Peer research with populations of people who use street tablets in areas over-represented by drug-related harms in the UK: a case study

Abstract

Background

Engagement with the illicit street tablet market in Middlesbrough, North-East England, has been shown to impact treatment engagement, and the area appears to have a unique z-drug market, potentially not observed in other areas. When combined with high levels of injecting opioid and polydrug usage, this context may account for the steep increases in drug-related deaths reported locally. However, little is known about the volume, dosage, frequency, drivers, and dislikes of street tablet usage from the perspective of those who use drugs. In areas of high drug-related harm, local drug market intelligence is crucial to co-developing acceptable harm reduction and treatment offers that are attractive to those most at risk from a drug-related death.

Methods

This project used a peer research model. The peer researcher engaged a group of high-risk individuals (traditionally underserved by standard research processes) in a survey regarding street tablet usage, drivers, dislikes, and desired treatment options.

Results

A small but notable sample of 38 individuals engaged with the survey, the majority of whom (60%) were not involved in drug treatment, with a high proportion of street homelessness (38%). Street tablets were perceived as a multifunctional remedy to achieve a range of perceived mental and physical effects or for pragmatic purposes, such as cost. Most (89% and 87%, respectively) respondents [with current or historical use] (n = 38) reported extensive illicit pregabalin and zopiclone usage. When only looking at those currently using street tablets (n = 32), 100% were using zopiclone, with nearly all reporting this in combination with pregabalin (n = 31, 96%). Reported drivers of tablet usage included attempts to self-medicate due to untreated mental health conditions. Self-dosage rates were substantially higher than the recommended therapeutic dose rates.

Conclusions

Collaborating with the peer workforce in areas of high need relating to drug harms was an acceptable way of engaging some of the most vulnerable individuals at risk from mortality and morbidity in the research process. Our data highlights this population’s complex, high-dose, polydrug use. There was an appetite to develop harm reduction interventions for illicit street tablet usage amongst the population sampled. Further work should develop tailored harm reduction advice for complex issues such as street tablets and opioid co-use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-025-01273-1.

Background

Patterns of drug usage and harms differ throughout the UK, with concentrated clustering of socioeconomic disadvantage alongside high levels of drug-related deaths, drug-related harms, crime, and overall deprivation [1–3]. Middlesbrough, a post-industrial town in Teesside, North-East England, is such an area. Intersections of deprivation and disadvantage collide, having more than three times the rate of drug-related deaths than London [4]. No single causal explanation can likely account for these disparities. Strict austerity measures, disinvestment in treatment and housing services, scarce employment opportunities, above-average rates of social care intervention, domestic violence, high crime, and poor mental health outcomes in Middlesbrough exist, likely having both additive and synergistic impacts on increased levels of drug and alcohol use overall [2, 3, 5–10].

Street tablets are diverted prescription tablets used without medical advice, or those obtained through non-medical routes, often from illicit manufacturing processes. Street tablet usage, specifically street benzodiazepines is an increasing problem in the UK, with street benzodiazepines implicated in over 70% of drug-related deaths in Scotland [11]. Street drug usage elevates the risk of adverse outcomes, with risk increasing substantially where multiple substances are consumed, e.g. polydrug use [12].

Using street tablets can increase poly-drug use toxicity [13, 14], which increases the risk of a subsequent overdose, although the exact mechanisms of this are not yet fully understood [15]. Work in Scotland is underway to establish patterns and risks of polydrug use behaviour influencing mortality outcomes. For example, Ciesluk et al. identified a high prevalence of etizolam and gabapentinoids in driving drug-related death outcomes, with key populations accounting for increases within this group, e.g. older women [16]. Benzodiazepines, zopiclone and pregabalin have all been attributed to increased drug-related deaths when co-used with prescribed opioids [17]. In the North-East of England, high levels of opioid usage combined with the prevalence of an illicit street tablet market provide a deadly risk environment, due to interactions between these depressant drugs, which can significantly increase the risk of a drug-related death [18, 19].

Understanding street tablet use is of critical importance to the UK. Particularly from within the context of more complex behaviours such as the co-use of benzodiazepines/z-drugs with opioids (prescribed or street), including how co-use relates to the risk of drug-related death [20]. For example, research conducted in Bristol, Glasgow, and Teesside has identified motivations and patterns of co-use and harm reduction strategies used to minimise overdose risk [21]. These efforts are hindered where limited local drug market information exists to draw upon. Understanding the nature and context of local drug markets to promote harm reduction opportunities can prevent further mortality [22].

