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2. Response To Recommendations
Recommendation 1: Funding
There is a need for a dedicated fund to encourage new responses to reduce drug-related deaths in Scotland. It is therefore recommended that the Scottish Government consider allocating funding specifically for initiatives aimed at reducing drug-related deaths.
Scottish Government Response
Substantial resources are dedicated to tackling the problem of drug use in Scotland. The 2007 Spending Review proposes a drug misuse budget within the Justice portfolio of £29.5m/£32.0m/£32.8m for the period 2008-9 to 2010-11. This represents a 14% increase in spending overall by 2010-11. This is only part of the overall picture, as there is a significant funding from other budgets, such as local government, the police and the Scottish Prison Service. The Government has asked Audit Scotland to undertake a thorough review of the scale and effectiveness of public spending on tackling drug use, and looks forward to its conclusions early in 2009.
Within the Scottish Government Justice portfolio, there is already funding specifically to tackle drug-related deaths. Some of this funding will be used to take forward key recommendations from the Forum, including establishing a database to collect and analyse information on drug deaths.
In addition, local partners fund initiatives aimed at raising awareness of the dangers of overdose, such as information campaigns. We are also funding the Scottish Drugs Forum to deliver critical incident training, produce a training manual and to train key workers to deliver the overdose awareness training within their own services.
Recommendation 2: Prisoners
The number of deaths amongst prisoners on release and gaps in services offered to people on short term sentences continue to cause concern. It was felt important to recognise the dangers faced by this group and it is therefore recommended that:
- There should be more support and overdose awareness training for short term prisoners, i.e. those on remand or serving sentences below 31 days.
- SPS consider revising access criteria for pre-release to prisoners serving 31 days or more.
- There is consistent policy implementation and practice regarding delivery of overdose awareness sessions, prescribing practice and detoxification across the prison service nationally.
Scottish Government Response
The Scottish Prison Service ( SPS) have taken action on, or working towards implementing these recommendations. The SPS delivers Harm Reduction Awareness Sessions ( HRAS) to all eligible admissions to custody (including remands) within 5 days of admission. As from 1 August 2007, pre-release sessions are offered to those in custody for 31 days or more (including remands). The programme for HRAS is being revised and updated in partnership with the Scottish Drugs Forum to include overdose awareness and basic life support. Alerting vulnerable drug users to the dangers of lower tolerance, such as those being released from prison, may help prevent some deaths.
Overdose awareness is a part of the HRAS delivered on admission to all prisoners, as well as at the pre-release session for those in custody for 31 days or more.
SPS are committed to consistency in prescribing practices in relation to substance misuse. All doctors working in prison settings will be undergoing Royal College of General Practitioners ( RCGP) training on substance misuse. This will ensure there is a level of consistency in prescribing practice. Doctors now have a consistent approach to continuous professional development both in terms of relevant training, supervision and support.
Doctors now also have access to training courses run by Scottish Training on Drugs and Alcohol ( STRADA) on substance misuse and dual diagnosis.
Current SPS policy around prescribing recommends that a move away from detoxification and towards stabilisation and maintenance happens as a matter of priority.
SPS routinely conducts Critical Incident Group Reviews in respect of drug-related deaths soon after release. This process enables 'lessons learned' to be identified in relation to systems, processes and practice and recommendations for improvement are put in place. The drug death analysis reports and relevant information are shared with key stakeholders including the National Forum, Scottish Government and Alcohol and Drug Action Teams.
Recommendation 3: Providing Naloxone in Order to Save Life
With take home naloxone being more widely used across the world to save lives, e.g. in Berlin, San Francisco and Chicago, consideration should be given in Scotland to extending take home naloxone provision beyond Glasgow and Lanarkshire into other areas. This recommendation is made with the understanding that any pilot is rigorously evaluated to prove effectiveness.
Scottish Government Response
It will be some time before the real impact of naloxone provision can be determined. We will be looking at the evaluation of the pilot studies which have taken place within Glasgow and Lanarkshire with interest.
Local planners should consider the findings from the evaluations when they are published, and decide if naloxone provision is an intervention they would wish to adopt in their area. Before any roll-out of the programme, thorough training would have to be in place that covered the use of naloxone and overdose awareness, such as the training programme devised for the Glasgow pilot. Naloxone should not be distributed without such a training programme being in place first.
