workforce development as broader social and health care needs and systemic barriers to services need to be addressed.