Zopiclone, a benzodiazepine-like hypnotic agent, works by modulating benzodiazepine receptors. A recent study on zopiclone usage and drug-related death found that only 8% of fatalities involved only zopiclone, with no additional substances involved [23]. Focusing on geographies such as Middlesbrough in Teesside, which features a unique z-drug market compared to other areas of the UK (e.g. Bristol or Glasgow) [24], alongside high levels of polydrug and opioid co-use, is crucial. These endeavours enhance our understanding of the relationship between the use of these street tablets and increased drug-related mortality. The presence of synthetic opioids in the UK illicit drug market has reprioritised efforts to promote harm reduction within a context of already worsening outcomes relating to drug-related deaths [25, 26].

Despite a marked prevalence of street tablets on the local drug market in Teesside [19], combined with high populations of people who use drugs, limited information is known about street tablet drivers and dislikes [27]. Overlaying this gap in knowledge, representation in the research process can be poor, particularly by those who are not engaged in drug treatment such as an opioid agonist treatment (OAT) [i.e. methadone, buprenorphine or buivdal]. Often individuals are considered as ‘hard to reach’, whereas in practice they are often infrequently approached [28] and/or the research methodology (particularly large-scale studies) can exclude people by design, e.g. an internet survey for individuals who are street homeless, or are recruited from within drug treatment centres. This is problematic as individuals not in treatment are the most at risk of a drug-related death, often engaged in complex polydrug use and experiencing multiple vulnerabilities [29]. Utilising participatory research designs to include underserved research populations is a method of promoting social justice for some of the most marginalised people in our communities. This ensures that interventions which are developed are based on the perspective of all people who use drugs, and not just those regularly engaging with treatment services.

The principles of Asset-Based Community Development [30] suggest that areas should harness the power of their assets rather than their deficits, whilst addressing challenges (i.e. focus on the strengths which exist as opposed to problems that they face). Within Teesside, there exists a rich infrastructure of peer, voluntary, community sector organisations aiming collectively to address and respond to shared priorities such as problem drug and alcohol use [31, 32].

Harnessing the power of the peer and lived experience community to support knowledge generation on behavioural trends in areas of high need is a critical development for social justice and health equity. These efforts can increase the representation of individuals who would not usually engage with the research process, and may be a way to build a picture of local drug markets to mitigate against drug-related harms. Peer research models have been used successfully for research concerning a plethora of health conditions associated with drug use behaviours, such as HCV/HIV [33, 34]. The merits of collaborating with the peer workforce have been cited as better respect and engagement with hidden populations of people who use drugs, with better levels of engagement facilitated by trust [33, 34].

This study involved a peer engagement model facilitated by coproduction to establish the community perspective in a high-risk area regarding street tablet usage. This involved an individual with lived experience of complex polydrug use, before entering abstinence and recovery (who we refer to as the peer researcher forthwith), leading on engaging and collecting data. Data on preference, usage, drivers and dislikes of street tablet use, combined with perceived interventions and harm reduction solutions, were sought. The aim was to generate a current picture of the local drug market regarding street table usage.

Methods

This paper reports survey findings from the Targeting Health Needs project funded by National Institute of Health and Care Research [NIHR] 2022/23 Clinical Research Network (ref: 17969707) which aimed to bring together stakeholders from across the local system (academics, lived experience, public health, the police) to co-produce and conduct public health surveillance on street tablet usage in Teesside.

Site and recruitment: Data was collected face to face in Middlesbrough town centre and the waiting room of a local drug service in Hartlepool (both located in the North-East of England). The survey link was also sent to local drug treatment services in Teesside (non-NHS) to complete with interested patients, although there was poor engagement in this recruitment method. In Middlesbrough, an active outreach model of recruitment was conducted in known areas with high street homelessness, driven by local knowledge of popular geographical locations where people who use street tablets may congregate. This model involved the peer researcher attending these sites and asking participants if they would like to take part in the research (as opposed to waiting for this population to attend the usual services, in which they might attend, e.g. needle and syringe provision services in the locality). Recruitment and data collection took place during the day, with initial rapport-building techniques being used to support the population to feel at ease with the peer researcher. In Hartlepool, an active outreach model was not used to recruit participants, and participants were opportunistically sampled in a treatment centre. Inclusion criteria were anyone with current or previous experience of street tablet usage and able to provide consent.