New developments such as Intra-nasal ( IN) naloxone should be explored as no special training is required to administer the medication, it is easier to administer and it reduces the risk of needle stick injury in those who are higher risk of blood borne viruses. The Forum may wish to look at this for the future.
Recommendation 4: Research
The Forum believes that in addition to accurate data collection there is a need to continue to investigate the circumstances and settings of drug-related deaths and how such factors contribute to them.
The Forum also recommends that research should be commissioned into other treatments that may assist addicts to become drug free, e.g., the use of naltrexone highlighted in this report, and the effects of the introduction of Subutex and Suboxone in drug treatment.
Scottish Government Response
The National Evidence Group being set up under the auspices of the Scottish Advisory Committee on Drug Misuse ( SACDM) will, as an early action, consider the adequacy of the overall evidence base in Scotland, and deliver a more systematic and co-ordinated approach for feeding evidence into national and local policy-making and practice.
Dissemination of the evidence will be key to ensuring that the research and good practice that flows from the evidence group is used to its best advantage. While not wanting to pre-empt the group's deliberations, the Government will be proposing improving the evidence base on reducing drug-related deaths as an early priority.
Recommendation 5: Suicide prevention
Approximately 23% of all drug-related deaths in Scotland are intentional self-poisoning or where the intent is undetermined. Prevention of suicide amongst drug users should therefore become a key priority as part of the drive to reduce drug-related deaths in Scotland. It is therefore recommended that:
- Suicide prevention be incorporated within the ethos of reducing drug-related harm and becomes a key priority for the attention of Alcohol and Drug Action Teams ( ADATs), drug agencies and related services.
- Action to prevent suicide should include prioritising suicide prevention training for front-line agencies and developing greater awareness of heightened risk factors for drug users, particularly in relation to intentional overdose.
ADATs take a lead role in utilising the linkages to local Choose Life (suicide prevention) networks to access training and other resources and promote greater understanding of mental health problems (such as depression and bi-polar disorder) as likely determinants of suicide.
Scottish Government Response
Choose Life is Scotland's National Strategy and Action Plan to Prevent Suicide. With funding from Scottish Government, Choose Life teams have been actively working with Alcohol and Drugs Action Teams ( ADATs) and substance misuse agencies on suicide prevention. There was a pan-Ayrshire conference during Suicide Prevention Week last year and there is work being done with Scottish Training on Drugs and Alcohol ( STRADA). That work will examine how Choose Life can incorporate ASIST (suicide prevention) training into their programmes and tailor such courses to drug/alcohol related situations.
Choose Life are training frontline staff working in drug agencies across Scotland who are most likely to come into contact with substance misusers who may be suicidal - especially those at the more chaotic end of the scale. They are also working to ensure that substance misuse staff have a working knowledge of mental health issues and vice-versa for mental health staff. Prevention of suicide is only part of this. The ability to work with and respond appropriately to by substance misusers who are presenting with mental health issues should have a positive impact in preventing suicide - particularly in response to crisis.
We are committed to reinforcing suicide prevention action by increasing availability of evidence-based psychological therapies; working with GPs to improve support for people experiencing depression; and by introducing suicide prevention training for frontline staff working in primary care, in mental health services and in A&E services.
Action at local level is fundamental to reducing suicide and achieving the objectives of Choose Life. Each area across Scotland has a nominated Choose Life Co-ordinator who plays a key role in implementing their local plan. In general, local Choose Life action plans focus attention on:
- Preventing suicide within communities
- Improving the capacity of local communities to educate and raise awareness of suicide
- Delivering prevention and intervention activities
- Providing practical support to those affected by suicide
- Involving a range of partners in preventing suicide
This will enhance take-up of suicide prevention from the menu of local Single Outcome Agreements. Choose Life will be actively working to ensure that the capacity for training and other supports are in place to facilitate take-up of suicide prevention activity across the substance misuse sector.
Recommendation 6: Treatment and Support
The revised 'Clinical Guidelines on the Treatment of Drug Misusers' (Orange Guidelines), published in September 2007 should be properly implemented by practitioners. The guidelines make it clear that, if properly implemented, the treatments outlined in the document will reduce drug-related deaths. The document also highlights areas which are not effective or can be dangerous such as rapid detoxification, long waiting lists and under-medicating patients. In addition, there are examples of those treatments which need further research before they can be recommended or discarded.
Services should comply with the National Quality Standards for Substance Misuse Services to improve the consistency and quality of substance misuse service provision in Scotland.
