QMJC August 2021: Drug fatalities and treatment fatalism: Complicating the ageing cohort theory

First published: 01 September 2021 | Last updated: 04 October 2021

The Qualitative Methods Journal Club discuss a paper that rethinks the assumed causal link between age and drug-related deaths. The study draws on the experiences of 15 older people based in South London, who had been using heroin for more than twenty years. The findings add a fresh perspective to the conversation about drug-related deaths, turning attention away from inherent vulnerabilities in the individual to flaws in the treatment system.

About this month’s Journal Club

The article (available here) was purposely selected for the August 2021 meeting of the SSA QMJC at King’s College London to coincide with the release of the annual drug-related death data from England, Wales and Scotland (Summer 2021), and as an opportunity within the National Addiction Centre to further spotlight International Overdose Awareness Day (31 August 2021). It was discussed online (MS Teams) within the National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience at King’s College London with 6 attendees (all from King’s College London). Stephen Parkin (National Addiction Centre, KCL) presented and led the discussion.

Summary of the article

The publication of this article (in May 2021) offers a timely adjunct to the annual drug-related death data that are released each summer by health authorities throughout the UK. For several years, these annual reports have noted consistent rises in the number of people dying from drug-related poisoning, especially amongst people aged over 45 years and, especially, involving the use of heroin/opiates.

This trend has given rise to the ‘ageing cohort theory’, that posits those who have longer drug-taking careers (that started in the 1980-90s) are now more susceptible to death/opioid overdose due to cumulative mental and physical health conditions, ongoing participation in risk-related behaviours and continuous poly-drug use. For almost 10 years, this ageing cohort has also been informally termed the ‘Trainspotting Generation’, due to parallels drawn with Irvine Welsh’s (1993) novel (‘Trainspotting’) set in Edinburgh during the 1980s.

Dennis’ article offers a critical reflection of the ageing cohort theory and also simultaneously deconstructs the widely held (and seemingly accepted) assumptions associated with the so-called ‘Trainspotting Generation’. These critical reflections are documented in a qualitative study of 15 older people’s experiences of drug use, and their (dis)engagement with treatment services, based in the South London area of England.

The article concludes with an alternative view that purposely complicates the ageing cohort theory. Namely, “current treatment practices, often designed around younger, newer users, and thus drugs being recover-able, are leaving older service users feeling ignored, or worse still, punished and constrained by limited and inflexible OST medications and regimes.”

Discussion of the article

The SSA QMJC greatly enjoyed the content of this article and discussed at length why this work should be regarded as a ‘good example’ of a qualitative research paper. These included ‘the author’s writing style’, ‘methodological design of the study’, and the overall ‘interpretation’ of data. These qualities are summarised further below.

‘The author’s writing style’

“The narrative style attached to the text resulted in one of the best articles read in recent times and provided a refreshing alternative to more detached styles of writing”.

There was consensus in the group that Fay Dennis has a great style of writing that blends academic prose with a humanitarian approach and an empathetic narrative in this article. For several members of the group this was an exceptional piece of work that was considered atypical of academic publications – especially with regard to such a serious and sombre topic. This atypical approach to academic writing reflected a more creative style in communicating important public health messages to international audiences.

For some within the group, the narrative style attached to the text resulted in one of the best articles read in recent times and provided a refreshing alternative to more detached styles of writing. For example, the author’s use of the first-person pronoun (‘I’) was considered unusual and engaging for such a high-profile academic journal. This approach was applauded at it seemed to emphasise the author’s direct involvement, and associated interpretivist subjectivity, throughout the text.

In addition, the author was hugely applauded for incorporating an adversarial writing style closely connected to the discipline of sociology into her work (and thereby accurately reflecting the journal title and content). As one of the group commented, ‘Pierre Bourdieu famously described sociology as a combat sport’, and Fay Dennis certainly reflects this view in the content of this article. Her use of the words such as ‘complicating’, ‘disrupting’, ‘rebuttal’, ‘(structural) failure’ and ‘fighting a cause’ were each considered to represent sociologically-informed challenges to mainstream and accepted views in the field of substance use. In using the language of contestation, Dennis offers alternative constructions of a public health phenomenon (age-related and drug related death) to be re-considered via an alternative (and equally legitimate) lens of analysis.

Similarly, the group found that Dennis’ use of qualitative data extracts to be particularly noteworthy. In this regard, the group liked the way in which larger interview extracts complemented specific comments built within the author’s own interpretations of the data. This approach of complementary illustration was considered as a great way of representing qualitative data in a balanced and even approach.

‘Methodological design of the study’

“The depth of qualitative methods attached to this article was considered reflective of the proximity of the author to her field and, more importantly, to the participants in her study”.

Associated with the disciplinary background of the study, the group also commended the account of the methodological design of Dennis’ study (funded by the Wellcome Trust). In what appears to be a multi-model study, the author highlights that the findings in this article are obtained from only one component of an ongoing ethnographic and participatory project based in South London. Accordingly, the depth of qualitative methods attached to this article was considered reflective of the proximity of the author to her field and, more importantly, to the participants in her study.

In addition, the author’s methodological design is clearly theory driven – and appears to be located within the field of Science Technology Studies (STS). This is noted in the way in which Dennis draws upon the theoretical frameworks of Donna Haraway’s ‘response-ability’ and upon the assumptions of enactment (including embodiment and performance). These theoretically informed approaches to understanding drug-related deaths in the UK were considered unique – and refreshing. In addition, the findings provide a new contribution to knowledge and are informed by the way in which the author has applied her version of the qualitative paradigm of interpretivism.

