National Forum on Drug-Related Deaths in Scotland - Annual Report 2011/12

ANNEX C

SCOTTISH GOVERNMENT RESPONSE IN MAY 2012 TO RECOMMENDATIONS MADE IN THE NATIONAL FORUM ON DRUG-RELATED DEATHS 2010/11 ANNUAL REPORT

Recommendation 1

All prisoners believed to be a high risk of drug overdose should now be offered naloxone training and a take home kit on release from prison. Take up numbers are available but not the total number offered. The Forum would request that this information should be collected as it is essential to the understanding of the success of the programme.

Response: The Scottish Government recognises that individuals with a history of opiate use released from custody are at an acute risk of opiate overdose. As in 2011/12 the Scottish Government will continue to provide funding to all NHS Boards to provide naloxone kits to their prisons throughout 2012/13. We will also continue, through the Information Services Division (ISD) naloxone monitoring programme, to collect as much data as possible on prisoner uptake, and assess any potential barriers that may prevent an individual from taking a naloxone kit with them on release.

The Drugs Policy Unit (DPU) will work in partnership with the national naloxone co-ordinator and with the Scottish Prison Service (SPS) to ensure that all prisoners identified at risk, are offered a kit pre-release from custody.

We are pleased that all Scottish Prisons are fully engaged with the national naloxone programme. The programme launched in June 2011 is still new and this may explain the reason for some unavoidable gaps in our data, just five months into the programme when this recommendation was published. There may be a number of logistical and personal issues that result in an individual not taking a kit with them on release. The 2012/13 programme will carry out some targeted work with SPS to identify and address these issues and we will report back to the Forum on progress and for further advice.

Recommendation 2

The Scottish Government Research Evidence Group should be refreshed and reconstituted. A drug "attributable fraction" study should be commissioned.

Response: The National Evidence Group was consulted early in 2011 as to the future remit of the group. It was agreed that moving forward, a standing group was no longer necessary and that the DPU would seek to organise a national research conference in 2012/13.

This event is now in the project planning stage and the Chairs of both the National Forum on Drug-Related Deaths and the Drugs Strategy Delivery Commission have been (and will continue to be) consulted on its planning and delivery. The DPU has also met with the Scottish Government Chief Scientist for advice on current academic activity on drug related research across Scotland. The feedback from this advice will shape the planned national conference.

The DPU is pleased to discuss further with the Forum its views on ways in which Scotland might position itself as a leader in addiction research for drug-related deaths and in the broader themes of care, treatment and recovery.

The drug-related deaths database is a product of the Forum's recommendation to the Government. If the Forum wished to expand that work to include work on attributable fractions then we are happy to scope that work out with the Data Collection sub group and ISD. If the policy rationale is clear and resource is available then the Scottish Government will consider this work.

Recommendation 3

Drug Misuse and Dependence: UK Guidelines on Clinical Management 2007 (Orange Guidelines) should be updated by Departments of Health and/or NICE/SIGN in order to renew the management of drug users in line with the recovery agenda. Community and Primary Care services need to be better integrated to increase their capacity for collaboration on joint areas of responsibility.

Response: The Scottish Government agrees that Community and Primary Care services need to be well integrated to ensure their capacity for collaboration on joint areas of responsibility, and that the Orange Guidelines for healthcare professionals should be updated, in line with the recovery agenda in Scotland. The Drugs Strategy Delivery Commission has also made a similar recommendation regarding the Orange Guidelines.

Bearing in mind that this is a UK wide document, the DPU will keep informed on relevant work of NICE in this area and will look, with advice from members of the Forum and the Commission, to see how this recommendation should best be taken forward. Priorities for 2012-15 have been already agreed with Ministers; however, we will look at this again when work to revise the National Care Standards has been completed. The new national quality standards for drugs will replace the National Quality Standards for Substance Misuse Services published in September 2006 and will be recovery focused. The work to redevelop the quality standards will also help inform thinking on the Orange Guidelines.

Recommendation 4

Hepatitis C treatment in the community should be developed in order to increase the uptake of curative therapy for this condition and to substantially alter the course of the epidemic in Scotland. In the longer term this might have a greater impact on preventing drug-related deaths than almost any other initiative. Specific resources should be directed towards those infected patients currently outside treatment services, as treating this group might have a disproportionately high benefit in slowing down transmission.