Survey design and measures

The survey was co-produced by academics, practitioners and the peer researcher, and the main project team (HP, HM, GT, PD) all took part in the conceptualisation of the research idea and the co-production of the survey. Due to time and funding restraints, the survey was designed to be quick and simple to safeguard against fatigue. The items sought to establish demographics, current daily street tablets consumed, the perceived dosage (self-reported rather than obtained via drug testing), frequency of use, drivers and dislikes and suggested interventions (help) for street tablets. The drivers, dislikes, and interventions were a drop-down list with an option for ‘other’ and a free text box so that participants could add responses not explicitly mentioned. One item within the ‘suggested help’ section was also included to distinguish harm reduction-based treatment goals (i.e. support just to reduce the harms of street tablets without an expectation to reduce), recovery-based treatment goals (i.e. support just to reduce the harms of street tablets with an expectation to reduce), and populations of individuals requiring no support for street tablets. This measure was suggested for inclusion within the survey by the peer researcher to distinguish between these complementary but distinct treatment goals.

The range of drivers, dislikes, and interventions was co-produced as follows: During the research management meetings of the overall project, there was time dedicated to developing the research questions as a team for this survey. The first part of this process was a brainstorming of drivers of usage of street tablets and dislikes generated by the peer researcher, practitioners and academics. Time was then allocated so that each team member could spend time independently reflecting on the content and language of the questionnaire. This ensured that positionality had been critically addressed in this phase of research development. Once the survey was uploaded to Bristol Online’s secure server, we piloted the survey for ease of use and language with the peer researcher. It was made clear to participants that the suggested interventions were not an exhaustive list, and individuals could suggest their own via the ‘other’ box using free text. A copy of the questionnaire is attached in the supplementary material.

Data collection procedure

The peer research had lived experience of complex polydrug use before entering abstinence and recovery. The peer researcher was a team member on the original funding application, co-produced the questionnaire and led on the data collection for this survey with support from the rest of the team. The peer researcher had received research methods training and had recently co-facilitated interviews with another researcher (HP) via another funded project, in addition to a BSc-level research methods module in a higher education institute.

The survey was administered face-to-face via entry onto an online survey electronically, which took approximately 8 min to complete. Consent was taken via the online form, and was necessary to progress to the survey questions. The peer researcher completed the survey with the participants and entered the data into the online form for them. The peer supported both the analysis of the data and the local dissemination of this work at a public health event in October 2024.

Analysis

Due to the low sample size, descriptive statistical analysis was used looking at percentage changes and means using Microsoft Excel and the Bristol Online analysis function.

Ethics

Ethical approval was obtained from Teesside University, School of Social Sciences, Humanities and Law, Research Ethics Subcommittee (Ref: ). Participants could enter a prize draw for the opportunity to win one of five £20 vouchers for their time.

Results

Demographics

The total number of respondents was 38 individuals, of whom 68% (n = 26) were male, 28.9% female and 2.6% other. All participants reported either current (84%) or historical (16%) street tablet use. Over a third, 37% (n = 14) of respondents were street homeless. Of those who were not homeless, 31% (n = 12) who lived in their own home, rented from social housing providers or lived in supported accommodation, just under a quarter [24% (n = 9)], lived with friends or family 55% (n = 21). The rest of the sample were either street homeless or transiently housed in hostels.

Self-reported drug treatment participation was lower (40%) than national averages around treatment engagement for opioid use (e.g. approximately 48% of individuals were not engaged with treatment, a number which has risen from 40.8% in 2014/15 [35]. Drug treatment programmes included methadone (45%) and buprenorphine (11%), and a free text box for ‘other’ (3%) treatments, which participants reported as ‘antidepressants’, ‘camprasate’.

Of those currently using street tablets (n = 32), in addition to street tablet usage, all participants report polydrug use of at least one additional substance. This includes the use of crack (94%), opioids (53%), alcohol (44%), cannabis (44%) and cocaine (28%).

