The Scottish Government

« Previous | Contents | Next »

Listen

Chapter 5: Service contacts in the 6 months prior to death

What is in this chapter? The information below sets out the nature and frequency of contact with services and identifies the overall patterns of these. The information described in this section should be regarded, and read, as population trends rather than the contact patterns of individual cases.

Where did the information come from? Data were drawn from different sources to build a comprehensive picture:

1. Records of care/interventions were identified and accessed for 305 (96%) people who ever had contact with services. No records were available for 12 cases. Of the 305 for whom records were available, 237 (78%) had had contact with one or more services during the 6 months prior to their death and information was extracted from the records of all services known to be involved in their care. For the remaining 68 people, their casefiles showed no record of any service contact in the 6 months prior to their death.

2. Information was collected from hospital returns data ( ISD databases SMR00/01/04) identifying 227 (72%) cases who received hospital care in the year prior to their death.

3. Two hundred and seventy-four of the 317 drug deaths (86%) were known to the Scottish Criminal Records Office.

4. Seventy of the drug-related deaths had been in a Scottish Prison in the six months prior to death and SPS files were accessed to add depth to the CSC dataset. 34 people had been offered formal Transitional Care and information was made available regarding whether this was accessed and outcome.

Introduction

"Integrated Care for Drug Users, Principles and Practice" ( EIU 2002) acknowledges that people with drug problems often have multiple needs and do not access services in a uniform manner. They will move in and out of contact as needs arise, accessing a range of different agencies in an ad-hoc way. This poses difficulties for services in terms of ensuring that they give an appropriate response to meet the user's needs and collaborate effectively with partner agencies to maximise outcomes. This section considers information from diverse sources to help understand this process and identify potential areas where a timely intervention may impact on outcome.

Mapping contact with health and social care services

It is recognised that being engaged in a process of care and treatment has a positive impact on outcomes, including drug-related deaths. In order to co-ordinate and integrate the care that is provided to individuals it is important to recognise the extent to which people access more than one service and the various interventions which they may be accessing from these services.

Of those 305 people who died of drug-related causes in Scotland in 2003 and for whom records were available, 68 people had no recorded service contacts at all during the six months prior to death. Data from the health, social work and independent sector casefiles of the 237 people who had been in contact with services during the six months prior to death were examined to determine the extent of service involvement, including their degree of engagement, the number of services involved (including whether these were generic or specialist) and the purpose of attending - including the types of interventions received.

Degree of engagement - time intervals between last service contact and occasion of drug-related death

The table below (Table 5.1) describes the number of people who were in contact with any service during the six months prior to death and the time interval between last recorded contact with services and death. Of the 237 cases that had contact with services in the 6 months prior to their death, 136 (57%) were still in contact with at least one service within one month of their death.

Table 5.1: Number of cases in contact with any service at any month in 6 months prior to death (n=237)

Number of agencies involved

Table 5.2 shows the number of agencies accessed by individuals in each of the six months prior to death. This table does not describe multiple contacts with any single agency. In their last month prior to death 136 people had 175 agency contacts on at least one occasion. During this period, over half of those who experienced a drug-related death in 2003 had documented contact with only one service. Some accessed many services though none accessed more than 8 services in any one month.

Table 5.2: Number of agencies accessed by each person

Services used

Table 5.3 shows the main services accessed in each NHS Board area at any point during the six months prior to death. The list of services is not exhaustive - i.e. people also had contact with additional agencies during this period, but in very small numbers. The table illustrates that the pattern of contact is not uniform across Scotland, with different services in each area apparently having more contact with this group. This may reflect the local pattern of services available.

Some patterns do appear across Scotland as a whole. Significant contact was with general practitioners ( GPs), with 183 (77%) of all those in contact with any service accessing GPs during this period. General Practitioners may have some formal links with specialist services through "shared care" arrangements. In most areas, the majority of contact was not with specialist drug services but with generic providers. Over all only 40 (17%) were known to specialist services, while in most areas there were significant contacts with psychiatric services (41 people, 17%), acute services - including Accident & Emergency (59 people, 22%) and NHS outpatients of various types (37 people, 15%).