Specialist services need to monitor waiting times and retention rates. The Drug Outcome Research in Scotland ( DORIS) study highlighted a wide variation in retention rates across Scotland. Services need to do more to retain people in treatment, particularly those who have a history of previous overdose.
Scottish Government Response
The UK Guidelines on Clinical Management - sometimes known as 'the Orange Book' are based on current evidence and professional consensus on how to provide drug treatment for the majority of patients, in most instances. They emphasise the need for both pharmacological and psychosocial treatments for people with problem drug use, with individual care plans and co-ordination of care across professional groups, including health and social care. The Government strongly supports these Guidelines as the basis on which clinicians and other professionals should consider the treatment of patients with drug misuse problems. Apart from other factors, they are entirely consistent with the promotion of recovery that the Government aims for through the new national drugs strategy.
Scotland's Chief Medical Officer, Dr Harry Burns, has made it clear that he expects NHS Boards to discuss with local service providers how the guidelines will be implemented by practitioners at local level. There is a clear expectation that the guidelines will be adopted as good practice by treatment providers as a means to achieve optimal outcomes for drug users and their families.
The National Quality Standards for Substance Misuse Services were developed to highlight the necessity of addressing all clients' needs through partnership working and having clear exit strategies. The Government is working with partners to improve delivery of services at the local level. Part of that will be to consider including how a new national support function might promote and monitor implementation of national quality standards.
The Government accepts that long waits for treatment are unacceptable. Access to effective treatment and rehabilitation is critical to the long-term goal of recovery from drug use, and it is clear that services need to improve. We have already written to ADATs pointing out the importance of improving access to treatment and the need to make progress in this area.
We are determined to have the right structures in place to tackle drug use more effectively. As part of our new drugs strategy, we are reforming local structures to improve the range, access to and quality of drug services delivered locally.
Recommendation 7: Young People in Care and Leaving Care
There should be continuing practical 'wrap around' support for young people whilst in and leaving care including harm reduction and overdose awareness training. There should also be easy access to essential services that are specifically tailored to young people's requirements and where assessment of risk can be carefully undertaken.
Scottish Government Response
Local authorities have a duty to ensure that all looked after children and young people have a care plan. This care plan should fully reflect all health care needs and, in drawing up the plan, the authority should ensure that the child is provided with adequate health care.
The Scottish Executive publication 'Looked After Children and Young People: We Can and Must Do Better', recognised that life outcomes for looked after children and young people need to be improved. A key theme of this Action Plan centres around being emotionally, mentally and physically healthy and this theme has action points aimed at ensuring looked after children and young people have access to a range of appropriate services designed to meet their emotional, mental and physical needs.
Recommendation 8: Piloting Innovative Projects
There is a particular need to look at those who are known to be at high risk of overdose. If they are not given intensive support they may be more likely to die. These are typically males in their thirties and forties with a long history of substance misuse, marginalised from their families and society, often homeless and in poor general health.
Consideration should be given to identifying and piloting methods used in other countries that have been shown to have an impact on drug-related deaths with this target group, for example, piloting a safe injecting clinic such as those established in Australia, Canada and Switzerland. If a scheme is evaluated and has proved to be effective we should think about trying it here. The JRF report should be considered carefully by service commissioners in Scotland.
In Canada, for example, the results of an evaluation of an injection clinic called Insite, in the Downtown East Side area of Vancouver, showed that in the 500 overdoses that had occurred at the site over a two year period, none had resulted in a fatality. If these overdoses had happened elsewhere the outcome may have been very different.
Scottish Government Response
The Scottish Government accepts that there is a need to look at innovative projects that help people to get drug free for good. We have already commissioned research to look at services that are producing better outcomes for homeless substance misusers. This research is looking at the links between homelessness and substance misuse, to identify the models of service available for people who are homeless and have problem drug or alcohol use. The research is expected to report in the summer of 2008 and findings will be widely disseminated to service commissioners.
We are also part-funding a project that will explore and monitor the situation of senior drug dependents in different age brackets and by gender (starting at age 35 up to 70 and older) in partner countries in Europe. The Senior Drug Dependents and Care Structures ( SDDCare) project will re-analyse existing data sets on a European, national and community level (of the partner cities). It will look at the older users' mental and physical health status (including chronic infectious diseases such as HVC-infections, HIV etc.), their life circumstances, social networks, accommodation and their needs of care and treatment. The project is expected to report in 2011.