Street tablet usage

No significance testing was conducted due to the descriptive nature of the study; however, most (89% and 87%, respectively) respondents reported extensive illicit pregabalin and zopiclone usage (Table 1). When only looking at those currently using street tablets (n = 32), all were using zopiclone, with nearly all reporting this in combination with pregabalin (n = 31, 96%). Our data highlights complex, high-dose, polydrug use of this population, with perceived self-dosage rates being substantially higher than recommended therapeutic dose rates listed in the British National Formulary [BNF] [36]. For example, self-reported dosage rates for alprazolam were 10X the recommended dose (at the lower end of the dose range [see supplementary material for BNF, which indicates the approved dosage levels and licensed usage for the prescription of these items]).

Table 1.

Type, volumes, strength cost and dose range of street tablets reported in the survey

Substance	% of respondents	Volume per day (range [mean])	Strength (mode)	Cost per tablet (range [mode])	Dose range (mg per day [range min-max])
Zopiclone	33 (87%)	1–20 (9.65)	7.5 mg	Free- £1 (£0.50p)	40 mg- 300 mg
Pregabalin	34 (89%)	1–12 (4.66)	300 mg	£0.50p-£2(£2)	350 mg − 3000 mg
Other Gabapentinoids	1 (3%)	2–10 (4.66)	n/a	£0.50p-£2(£2)	10 mg- 500 mg
Alprazolam	9 (24%)	1–5 (0.6)	5 mg	£1-£2 (£2)	10 mg-30 mg
Diazepam	12 (32%)	4–30 (3.05)	10 mg	Free-£1(£1)	10 mg-300 mg
Temazepam	1 (3%)	n/a (10)	10 mg	n/a (£1)	100 mg

Please note responses were not mandatory and therefore numbers may not equal 100%

Drivers and dislikes of street tablet usage

Drivers of street tablet usage

Participants identified multiple drivers of street tablet usage, street tablets being used as a multifunctional remedy to achieve a range of perceived mental and physical effects or for pragmatic purposes such as cost (Table 2). The majority (94%) of individuals reported self-medicating with street tablets for mental health conditions. Drivers for the use of street tablets included pragmatic approaches for addressing health needs, such as addressing physical pain (82%), poor mental health (95%), and aiding sleep (82%). Other drivers were euphoric or provided a sense of well-being, such as feeling high, confident, numbed, or changing reality.

Table 2.

Drivers and dislikes

Drivers of street tablet use	Number of responses	% of responses
Self-medication for mental health problems	36	94.70%
To feel high	33	86.80%
To stop physical pain	31	81.60%
Difficulties accessing prescribed medication	31	81.60%
I like the feeling	31	81.60%
To sleep	31	81.60%
To stop withdrawal from street tablets	30	78.90%
They are long-lasting	29	76.30%
They are cheaper than other drugs or alcohol	28	73.70%
To stop withdrawal from other drugs	28	73.70%
Suppressing harmful side effects associated with stimulant use	27	71.10%
To enhance the opioid effects	23	60.50%
To enhance the poor quality of opioids	23	60.50%
Other (‘confidence and everything’, ‘numbing’)	4	10.50%
Dislikes of street tablet use	Number of responses	% of responses
Feeling addicted/ unable to cease using them	32	84.20%
Anxiety around risk of overdose	31	81.60%
I don’t know what quality is like	30	78.90%
Memory loss	30	78.90%
Problems with accessing a regular supply	29	76.30%
Sedation	28	73.70%
Cost	26	68.40%
Nothing	4	10.50%
Other (weight gain)	1	2.60%

* Please note responses were not mandatory and therefore numbers may not equal 100%

Dislikes of street tablet usage

A small proportion of people (11%) responded with no dislikes. Concerns with being addicted to (84%) or experiencing an overdose (81%) from street tablets were the main concerns cited by the participants. Quality (79%) and access (76%) were prevalent issues that individuals disliked about street tablets. These data highlighted that worries about overdose were pertinent, and individuals were concerned about potential contaminants in their drug supply. The data highlights a complex myriad of potential risk factors (for example, drivers for street tablet usage because they are cheap, alongside being worried about sedation, memory loss and problematic usage) for people who use street tablets.

Suggested interventions

Data highlights an appetite for both support to reduce usage, and support to reduce the harms of (without an expectation of reduction of) street tablets (Table 3). Approximately four-fifths identified that they would like an intervention for street tablet usage. A range of individual (anxiety, and aid to sleep) and community level interventions were recommended (access to safe prescribed medication [both a reducing script and maintenance therapy], drug safety checking, provision of Flumazenil), and there was a free text option for participants to state their ideas for desired interventions, although this was not utilised.