In total, 71 (30%) were known to Social Work over all, though one area ( NHS Glasgow) is responsible for over half of all Social Work contacts identified. In most other areas there was limited Social Work contact recorded. The Glasgow data regarding Social Work teams allows a break down of specialist/generic involvement. This shows that, of the 42 people in contact with Social Work, 11 were being seen by a "generic" team, four by the "homelessness" team and 10 by Criminal Justice. Only 17 (40%) were being seen by specialist drug & alcohol Social Work staff. Organisation of Social Work services will vary from area to area.

Table 5.3: Number of drug-related deaths accessing specific services during 6 months prior to death by NHS Board area (n=237)

Purpose of contacts

Table 5.4 describes the main reasons for contact with services in each of the six months prior to death. It identifies the number of times a particular type of contact was made by different people in any one month. It does not capture multiple interventions delivered to the same person in the same month, e.g. one person attending for a "medical consultation" three times in the month before death would only be noted as one event.

Table 5.4: Reasons for contact with services in the 6 months prior to death.

Forty-seven per cent (47%) of all contacts recorded in the six months prior to their death were "medical consultations", the majority with GPs in primary care. Only 5% of contacts were described as "specialist substitution prescribing programmes". However, 66 people (24% of those in contact with services) were prescribed methadone during the 6 months prior to death, with 40 still prescribed at the time of death. 80% of all information on methadone prescribing was extracted from General Practitioners' notes, showing that, for the drug related death population, the majority of methadone prescribing was in the primary care setting with a significant proportion of these "medical consultations" relating to replacement prescribing. "Shared care" schemes operating throughout Scotland are modelled on the premise that stabilised drug users are generally seen in general practice and those whose drug use is more chaotic or problematic are cared for by specialist drug services. The data presented here may imply that this type of "shared care" model is not operating in practice in many areas of Scotland as it would be expected that the more chaotic users (who would be attending the "specialist services" in such a model) would be more at risk of drug-related death.

In Scotland, General Practitioners have taken on a more prominent leading role in the delivery of methadone replacement prescribing - reflecting a lack of capacity and waiting lists in specialist services. This may explain the apparently skewed balance of prescribers in this investigation.

"Case management" - delivered by Social Work - accounted for 12% of contacts while counselling - supposedly a key element of care for drug misusers in treatment - accounted for only 3% of all contacts. Appendix 4 contains a list of all contacts defined as "other" in Table A4.1.

It is notable that the majority of the contacts (other than with a doctor or social worker) appear to be in emergency situations ( A&E, emergency psychiatric care).

Interpretation

This is not an unknown population. Only 68 (21%) of those who died of drug-related causes in Scotland in 2003 and for whom records were available had had no recorded contact with any agency in the six months prior to death. Of the 237 who had service contact, many were accessing multiple services and more than 50% were still in contact with at least one agency at the time of death. The agencies involved include specialist services, but contact was dominated by attendances at generic services - mainly general practitioners but also psychiatric services, acute hospital services (including Accident & Emergency), NHS out-patients and social work. Contacts were often for the purpose of delivering medical interventions or a response to an emergency situation. There is a notable lack of recorded contact for delivery of counselling services or other psychosocial interventions. This pattern of contact implies that, if services are to have an impact on drug deaths, this will have to reflect activity in the more generic health and social care settings - areas where concern regarding drug use may not be the priority of the professional concerned during that contact.

More detailed analysis of the specific treatment received from health services is contained in the next section.

Contact with Health Services

This section describes in more detail the care of individuals who had received medical treatment for drug misuse and, when possible, compares the clinical care received by those who were in treatment with national clinical guidelines and considers whether there was anything that "services" could have done, or could do in the future, to prevent death. Data were extracted from national ISD databases relating to episodes of health care and, when these data are used, the definitions reflect those under which these data were recorded by the staff responsible for their care.

Hospital admissions

Initial analysis of data obtained from selected ISD databases ( SMR 00/01/04) indicates that in the year prior to death there were 1435 recorded episodes of hospital care for this population (n=317). This does not include attendances at Accident & Emergency Departments not resulting in admission, as ISD does not collect these data. Of these 1435 episodes, 734 resulted in hospital admissions (51%), of which 198 (27%) were discharged the same day, 220 (30%) after one day and a further 95 (13%) after two days. Five hundred and thirteen (70%) of all hospital admissions for this population were for two days or less.