Response: The Sexual Health and Blood Borne Virus Framework was published in August 2011 and will build on the foundations established by the Hepatitis C Action Plan for Scotland. In this respect, NHS Boards continue to initiate increasing numbers of people onto anti-viral treatment for hepatitis C in line with the national treatment target (1100 in 2011-12) which increases on a year by year basis. This includes the provision of anti-viral treatment in specialist treatment centres and approximately 23 community settings across Scotland in large and medium sized NHS Boards, with further shared care arrangements with affiliated island NHS Boards. In the community, these are a mix of nurse or consultant led clinics, primarily operating out of addiction or harm reduction services, community hospitals and health centres. Anti-viral treatment for hepatitis C is similarly provided in almost all prisons across Scotland.

Recommendation 5

The practice of instructing, investigating and reporting suspected drug-related deaths should be standardised across Scotland. The final cause of death should be reported within reasonable timeframes.

Response: While this recommendation is an action for the Crown Office the Scottish Government fully supports this recommendation as families should not have to wait an unacceptable length of time to hear the cause of death of a loved one. The DPU will continue to work with the Forum's Pathology sub-group in its discussions to standardise the timescales for toxicology reports in Scotland. The Forum has written to the Lord Advocate highlighting their concerns in this area and once a response is received the DPU will work with the Forum to progress this.

Recommendation 6

Following the transition of prison health care to the NHS, we would expect better continuity and planning of care between different sectors, particularly prisons and NHS acute services. Links with primary care, social work, local drug services and recovery support in the community on discharge from prison, must be prioritised.

Response: This recommendation is for Health Improvement Scotland (HIS) who has established a Network Team to develop and lead on the National Prisoner Healthcare Work plan. This recommendation will be shared with HIS via the Forum's secretariat who may wish to respond directly to the Forum.

The Scottish Government Drugs Policy Unit chairs a Prisoner Health Group attended by policy leads in drugs, alcohol, mental health and community justice. This policy group also has representation from the Scottish Prison Service and ISD. The aim of the Scottish Government group is to ensure continuity and collaboration at a national policy level and to work closely with, and offer support to HIS.

There are several Scottish Government officials on the HIS Network Team, including the Drug Policy Unit's Head of Strategy.

Recommendation 7

Treatment services need to address the under prescribing of alternatives to methadone, and where this is attributed to causes not related to evidence based best practice, must strive to correct this omission. Buprenorphine is effective in maintenance treatment of opiate dependency and should be offered more frequently to patients who might benefit from this alternative to methadone. Its efficacy in detoxification is less clear. The Forum suggests that the Scottish Medicines Consortium might provide a briefing on the effectiveness and cost effectiveness of Buprenorphine which might be given to Health Boards to assist them in incorporating this in the first line of their formularies. Community pharmacies should be offered a joint contract to support supervision of medications such as methadone or buprenorphine rather than a single methadone or multiple contracts.

Response: While we recognise the Buprenorphine can and does have an important role to play in recovery from drug addiction, it is not for Scottish Ministers to promote or recommend one treatment over another. It is the responsibility of the prescriber to determine the appropriate course of treatment for an individual patient with an opiate dependency and this should be done in line with good practice, the Drug Misuse and Dependence UK guidelines on Clinical Management (Orange Guidelines) and in line with their local drug formulary.

It would not be for the Scottish Medicines Consortium (SMC) to provide a briefing on the (clinical) effectiveness and cost effectiveness of buprenorphine products to NHS Boards. Each NHS Board has an Area Drug and Therapeutics Committee (ADTC) and one of their functions is to consider the effectiveness, safety and economic use of medicines. It would, therefore, be more appropriate for NHS Boards, via their ADTCs, to review buprenorphine in the context of other existing medicines available within their respective Board formularies to treat the opiate dependency and make a decision regarding whether or not to include buprenorphine products in their formulary.

The dispensing and supervision of opiate substitute therapy is a locally negotiated service. A small number of NHS Boards have contracts to support supervision of buprenorphine in addition to existing methadone arrangements, however in some cases this is under detoxification arrangements as opposed to maintenance. It is worth noting that the supervision of solid dosage forms takes longer and consideration would need to be given to the service provision implications in the community pharmacy. It would be for the NHS Board to determine whether these contracts should be single or multiple contracts. Finally NHS Boards would require to make additional funding available (presumably from local funding for drug and alcohol budgets) to pay for the additional supervision arrangements service.