‘Interpretation of data’

“Dennis is to be applauded for advocating an opinion that will almost certainly challenge orthodoxy and conventional thinking about the ageing-cohort theory”.

The author’s empirical application of response-ability and enactment to the contemporary topic of drug-related death offers an alternative perspective on a societal problem. Whilst it may be an empirical study, and whilst the Findings section may not fully transfer to the wider UK, the conclusions offer genuine attempts at re-situating constraints between structure (in this case treatment providers) and agency (in this case service users, people who are in receipt of opiate agonist treatment). Accordingly, whilst these views may not be widely accepted within the field, Dennis is to be applauded for advocating an opinion that will almost certainly challenge orthodoxy and conventional thinking about the ageing-cohort theory.

Finally, connected to the above, one member of the group was impressed with the way in which the author has made her data available (upon request). This approach to social science was considered useful for the external scrutiny of data and their quality – and for the cross-checking of interpretations made and claimed by the author. However, this did provoke a wider discussion regarding how such Open Access to Science would maintain participant confidentiality and anonymity.

Overall, the group thoroughly enjoyed the article written by Dennis. So much so, several of the group stated they looked forward to reading more work to arise from this study. This was especially as Dennis only appeared to focus upon two themes from her analysis in the current article. Relatedly, the group would like to have read more about the analytical procedures described as ‘grounded thematic analysis’ (as this was given only a cursory mention in the section on Methods) and how this may have differed or diverged from any deductive analysis (pertaining to Haraway’s theory).

About the article

Dennis, F. (2021) Drug fatalities and treatment fatalism: Complicating the ageing cohort theory. Sociology of Health and Illness. 43, 5, pp1175-1190.

The article can be accessed here.

Author response to discussion (added as postscript)

Thank you to the SSA Qualitative Journal Club for this generous discussion of my work.

With this invitation to offer a postscript, I wanted to take it as an opportunity to add some context and highlight the collaborative spirit in which the article was written (which I didn’t get time to go into in the article itself).

‘Drug fatalities and treatment fatalism: Complicating the ageing cohort theory’ is based on a talk I gave and the discussions that took place at the International Society for the Study of Drug Policy conference in Paris in 2019. This was on a panel with Basak Tas (King’s College London), Zoe Carre (Release, now at SNP Westminster Group), Amal Ali (Release, now at Criminal Justice Alliance) and Andrew McAuley (Glasgow Caledonian University), chaired by Alex Stevens (University of Kent). I had met these researchers in various capacities in the years running up to the conference and was taken by their different modes of approaching and problematising opioid-related deaths and their unifying passion and concern. We gathered, in the panel, to think about what our diverse disciplines (epidemiology, experimental science, policy, and sociology) and methodological orientations could offer an understanding of and action on these deaths.

Basak Tas studies opioid-related overdose and death experimentally, at the level of the body. Linked up to various monitoring equipment in the clinic, she observes research participants’ physiological responses to an increase in diamorphine dose. Tas describes where the medical team would normally be rushing to a patient in cardiac arrest, participants, with very low levels of oxygen in the blood, might be calmly reading a book. As long-term heroin users, participants’ respiratory system and brain function had adapted to these low levels of oxygen, problematizing when overdose occurs as a deeply individuated (inter-individual variability) or situated matter. Andrew McAuley explores opioid-related death at the level of the population, and through this, problematizes and complicates discussions on the opioid-overdose antidote, naloxone, as the ‘silver bullet’ solution, with deaths continuing to rise despite growing naloxone programmes. Complicating this response yet further, Zoe Carre and Amal Ali trace via freedom-of-information requests the political dimensions of these deaths which meant naloxone may, in theory, be available but was still not accessible to many people who illegally consume or are prescribed opioids.

Looking at opioid-related deaths through the scale and methods of the disciplinary ‘other’, we asked not only social and political questions about these deaths – why they are happening – but empirical ones – what are drug-related deaths and when and how do they occur. Moreover, we reflected on how these social and empirical questions and processes intersect. We asked how these deaths are measured, tested, and known by scientists, coroners, but also by members of the public and people with direct experience of overdose, and responded to, or not, by governing bodies. Crucially, we asked how these knowledges, practices and policies might re-form the problem itself.

My presentation in the panel, which developed into the article discussed here, speaks to this interest in the entangled relationship between the social and material, epistemological and ontological. By looking at how overdose was experienced by those who had overdosed and had witnessed overdose and deaths among their peers, I was able to distance these deaths from a clear causal effect (from age, or, in Tas’s example, potency), instead thinking about how our interventions (in OST, or naloxone programmes, in McAuley’s example) or lack of (in Carre and Ali’s discovery of limited coverage) could be involved. Zeroing in on opioid treatment among older heroin users, I found despondency, and argue for a more responsive treatment system, to engage and retain older people in substitution treatment that is known to save lives when delivered meaningfully.

In light of further increases in deaths this year in the UK, there is a growing desire among scientists and activists to complicate our understanding and response. In this, it is vital that we listen to those affected and take seriously the social processes that make support inaccessible or ineffective. I really hope this article and discussion goes some way to further stimulating these conversations, awareness, and action.

The opinions expressed in this post reflect the views of the author and do not necessarily represent the opinions or official positions of the SSA or the author’s academic institution.

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