SMR returns recorded general reasons for admission for only 340 of these 734 episodes: 296 to a general hospital and 44 psychiatric admissions. Reasons for admission were not recorded for the remaining 394 admissions. The majority of general hospital admissions for which this information was available were classed by ISD as having been for "observation, treatment or investigation" although 49 (17%) were for "self-inflicted injury" and a further 26 (9%) for "accidental or other injury".

Psychiatric treatment

In the six months prior to death 86 (36%) people were prescribed anti-depressant medication. Of these, 75 (87%) were prescribed these medications by their general practitioner. Twenty people were prescribed anti-psychotic drugs with two receiving Clozapine (a drug requiring close review by mental health services) and one received a depot antipsychotic which would require regular contact with professionals to administer. Table 5.5 sets out the drugs prescribed.

Table 5.5: Medical treatments for psychiatric disorders

In the casefiles of the 273 people who had been in contact with services during the six months prior to death, 83 had at least one episode of psychiatric care recorded. Casefiles show that five people had records of at least five different treatment episodes in the last six months.

SMR04 data shows that 44 of the psychiatric contacts made by these 83 people required hospital admission. Records were available for 28 of the psychiatric contacts. Table 5.6 sets out the nature of these 28 contacts. The definitions reflect those recorded by the clinicians delivering the care.

Table 5.6: Psychiatric service contacts

In SMR04, aftercare details are recorded for the 44 episodes of psychiatric care that required hospital admission, relating to the care of 29 people. Of these episodes, 22 (50%) cited ' GP' as the planned aftercare arrangements, nine (20%) cited outpatient clinics, four (9%) community care teams and two psychiatric day hospitals. Two were transferred to psychiatric wards for ongoing care. No details were recorded for the remaining eight episodes. No referrals to Social Work or any voluntary agency were recorded in any casefiles following these episodes of care.

Previous non-fatal overdose

One hundred and thirty eight (50%) of the people who were in contact with services in the six months prior to death had details of previous overdoses recorded in their notes. The tables below (Tables 5.7 and 5.8) set out the assessed nature ( i.e. accidental or deliberate) and frequency of overdoses and the treatment received for each overdose event. In some cases, other than to mention that an overdose had occurred, no specific details were available.

The tables show that four people had been treated for at least four non-fatal overdoses in the six months prior to death. The number seen at A&E exceeds the number seen by ambulances indicating that some overdoses arrived at A&E departments via means other than ambulance conveyance. This suggests that ambulance records of overdose attendances underestimate the total number of overdoses attended to by professional staff. Of the total number of people admitted into hospital for overdose, 44 (57%) were psychiatrically assessed, and in most cases (95%), psychiatric follow-up was arranged. Of these, however, less than half (43%) presented for follow-up and no further action was recorded for those who did not attend.

Table 5.7: Number of people experiencing non-fatal overdoses by type (n=118)

Type 1 - accidental
Type 2 - deliberate

Table 5.8: Treatment received by episode of non-fatal overdose

Specialist treatment for drug or alcohol problem in the last 6 months

Data obtained from casefiles indicated that in the six months prior to death, only 38 (12%) of the 317 people had at least one contact with a specialist drug misuse service. Details relating to the majority of these contacts were not routinely noted in clinical records. Table 5.9 below summarises the interventions for the 47 recorded contacts by these 38 people.

Table 5.9: Type and frequency of specialist drug treatment contact (n=38)

Medical treatment for a drug problem

There is a relationship between dose and outcome in methadone prescribing with higher doses associated with better clinical and harm reduction outcomes. Good practice is for methadone prescribing to be delivered alongside various psychosocial or counselling interventions, an approach which has also been associated with better outcomes. Prescribing guidance recommends an optimal dose range of 60-120 mg of methadone per day. Risks (including those of overdose) increase when methadone is reduced or stopped. National Clinical Guidance on prescribing for drug misusers makes it clear that methadone prescribing should only follow adequate assessment of extent of drug problems and dependence. Initial methadone dispensing should involve supervision of consumption with progress to "take home" dependent on successful stabilisation (Drug Misuse & Dependence. Guidelines on Clinical Management HMSO 1999).

Seventy-eight people were receiving medical treatment for a drug problem in the six months prior to death, of which 66 were prescribed methadone by their general practitioner or specialist service doctor. No records of other specific medical treatments for drug misuse were recorded - though in three cases it was noted that one had received "detoxification"; one "assessment" and one "tolerance testing".