Table 3.

Solutions and desired interventions

Solutions and desired help	Number of responses	% of responses
Yes- I would like some support to reduce the harms of, and stop using street tablets	18	48%
Yes- I would like some support to reduce the harms of street tablet usage	12	32%
No- I would not like any support with my street tablet usage	8	21%
What would you like the help to look like?	Number of responses	% of responses
Support for anxiety	34	90%
Support for sleep	32	84%
Drug safety checking	29	76%
Prescription of safe prescription tablets with aim to reduce	26	68%
Prescription of safe prescription tablets with no aim to reduce (maintenance therapy)	20	53%
Availability of Flumazenil (a drug that reverses sedative effects of benzodiazepines)	19	50%
Other (prescription but not currently taking them)

Please note responses were not mandatory and therefore numbers may not equal 100%

Discussion

Findings highlight that harnessing the power of the lived experience community via peer research methodologies can be an acceptable way to engage a highly marginalised and vulnerable population in the research process. Many of the participants reported being out of drug treatment systems (such as OAT) [approximately 60%] (and therefore at elevated risk of a drug-related death, street homeless or experiencing insecure housing, and reported experiencing multiple physical and psychological issues such as pain or mental health problems. Although a relatively small population, this is a notable sample (i.e. representative of a high-risk group of individuals at increased risk of severe health outcomes). In relative terms, the survey was successful in reaching a large proportion (77%, n = 14) of the total population of individuals reported as street homeless by Middlesbrough Council in 2023 (n = 18) [37], a number which has risen by 200% compared to the previous year. We tentatively suggest these individuals may be unlikely to engage with standard surveys and data collection mechanisms such as the treatment outcome profile (a data return completed within drug treatment services in England), due to being out of treatment and facing multiple layers of disadvantage.

Most (89% and 87%, respectively) respondents reported extensive illicit pregabalin and zopiclone usage, predominantly for untreated mental health problems (95%). When only looking at those currently using street tablets (n = 32), 100% of respondents were taking zopiclone, with nearly all reporting this in combination with pregabalin (n = 31, 96%). The zopiclone market is a unique feature of the local drug market in Teesside [38], which was not observed in other areas of the UK (Glasgow or Bristol) in a recent multisite study [24], warranting further exploration in terms of the unique risk factors of zopiclone and its contribution to worsening drug-related deaths. Individuals reported taking dosages of street tablets (in combination with other street drugs such as crack, cocaine, and cannabis) which far surpassed the approved clinical dosages of these substances (see supplementary material for the BNF). Crack usage was particularly high (94%), and nearly all those currently using street tablets were using crack, mirroring an overall increase of crack usage throughout the UK [39] (although we are unable to tell if this is via injection or inhalation in our data). There was variation within the drivers for and dosages of street tablets, which suggests different subpopulations of individuals using street tablets for different motivations and desired outcomes, which should be explored with further research.

This study also identifies that illicit street tablets are perceived by a proportion of people who use drugs to be a multifunctional remedy for addressing a range of concerns. These drivers could be both pragmatic (such as being cheap) or provide an embodied experience, such as numbing or perceived relief from poor mental health or physical pain. The drivers and dislikes suggest people may feel conflicted about the benefits and harms of street tablet usage, i.e. impacts on sleep were both a driver and a dislike for some individuals. There is also a concern that this population are concerned about experiencing an adverse outcome such as overdose. The additional needs described by this group (e.g. pain) may facilitate further street tablet consumption, and therefore expose a role for the provision of adjunct therapies alongside an effective drug treatment offer, for example, for sleep. Such provision would reflect a contemporary approach to drug treatment policy which extends beyond drug use, taking a holistic perspective to health [40]. Efforts which are being addressed in other areas of the UK [41].