DPU will be happy to share this recommendation with Alcohol and Drug Partnerships in the Forum's name.

Recommendation 8

The development of specific pharmacy support in the management of dual addiction problems in the form of supervised disulfiram along with supervised opiate substitute drugs should continue to be funded and developed. Alcohol services should assess and advice of the risks of concomitant drug use, especially opiates, in problem drinkers; and drug services should be aware of the risks of co-dependency with alcohol in problem drug users and have appropriate interventions to minimise risks. The merging of specialist alcohol and drug services can only help in the better management of poly-substance use.

Response: It is the responsibility of the prescriber to determine the appropriate course of treatment for an individual patient with addiction problems, including dual treatment where appropriate, and this includes the option to request supervised administration of the treatment concerned. Where a prescribed dose is supervised in the pharmacy it is undertaken by the pharmacist or a member of their support staff and occurs in a discrete or quiet area of the pharmacy to ensure a degree of patient confidentiality. The dispensing and supervision of opiate substitute therapy is a locally negotiated service and NHS Boards would need to consider the additional resources required to support the provision of dual supervision and then agree the terms and conditions and funding arrangements with their local community pharmacy contractor committees.

The DPU will share this recommendation with NHS Boards and ADPs.

Recommendation 9

To look for examples of good practice (countries with lower drug prevalence and lower drug-related deaths), a National/International meeting should be convened to compare experiences with other centres with similar problems.

Response: This is, in part, already being progressed through our work with the British-Irish Council and our reporting to the United Nations Office on Drugs and Crime (UNODC) and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).

The Scottish Government is a member of the 8 administration (England, Scotland, Ireland, Wales, Northern Ireland, Jersey, Guernsey and Isle of Man) British-Irish Council, which has a sub group that specifically focuses on the misuse of drugs. The purpose of the group is to share best practice and look at potential areas of policy collaboration. It is recognised within the Council that Scotland has developed a strong policy response to its high prevalence and drug-related deaths, and it is noted that both these trends are higher in Scotland than in any of the other members.

Scotland also regularly responds to the UNODC and EMCDDA. These offer valuable centre-points of both quantitative and qualitative international and global data. Where we sometimes find limitations in this reporting is with the binary comparison of countries, without considering a country's investment in data collection, quality assurance and frequency of reporting - in all of which Scotland is a world leader.

As with recommendation 2 the DPU will discuss with the Forum and other stakeholders, ways in which Scotland might position itself as a leader in addiction research, including the broader themes of care, treatment and recovery and learn from countries who have made early progress, in tackling drug prevalence and drug-related deaths.

Recommendation 10

Older drug users should be drawn into national campaigns such as Keep Well. Addiction services should be more active in other health related areas such as smoking cessation, weight management, dietary advice and the importance of exercise. Suicide prevention training should be prioritised. Mental Health First Aid and other interventions to prevent suicide should be highlighted given that this may account for around 25-30% of all drug-related deaths. A significant number of drug service staff (and others) have received this kind of training, which has been positively evaluated in Scotland.

Response: Through the Scottish Government's Keep Well Programme of targeted health checks, as from April 2012, individuals over the age of 35 on an identified support programme including substitute prescribing; will be offered a health check. This is in recognition of their vulnerability to cardiovascular disease (CVD) and the need to target services at adults. Part of this health check will assess the risk factors associated with CVD and where appropriate, refer individuals for support in changing their behaviour - this will include smoking cessation, weight management, health coaching, employment support and mental health services. All of this work has been built on learning to date including the successful engagement of community pharmacy with those on substitute prescribing programmes. Those leading on local Keep Well programmes and ADP co-ordinators have been encouraged to link up so local responses to those at risk of CVD can be maximised.

On suicide prevention training, the HEAT 5 target for 50% of NHS frontline, primary care, accident and emergency, and substance misuse staff to undertake suicide prevention awareness training by the end of 2010 was achieved. From engagement with NHS Boards, we know they are still investing in this activity. It is intended that this will be further considered within the development of the successor to the Choose Life Strategy which runs to 2013.

Work is currently being undertaken with NHS Tayside to test an assertive approach to improving access to treatment for people, especially young men, with a drug or alcohol problem that have presented in crisis at A&E. Learning from this and targeted work on how mental health and drug and alcohol services work better together will feature in the Scottish Government's Mental Health Strategy.

Scottish Government
May 2012