Identification of dependence

All case records available for those who had ever had access to any services (n=305) were searched for documented, objective evidence of the person having a recognised dependence syndrome. Only eight case records (2.6%) had this information recorded.

Methadone dose

Sixty six people were prescribed methadone during the six months prior to death. Only 40 were prescribed methadone by their time of death. For one person, information on dose or duration of prescription was unavailable in any case record.

For the remaining 39, dose range was from 4 to 100 mg (mean 53.9; SD 24.1). Sixteen people (34%) were prescribed 60 mg or more while 24 (66%) were prescribed less than 60 mg. When dose at death is compared with their previous recorded dose it can be seen that 21 people (54%) were having their methadone dose increased and 8 (20%) were being reduced. In 11 (28%) cases there is inadequate information in casefiles to determine prescribing plans or trends.

People had been on methadone treatment for varying periods. No information was available on duration of treatment in 9 cases. Duration of prescription ranged from 2 days to over 7 years (mean 19.6 months; SD 26.93). Four had been in treatment for up to 1 month, 10 between one and 6 months and four between 6 months and one year. A further four had been treated for up to 2 years, three up to 5 years and four more than 5 years.

Prescribing information was available in casefiles for 14 of the 26 no longer receiving prescribed methadone. No records were available for the remaining 12 people. When available, records show that prescriptions ended between two days and eight months before death occurred. Table A4.2 in Appendix 4 displays these data in more detail.

Dispensing arrangements

Of the 40 who were receiving prescribed methadone at the time of their death 27 (68%) collected their methadone daily, either six or seven days per week. One person collected their prescription three days per week, five collected once a week and one person did so every two weeks. Arrangements for the remaining six cases were not recorded in casefiles.

Information on method of consumption was available for 32 of the 40 people receiving prescribed methadone at their time of death. This is displayed in table 5.10. Six collected their methadone from a treatment centre of whom five consumed their methadone under supervision. Of the 26 people who collected their methadone from a community pharmacy, 21 (81%) consumed their methadone under supervision on the pharmacy premises and five (19%) consumed at home.

Table 5.10: Method of collection and consumption of methadone

Of the five people who collected from the pharmacy and consumed at home, two were homeless and another two were on anti-depressant medications - implying they had complex problems. Notes recorded no evidence of injecting for any of these people in the last six months but no other indicators of stability were noted. All were unemployed and none had attended any specialist drug treatment services.

Non-specialist Detoxification

Clinical case notes recorded 26 people attempting to abstain or detoxify from drugs in the six months prior to death. Nine (34%) were recorded simply as self-detoxification. A further 10 (38%) were aided by a prescription from their GP, and seven cases (27%) sought abstinence by other means. Outcome data were recorded for 23 of these cases. Seven (27%) successfully completed detoxification and appeared to remain drug free until death. 11 (42%) completed detoxification but relapsed, and the remaining five (19%) did not complete their detoxification. Few details are recorded.

Did not Attend ( DNA) rates

Very little was recorded in service case notes and/or other information systems regarding 'Did Not Attend' rates. This cannot therefore be commented on.

Waiting times

Of the 237 cases in contact with services in the six months prior to death, 19 (8%) were identified to be on any waiting list. Only two of these were on a waiting list for a drug treatment or intervention service.

Interpretation

Of the 317 people who experienced a drug-related death in Scotland in 2003, only 66 were prescribed methadone during the six months prior to death. Of these, 26 (39%) were no longer prescribed methadone by the time of death. There was little information regarding the assessment carried out prior to initiation of a prescription with only 8 people having any records showing assessment of dependence prior to prescribing. Records for those prescribed were also limited with inadequate information available in 28% of casefiles to determine whether prescriptions were increasing or decreasing. Of those prescribed methadone at the time of death, 66% were on sub-optimal doses of less than 60 mg though 54% were increasing their doses. Records of dispensing arrangements show that those 5 people who were taking their methadone home may not have been stable with two described as homeless and two on antidepressants. Only 11% of people on methadone received any recorded counselling interventions during that period. Only one person prescribed methadone at the time of death was also in receipt of counselling.

The quality of recording in casefiles was often poor making judgements of the quality of care received impossible in many cases. In those where information was available, it is clear that there were inconsistencies in the delivery of methadone prescribing for this group, some of which fell outside the standards set in the available clinical guidance.