The data highlights an appetite for the provision of new street tablet interventions (at least those not currently on offer in Teesside). Excluding a standard offer of support for anxiety or sleep via GP or drug treatment services available for this population, the desired interventions suggested were locally unavailable or operationally rare in practice. For example, though theoretically possible, safe prescription of benzodiazepine or z-drugs is rare, particularly where OAT is being co-prescribed due to worries about overdose risk [42]. This would prevent the majority of individuals within the sample from accessing a prescription, promoting reliance on an unregulated and toxic drug supply. Of note, approximately 20% of individuals did not want to engage with any treatment offer around street tablets, and further qualitative research should address understanding this sub-population. For example, devising how motivations for tablet usage or co-use can impact subsequent behavioural factors influencing further harm production.

This survey has corroborated previous research [38], which identifies high levels of complex polydrug use (including street tablet use) within a location with disproportionately high drug-related deaths within the UK [3]. This paper extends that knowledge to identify levels of street tablet usage, including volumes, dosages, drivers, dislikes and suggested interventions. Our data suggests all individuals sampled who were currently using street tablets (n = 32) were engaged in polydrug use (i.e. taking more illicit substances than just street tablets). This data should be taken into account for sampling efforts where clusters of near-fatal overdoses have occurred to ensure a wide range of substances are sampled from a scene. This approach would reflect a harm reduction approach to policing, which has been recommended by experts in anticipation of a predicted ‘third wave’ of synthetic opioids in the UK [26].

Untreated mental health issues were the main facilitator of street tablet usage, which corroborates emerging findings relating to motivations for street tablet and opioid co-use [43]. Matheson and colleagues found that psychiatric comorbidities are prevalent in individuals who use benzodiazepines upon entry to treatment, highlighting different clinical profiles of people who use these substances [44, 45]. Indeed, percentages of individuals reporting mental health and substance use needs in our sample were far higher than those reported by individuals who were in treatment in Middlesbrough via National Statistics about Drug and Alcohol Misuse Treatment (NDTMS) in 2022/23 (e.g. 95% vs. 66%, respectively) [46]. This highlights the importance of engaging directly with individuals who self-report they are not in treatment, who may have higher barriers to engagement with traditional services and may require tailored engagement efforts.

Illicit z-drugs, as opposed to benzodiazepines, were the main street tablet reported in this high-risk sample in Teesside, and evidence suggests poor mental health could be an underlying variable in the relationship between fatal outcomes and street tablet usage [23], warranting further research. Recent work ongoing within the UK has identified that z-drug usage as a subset of wider co-use behaviour of opioids and benzodiazepines can be influenced by poor mental health, for example via uncontrolled consumption patterns (see Family et al.l [24] or motivations such as ‘oblivion seeking’ (see Vojt et al. [47]). Hockenhull (2021) suggest that z-drugs may be preferable over benzodiazepines by people using tablets, due to not causing amnesia [48]. In our study, 7% (n = 3) of the study population reporting only zopiclone (and/or pregabalin use) still reported cognitive impacts such as memory loss. However, it is difficult to assess the impacts of a singular substance on cognitive function in real-world samples with high levels of polydrug use due to the impact of drug interactions and behavioural factors affecting this, also known as the ‘lay pharmacology’, i.e. how and when a substance is taken. Further work should investigate how cognitive factors may influence overdose risk [44] in both laboratory and real-life settings. Whilst isolating impacts of singular substances is important in research, best practice advice from the European Union Drugs Agency (EUDA) is that harm reduction advice and support for individuals using drugs should extend beyond individual substances, and look at risky behaviours underpinning drug use [49].

Implications for practice and policy

The findings from this study have reinforced a mismatch between desired interventions available for street tablets, particularly for a population of people with complex polydrug use, and the offer currently available in the UK. Access to a safe supply of drugs and services such as drug checking was seen as desirable, yet they are unavailable locally in Teesside. Generic UK-wide services such as WEDINOS (Welsh [50] is available to these individuals, however, this would require internet access and money for postage to submit a sample, which inherently excludes homeless individuals from participating. The low treatment engagement observed in this sample may be reflective of the lack of acceptable and/ or engaging treatment options and the high levels of complex polydrug use, but further qualitative work should explore this more comprehensively. Until treatment options are optimised, low levels of engagement in treatment for high-risk individuals may be pervasive across the UK. In the period gearing up towards the increased prevalence of synthetic opioids [26], the UK must capitalise on all avenues to protect the most vulnerable populations of people who use drugs [25].

