Background: Illicit drug use continues to increase and impact individuals’ health worldwide. Critical voices surrounding the performance of enforcement-led policies continue to grow internationally, as they have been shown to be ineffective in reducing drug-related harms and lead to high expenditure to society. Instead, some countries and voices advocate a human right and public health approach to drug policymaking. These policies include decriminalisation of drug users, and services or facilities to support them, such as safe drug consumption facilities (SDCFs). The case of the SDCFs in Scotland presents a timely and highly relevant focus for this PhD work, as its implementation in the UK remains politically contested. Such a facility allows individuals to consume illicit drugs under clinical supervision, representing a public health orientated alternative to punitive, criminalisation-based responses. Incorporating scientific evidence of the services is an essential element of an evidence-based policy, and more frequently, economic evaluation and health technology assessment are being incorporated into the assessment of public health and social policies. This thesis, therefore, explores and examines whether health economics methods can support a rational and sustainable approach to drug policy decision-making in Scotland, using SDCF as an example. Methods: A multi-methods approach was taken to illustrate how health economic methods can contribute to the evidence base that informs policymaking in the Scottish context. This thesis is comprised of (i) a systematic review to understand what and how health economic methods were used to evaluate illicit drug policies worldwide, (ii) a literature review focused on the implementation of SDCFs in an international context. Two empirical studies were then developed, including (iii) a discrete choice experiment (DCE) that explored acceptability for different configurations of a SDCF by sampling potential service users (PWUD)’ perspectives in Scotland; and (iv) the decision analytical modelling to estimate the short- and longer-term cost, benefits, and potential cost-effectiveness of a hypothetical SDCF in Glasgow, Scotland, integrating findings from the DCE study. Results: The systematic review found that internationally, a large amount of the government budget has been allocated to enforcement policies, accompanied by a significant loss of productivity from people who have been incarcerated or have had overdose deaths. In the reviewed studies, public health policies were strongly supported by the evidence base, but evaluation was often conducted from a healthcare perspective, and limited research related to the enforcement-related policies (either criminalisation or decriminalisation). In Scotland, the DCE study found that participants preferred a SDCF that involved peer workers, provided drug checking service and inhalation spaces, and opened 24 hours a day, in comparison to one without peer workers, did not provide drug checking service and inhalation spaces, and opened daytime only. Among these features, peer involvement in the facility had a great impact on the willingness to travel to the SDCF. Participants were willing to travel up to nearly 1 hour to use a SDCF that involved peer workers compared to one without peer workers. A cost-effectiveness analysis was then undertaken to estimate the potential costs and outcomes of a hypothetical SDCF compared to the status quo (i.e. no SDCF) in Glasgow, Scotland. The findings of this modelling study suggested that implementing a SDCF would be cost -effective from a healthcare perspective. Over a 1-year time horizon, a SDCF would be cost-effective, with an estimated ICER at £1,378 per QALY gained (or £517,399 per death avoided) compared to having no SDCF available. In the lifetime cost-effectiveness analysis, implementing a SDCF remained cost-effective when incorporating referral benefits for service users engaging in long-term recovery treatment, with an estimated ICER at £2,640 per QALY gained (or £1,693 per life-year saved) compared to having no SDCF available. Conclusion: This thesis demonstrates that health economic methods can strengthen the evidence base for drug policy decision-making in Scotland and the wider context. In the systematic review, these methods were shown to provide multidimensional evidence of drug policies. It includes the assessment of the costs and cost-effectiveness of implementing polices to guide efficient resource allocation, quantified individual and societal preferences towards policies, and integration of broader societal considerations of implementing of drug policies. The DCE study provided robust evidence on the preferences of PWUDs, which are highly relevant for decision makers, highlighting which service features were most likely to drive engagement and thereby ensuring that SDCFs are designed in ways that maximise their impact. The cost-effectiveness modelling complemented this by quantifying the costs and outcomes associated with alternatives, offering decision-makers a clearer picture of value for money and the trade-offs involved in resource allocation. Overall, these analyses illustrate that applying economic methods in this policy space can produce actionable insights that directly support informed, transparent and evidence-based decision-making, moving illicit drug policy away from being shaped primarily by political or moral debates, and towards being grounded in rigorous evaluation of PWUDs’ needs, costs and benefits, as well as broader social impacts and uncertainties that are central to policy decisions.
Yuejiao Duan (Thu,) studied this question.