Contact with Criminal Justice System

Limited data were made available from the Scottish Criminal Records Office ( SCRO). Two-hundred and seventy four (86%) of those suffering a drug-related death in Scotland in 2003 were ever known to SCRO. Almost all (83%) of those known to SCRO were aged 20-40yrs. Detailed arrest data were not accessed during the investigation study period.

Contact with community- based specialist criminal justice schemes

Information on contact with community-based specialist criminal justice schemes showed very little contact for this population (Table 5.11). The available data may be an underestimate as some contacts may be unrecorded. It should also be noted that many of these initiatives were in their infancy in 2003 or were unavailable in some areas of the country.

Table 5.11: Contact with community based specialist criminal justice schemes

ARS - Arrest Referral Scheme
DFP - Diversion from Prosecution Scheme
CBATCS - Community-based Alternative to Custody Scheme
DTTO- Drug Treatment and Testing Order
EPO - Enhanced Probation Order

Outstanding charges at time of death were recorded in 21 cases (8.9%).

Contact with Scottish Prison Service

Of the 317 cases, 149 (47%) had previously had a prison sentence. Of these, 70 (47%) died within 6 months of release, including thirty-six deaths (24%) which occurred within one month of release, 10 (28%) of which were within three days of release. No drug-related death occurred within any Scottish prison in 2003.

These figures represent a reduction in the number of drug-related deaths when compared to the previous year (n=383). In 2002 176 (46%) of all drug-related deaths had previously had a prison sentence. Fifty four deaths (31%) had occurred within one month of release of which 18 (33%) were within three days.

Deaths following Friday release

Table 5.12 sets out the number of deaths that occurred after release from prison. Six of the ten people who died within 3 days of leaving prison were released on a Friday. Two of these were from Barlinnie and one each from Edinburgh, Greenock, Inverness and Kilmarnock.

It may be that Friday releases are at increased risk of drug-related death. However, it should be noted that, of all prisoners released by the Scottish Prison Service in 2003 (n=22,915), 32% were released on a Friday as all releases due on Saturday, Sunday or Holiday Monday occur on the preceding Friday.

Table 5.12: Number of people who died following release from prison

Deaths within six months of release

Of those who died within six months of release (n=70) 50 were dependent/long term users, one was a recreational user and 19 could not be determined.

Thirty-four (49%) had been convicted and one imprisoned for non-payment of fines. 15 (21%) were on remand. Sentence information was unavailable in the CSC file for 20 (29%) of these cases as they had not self-disclosed an addiction issue while in prison or this information had not been reported in the records identified. Of the six females who had been imprisoned, one had been convicted and the other five held on remand.

Deaths within three days of release from prison

Table 5.13 details factors relating to those who died within three days of release.

Table 5.13: Deaths within three days of release from prison

*Toxicology: Only positive results for Heroin, Diazepam, Methadone and Alcohol are displayed here. Other drugs may have been present but not displayed in this table.

Prison record by age group

The Bar chart (Figure 5.14) below illustrates the relationship between age and prison record. It can be seen that around half of those aged between 20 and 40 years had been in prison at some point in their lives compared to the over-40 age group where only one person had ever been in prison.

Figure 5.14: Relationship between age and prison record

Transitional care arrangements

In June 2000 the Scottish Prison Service launched a revised drug strategy which included plans aimed at effectively managing the transition between prison and the community. "Transitional Care" was introduced by SPS in 2001 to support prisoners who were serving less than four years or were on remand and who had an identified substance misuse problem. Prisoners serving more than four years do not have access to "Transitional Care" as they are catered for by the SPS Sentence Management System and statutory post-release arrangements. Some establishments offer Transitional Care to all drug misusers who are brought to their attention. In others, demand has led to waiting lists. Self-referral is also available in every Scottish prison, even for those not accessing casework services.

Scottish Prison Service records show that Transitional Care was offered to 34 (49%) of the 70 inmates who died of a drug-related death in 2003. Access to Transitional care was unavailable for 14 people (20%). Eight were on a waiting list ( HMP Barlinnie only) and one was in HMP Shotts where the scheme is unavailable. Five people in HMP Kilmarnock could only access Transitional Care by self referral. None did. Ten were not known to Cranstoun (4 in Barlinnie, 4 in Low Moss, 1 in Edinburgh, 1 in Inverness). Notes were not available in 3 cases (2 in Barlinnie, 1 in Cornton Vale).