A recent focus on street tablets such as z-drugs and efforts to understand their role in influencing mortality outcomes suggests an opportune moment to optimise current UK treatment policy more effectively for complexities such as poly-drug use. Current treatment policy has been criticised for not being properly equipped to deal with polydrug use, e.g. with existing harm reduction advice and pharmacological support currently geared towards addictions to singular substances [51]. This is a gap outlined by EUDA throughout Europe, and not just within the UK [49].

Using a peer research model was an acceptable method to engage some of the most marginalised individuals at risk of premature mortality and morbidity in the research process. Generating population-derived drivers, interventions and harm reduction preferences from high-risk and marginalised populations to inform targeting interventions represents best practice in addictions research [52]. The principles of the ‘nothing about us without us’ movement solidifies a key role for the lived experience of both people who have previously and are currently using drugs to influence drug treatment policies [53]. We posit that there are key missed opportunities to harness the lived experience of these individuals whilst collecting intelligence about local drug markets. Small targeted engagement efforts in local high-need areas can be vital to addressing unequally worsening outcomes.

Strengths and limitations

This is a small dataset (which had limited funding to support its delivery) and therefore analysis was limited to descriptive statistics, which impacts on generalisability of findings. The findings were never intended to be representative of all people who use drugs in Teesside and should be interpreted with caution. However, the significance of the small numbers is justified by the notability of this sample in terms of their increased risk of poor health outcomes related to their drug use and additional vulnerabilities. Where substantial marginalisation and high risk of drug-related harms exist, information that is nuanced and context-specific is justified, often leading to directly actionable results that are useful to the community [54]. Indeed, reflections of the data presented here have supported a public health planning activity via Middlesbrough public health in October 2024, delivered by the peer researcher. Within the item measuring treatment participation, we grouped all opiate treatment, non-opiate substances in one composite category, meaning we were unable to drill down into each of these categories compared to national data sets re: NDTMS, which is a limitation. However, as 63% reported concurrent use of opioids, we used the opiate based treatment data as a benchmark, but this should be treated with caution. This research targeted and engaged a high-need population, the majority of which self-reported being out of treatment. Over a third are street homeless and engaged in complex polydrug use factors, which increases the likelihood of an adverse event such as systemic infection, overdose, or drug-related death [55, 56]. Due to being conducted at the same sites, the data collected in this study has provided key local operating knowledge supporting the delivery of a multi-site project on co-use [20] run by Bristol University.

Conclusion

As far as the authors are aware, this study is the first to describe the levels of polydrug use and street tablet usage by a vulnerable population in an area of the UK experiencing high levels of drug-related harms. Novel methods of engagement, such as peer research, are an acceptable way to develop local drug market intelligence based on the views of individuals who may be unlikely to engage with standard surveys and data collection mechanisms such as NDTMS, especially for individuals reporting they are out of treatment. Utilising the assets of the lived experience community, in addition to developing local drug testing information to generate local public health surveillance in areas of high need, can help address the drug death crisis. With a rise in synthetic opioids such as nitrazepam predicted to hit the UK [25, 26], this group of individuals are the most at risk of harm, and novel efforts to engage this group are vital to prevent further avoidable deaths [25].

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

OAT

Opioid Agonist Treatment

NDTMS

National Statistics about Drug and Alcohol Misuse Treatment

BNF

British National Formulary

Author contributions

CRediT Statement: CRediT Hannah Louise Poulter: Conceptualization, Methodology, Formal Analysis, Investigation, Project Administration, Writing -Original Draft, Writing- review & editing. Peter Da Silva: Conceptualization, Methodology, Formal Analysis, Investigation Helen J Moore: Conceptualisation, Project Administration, Supervision, Writing – reviewing and editing. Joanna Kesten: Methodology, Writing – reviewing and editing. Mandy MacKinnon: Writing – reviewing and editing. Gillian Taylor: Writing -Original Draft, Writing- review & editing.

Funding

Targeting Health Needs project funded by National Institute of Health Research [NIHR] 2022/23 Clinical Research Network (ref: 17969707). JK is partly funded by National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) and NIHR Health Protection Research Unit in Evaluation and Behavioural Science. The views expressed are those of the author(s) and not necessarily those of NHS England, NHS Improvement, the NIHR or the Department of Health and Social Care.

Data availability

Due to the small sample size the data is not available for sharing.

Declarations

Competing interests

The authors declare no competing interests.

Conflict of interest

None disclosed.

CRediT statement

CRediT.