We are also already funding a number of innovative pilot projects. One of those is FV-Tox in Forth Valley. The overall aim of FV-TOX is to provide a structured, standardised, evidence-based care package to help clients dependent on opiates who seek to become abstinent. The programme gives people support through the effects of detoxification, encourages lifestyle and behaviour change and aims to improve their health and well-being, their family relationships and access to employment and training.
The Government however, does not support the need for drug consumption rooms. There are legal and ethical issues around their introduction that cannot be resolved easily. The Misuse of Drugs Act 1971 makes it an offence to allow the use of drugs on premises. We have no plans to introduce consumption rooms in Scotland.
Experience elsewhere suggests there is a small minority of heroin-dependent addicts who do not benefit from substitutes such as methadone but who do respond to receiving heroin in strictly controlled clinical settings. It is difficult to estimate the number of people who could directly benefit from supervised heroin, especially when methadone treatment in Scotland could be more effective. The Government are currently monitoring heroin prescribing pilots taking place in England and await the results of these with interest.
Recommendation 9: Data Collection
Drawing from the SACDM report and recommendations (2005), and after discussions with ADATs, the GROS, the SCDEA and NHS Services Scotland, ISD, the following recommendations emerged.
A new system for data collection should be constructed as follows:
ADATS should be asked to gather data in a systematic format on each death after being notified of these by the police or SCDEA.
- That data should be standardised and compiled by ISD in a suitable electronic format which will allow analysis and reporting.
- The national dataset will be augmented by adding information from other ISD files, in particular each case will be matched with information from reports from treatment agencies ( SMR25) and mortality statistics concerning hospital admissions ( SMR01 and SMR04) as well as GROS cause of death information.
- An expert group should supervise these exercises and will provide accurate clinical interpretations in order to correctly brief Ministers, the National Forum, the media and the public.
Scottish Government Response
We agree with this recommendation in full and have taken it forward as a matter of urgency. Discussions have already taken place with NHS Scotland, Information Services Division ( ISD) and ADATs to develop a standard national database for the collection of detailed information on drug-related deaths.
The database will cross-refer to existing ISD datasets to give a picture of the drug user's life prior to death which, following analysis, will assist in identifying interventions that may prevent deaths in the future. ISD will provide the analysis to the National Forum and local ADATs to help future planning.
As mentioned in the introduction, a sub-group of the Forum have also redesigned the form used by pathologists to gather information for GROS, which they use to produce annual National Statistics on drug deaths in Scotland.
We also recognise the need to look closer at those people who are classed as 'near misses', i.e. those who go into overdose but recover or are brought round by the intervention of others. The Forum report pointed out opportunities for intervention at Accident and Emergency (A&E) departments and by ambulance crews. We will work with the Forum to look at addressing ways of utilising these points of contact to their best advantage. One way of doing this would be to work with the ambulance service on materials that provide information to drug users who refuse to go to hospital. This information can contain helpline numbers or websites that can give details of drug services in the patients area. Another means would be to look at the role of 'drug liason nurses' in A&E departments.
Recommendation 10: National Campaigns
There is a need for targeted national information campaigns. Up-to-date information should be disseminated to those most at risk. For example, dangerous combinations of drugs and alcohol, in particular methadone and alcohol and cocaine and alcohol, need to be highlighted to drug users.
The Forum recommends that the Scottish Government review and update materials available on overdose and consider using information technology to highlight issues. For example, a dedicated drug deaths website to provide up-to-date information on available materials and where to get help would be very useful.
Scottish Government Response
There is a limited amount of material already available on drug overdose which centres around recognising the signs of overdose and what to do in the event of it happening. This material is published via the Government's Know the Score information campaign. However, we accept there is a need to develop more targeted material and we will work with the Forum in identifying ways of doing that.
Future work may focus on the dangers of drug taking and alcohol consumption, warning about the danger of drug injecting and poly-drug misuse or the development of material for 'older drug users', who make up the majority of the population of drug deaths, to highlight the dangers they face and the need for general health care within this group.
A new national drug misuse interactive website ( http://www.scotland.gov.uk/topics/justice/drugs-strategy) has been developed which has a dedicated area that focuses on drug deaths. We will use this area to highlight dangers like those mentioned above, to champion innovative practices, report on new research and keep others up-to-date with any developments.
We will continue to produce the newsletter 'Drug Death Matters' as another means of raising awareness of issues and for reporting the excellent work of the Forum.
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