Can Tele-healthcare Interventions Prevent Drug Related Deaths?
Authors: Catriona Matheson,Professor in Substance Use, University of Stirling, Simon Rayner, Aberdeen City Alcohol and Drug Partnership, Kirsten Horsburgh, Drug Death Prevention Lead, Scottish Drugs Forum, Tara Shivaji, Public Health Consultant, NHS Grampian, Joe Schofield, Coordinator, Drugs Research Network Scotland
The level of drug related deaths (DRD) across the UK has reached crisis point. With 1187 deaths in Scotland1and 4359 in England and Wales2(a rise of 27% and 16% respectively on the previous year), innovative solutions are being sought. The last decade has seen considerable investment and interest in tele-healthcare solutions to supporting independent living for the frail, elderly and those with long term conditions such as diabetes and epilepsy. Tele-healthcare is defined by the World Health Organisation as:
“Telehealth involves the use of telecommunications and virtual technology to deliver health care outside of traditional health-care facilities”3
No bespoke product is yet commercially available in the UK for the detection of overdose and prevention of DRD. However there are a number of products with potential for the target population of people who use drugs. Technology to monitor vital signs is an obvious application to consider. All opiates supress respiration. In an overdose the rate of breathing falls such that there is insufficient oxygen in the blood to supply vital organs and the heart stops. This effect will be accentuated if there has been ingestion of other sedatives such as benzodiazepines or alcohol. There are a few devices which are being tested and explored for DRD prevention, aiming at vital sign monitoring. The technologies involved include:
- Movement/accelerometers for gross motor movement;
- Pulse oximetry which measures blood oxygen levels;
- Heart rate monitors (Electrocardiogram and Reflective Photoplethysmography);
- Electrodermal activity which measure skin temperature and sweating;
- Respiration movement– using either sonar or radar;
- Heart rate monitors.
These technologies are included in devices which can be worn as chest straps/arm monitors/wristband; finger sensors (blood oxygen) and patches that measure ECG and respiration.
What are the Challenges to Using this Technology?
There are obvious challenges to detecting an imminent overdose situation. The greatest challenge to overcome is to have a sufficiently quick response to an emergency situation. In residential facilities including police custody suites, hostels or even prisons this should be possible if a device has an alarm function that is linked to a monitor. However the increasing number of ageing people who use drugs and live alone presents a challenge.4 Linkage to a naloxone response network is one technological and community response (with the caveat that this requires considerable coverage, ‘buy in’ and training for participants). Another response being considered is the automatic administration of a dose of naloxone from a pellet attached to the body, in response to detection of reduced respiration rate. A proof of concept model has been developed in the US but is still in early stages of testing.5
There may also be potential for using technology in a more general health monitoring approach that could prevent overdose situations arising. For example the use of smartphone apps and monitors for high risk groups such as those with respiratory disease and circulatory disease which are associated with high mortality in people who use drugs.6 There are several applications for management of COPD and cardiovascular conditions that could be applied now to this group. Pulse oximetry monitoring may have some application in this high risk group to raise awareness of baseline oxygen levels as a preventative measure.
In Scotland there has been a rise in cases in which benzodiazepines and gabapentinoids are implicated in DRD (often alongside opioids)1. This may alter the physiological manifestation and time between drug(s) being ingested and overdose effect. With this in mind baseline monitoring of physiological parameters such as heart rate, blood oxygen saturation, skin temperature, EDA, respiration rate and movement are crucial in relation to the type and combinations of drugs used to understand how different combinations physiologically manifest.
A further challenge is the acceptability of any potential devices to the target population. Consultation with people with lived experience indicated some people may be wary about wearing any monitors in case of data sharing or police tracking. Involvement of people with lived experience in trials may allay such concerns.
Unfortunately, the big technology companies who operate in the wearables and telehealth sector (Fitbit, Amazon, Google, Apple etc) have not yet shown particular interest in this application of technology. Development thus far has been through small start up and university spin-off companies but the time to secure the required approvals and licenses for new medical devices may be a barrier for bespoke DRD tele-healthcare devices in the UK. With this in mind, using existing technologies provides an expedient opportunity if we are to harness the benefits of this technology in our current DRD crisis.
The Current Situation
To sum up the current state of play with the application of tele-healthcare in DRD prevention. The types of tele-healthcare currently being tested or considered in our target population are:
- Wearables –wristbands, patches, tags for DRD prevention;
- Room monitors: smartphone apps, monitors for DRD prevention;
- Alert Buttons for emergency response to DRD;
- Smartphone apps for naloxone network emergency response
- Smartphone apps for information on overdose prevention;
- Smart phone apps for recovery support.
Testing and implementing technological contributions to a reduction in DRD in a timely and effective manner will need buy-in from professionals working with people as well as policy makers.6
The Drugs Research Network Scotland (DRNS) are coordinating the development and testing of tele-healthcare via a group of interested, non-commercial stakeholders including academics, service providers, homeless services and the Police. If you are involved or interested in testing or developing any such technology please get in touch (admin@DRNS.ac.uk).
- NRS (2019). National Records of Scotland. Drug Related Deaths in Scotland in 2018. Edinburgh. Available at: https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/drug-related-deaths-in-scotland/2018
- ONS (2019) Office for national Statistics. Deaths due to Drug Poisoning in England and Wales: 2018 Registrations. At https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2018registrations
- Matheson C., Hamilton E., Wallace J. Liddell D. (2018) Exploring the health and social care needs of older people with a drug problem, Drugs: Education, Prevention and Policy, DOI: 10.1080/09687637.2018.1490390.
- Gao, L., Robertson, J. R. Bird, S. M., (2019) Non drug-related and opioid-specific causes of 3262 deaths in Scotland’s methadone-prescription clients, 2009-2015. Drug and Alcohol Dependence; 197, 262-270.
- European Parliamentary Research Service (2017) Technological innovation strategies in substance use disorders. Scientific Foresight Unit (STOA) Report to the European Parliament.