Of the 34 offered Transitional Care in Scottish Prisons, 23 (68%) accepted while 11 did not. Distribution by establishment is shown in the table below (Table 5.15). In the case of those who were not offered formal Transitional Care, or were ineligible for it, it cannot be determined from existing data what attempts were made to ensure the continuity of care and treatment between community and prison, nor can it be determined whether the time in prison was used constructively to initiate treatment by referral to outside agencies.

Table 5.15: Offer of Transitional care (n=70)

Interpretation

Transitional Care should give an opportunity to offer support and enhanced access to treatments known to impact on drug deaths, to this vulnerable group. Fifty of the 70 deaths which occurred within 6 months of release, were known to be long term dependent users yet only 34 were offered access to Transitional Care. This may reflect the organisation of the Transitional Care services, including their inclusion and exclusion criteria. In some establishments there were clearly practical barriers to access - with one having no access to Transitional Care at all, one accepting only self-referrals (of which none of the DRD group availed themselves) and one having waiting lists. Some of the 70 may have received interim liberation or may have been released from court, in which circumstances they would not be in a position to be offered or to accept Transitional Care. There are varying degrees of success from establishment to establishment, regarding conversion of the offer to an accepted intervention. Some prisons converted 100% of offers while in others as little as one in three accepted the offer. Improving identification of this group, increasing the number offered such support and increasing the numbers accepting the offer gives potential for impacting on drug-related deaths after release from prison.

Conclusions

This chapter highlights the fact that the majority of those dying of drug-related causes in Scotland in 2003 were known to at least one service with some known to many. They were mainly accessing generic service providers and the services they accessed tended to reflect local service distribution. In all areas this contact was mainly with their General Practitioner or Primary Care team. Other generic services were regularly accessed in emergency situations including Accident & Emergency and Acute Psychiatry services. Repeated contacts were common but there was little evidence of a coordinated response or follow up. There are clearly opportunities to intervene in this group which have not been fully exploited - including education of generic services and improved coordination of response to those repeatedly presenting to services. This work should involve Psychiatry and Accident & Emergency services.

Those in contact with specialist services were mainly accessing medical treatment (such as methadone replacement prescribing) or Social Work interventions. Only 17% of those known to services were in receipt of replacement prescribing services at the time of death. Most methadone prescribing was through General Practice. Records of assessment and decisions regarding prescription alteration - dose increase or reduction; dispensing arrangements etc. - are poor. Most were prescribed low doses of methadone and few also received supportive counselling. There is a need to improve the demonstrable quality of prescribing treatments and to improve access to supportive counselling interventions which may impact on risk for this group.

Key Points

• There is a need to improve the quality of note keeping, in both community-based services and those within the Scottish Prison Service, to allow closer scrutiny of the care received.
• Most people suffering drug-related deaths were known to services and many were accessing more than one.
• These services are often generic ( i.e. not specialists in the field of substance misuse) and were often accessed in an ad hoc, chaotic manner. Most were discharged with inadequate follow up in place or failed to attend any such follow up appointments resulting in discharge and no further action.
• There is a need to increase awareness of this problem and to deliver training and improved coordination for those generic staff most likely to come into contact with this group - General Practitioners, Psychiatric services, Accident & Emergency and Social Work.
• Specific medical interventions for drug misuse were only accessed by a minority of these people. When accessed they were often prescribed methadone.
• Methadone replacement prescribing should be delivered alongside supportive psychosocial interventions, including counselling - which was only accessed by a small minority of the prescribed group.
• Methadone should be prescribed in line with the current evidence base - following a full assessment of drug problems and dependency; in adequate doses to meet need; dispensed safely and effectively under supervision until the person is demonstrably stable.
• Many had been in prison in the last 6 months. Ten died within 3 days of release of which 6 were released on a Friday. There is a need to ensure that effective communication takes place to ensure imprisonment does not interrupt treatment (if being accessed before incarceration) or that it gives an opportunity to increase access to treatment if not already in contact with services. DAATS should review the care pathways across the community/prison interface and ensure adequate accessibility to services for all newly released prisoners.
• Transitional Care is not being made available to all who require it. Prisons show varying success regarding take-up rates.
• There is a need to ensure all opportunities are taken to intervene when drug misusers are in prison. Prisons should look proactively at how they engage with prisoners at the start of their treatment cycle.

« Previous | Contents | Next »