National Mission on Drugs: Annual Monitoring Report 2023-2024

7. Outcome 3: People most at risk have access to treatment and recovery

7.1 Summary

Outcome 3: People most at risk have access to treatment and recovery

• 14,869 referrals resulting in treatment starting in 2023/24. Increase of 6% on 2022/23. Broadly similar level to at the start of the National Mission.
• 100% of ADP areas had referral pathways in place in 2023/24 for people who experience a near-fatal overdose. Consistent with 2022/23.
• The metrics present a broadly stable picture of access to treatment and recovery services, with challenges in understanding the extent to which there is unmet need amongst those who are most at risk.

7.2 Background

Evidence has shown that receiving treatment and being in contact with services are protective factors against drug-related deaths and harms^[39],[40] and so it is important to better understand the pathways into treatment. For people at most risk of drug-related death and harm, this can be explored using existing data on the number of referrals to have successfully resulted in starting treatment and data on near-fatal overdose (NFO) pathways. As part of understanding pathways to treatment and recovery it is important to understand how long people have to wait before they receive support. It is also helpful to understand how people at risk are proactively identified and offered support (MAT 3), and how pathways between the criminal justice system and specialist services are utilised.

7.3 Headline metrics

7.3.1 Headline metric: Number of referrals resulting in treatment starting

There were 14,869 referrals resulting in community-based specialist drug or co-dependency treatment starting in 2023/24 (Figure 8)^[41]. This is 6% (790) higher than in 2022/23 when 14,079 referrals resulted in treatment starting. It is 5% (730) higher than in 2020/21 before the National Mission began, when 14,139 referrals resulted in treatment starting.

Source: National drug and alcohol treatment waiting times, Public Health Scotland, December 2024 release, data extracted January 2025.

There was a general downward trend in the number of referrals starting treatment since March 2019. This was exacerbated following the first COVID-19 lockdown measures implemented in March 2020, which affected referral volumes and the delivery of treatment through changes to service provision (for example less face-to-face interaction). Following a spike in the first quarter of 2021/22, the number of referrals resulting in treatment starting has fluctuated quarter on quarter but has remained broadly flat.^[42]

Additional data provide insight about referrals for treatment for people in prison settings. In 2023/24, 1,357 referrals resulted in the start of specialist treatment for drug and co-dependency in prison settings. This was 7% (99) fewer than in 2022/23, when 1,456 referrals resulted in the start of treatment and 45% fewer than in 2020/21 (pre-National Mission) when 2,485 referrals resulted in the start of treatment for people in prison settings.^[43]

7.3.2 Headline metric: ADP areas where referral pathways are in place for people who experience a near-fatal overdose

In 2023/24, all ADPs reported having referral pathways in place in their area to ensure people who experience a near-fatal overdose are identified and offered support. This is consistent with findings from the 2022/23 survey. Pathways were most commonly in place through the Scottish Ambulance Service (in place in 97% of ADP areas), specialist substance use treatment services (in place in 93% of ADP areas), third sector (in place in 77% of ADP areas) and hospitals (in place in 73% of ADP areas).^[44]

Caution must be exercised when interpreting these data – although near fatal overdose pathways are in place in all ADP areas across Scotland, the data does not provide any insight into the accessibility, use, or outcomes of people who are referred through these pathways.

7.4 Supporting metrics

7.4.1 Supporting metric: Percentage of referrals resulting in treatment starting within three weeks or less

In 2023/24, 93% of referrals for community-based specialist drug or co-dependency treatment resulted in treatment starting within three weeks or less. This is a slight increase on the previous year (92%) but lower than before the start of the National Mission (2020/21) when 95% of referrals resulted in treatment starting within three weeks or less.^[45]

There have been some improvements in average wait times for community-based specialist treatment. In 2023/24 the median wait for specialist drug treatment was four days, a decrease from five days in 2022/23. However, the average wait time for community-based specialist co-dependency treatment was seven days in 2023/24, this has remained broadly the same since the start of the National Mission.^[46]

The waiting time standard that 90% of people should wait no longer than three weeks for community-based specialist treatment has been consistently met at a national level for both drug and co-dependency treatment. However, there is notable geographic variation. Only four NHS boards^[47] have consistently met the waiting times target for both drugs and co-dependency every quarter since the start of the National Mission in early 2021. By contrast, performance in other health boards is mixed.

The most common type of treatment in 2023/24 continues to be structured preparatory intervention, which accounts for around half of treatments started for drugs and co-dependency. The second most common treatment type was structured psychosocial intervention, accounting for 29% and 34% of treatments started for drugs and co-dependency respectively. These two treatment types have accounted for the majority of new treatments started since 2019/20.

7.4.2 Supporting metric: Percentage of ADP areas where MAT standard 3 has been fully implemented

PHS publish annual reporting on the implementation of MAT standards in their national benchmarking report.^[48] However, the most recent 2023/24 report included changes in the methodology for how assessments were undertaken since last year’s benchmarking report. Therefore, it is not possible to make direct comparisons between 2022/23 and 2023/24, and findings should be taken as a snapshot in time as opposed to a comparison progress report.

MAT standard 3 (assertive outreach and anticipatory care) is that all people at high risk of drug-related harm are proactively identified and offered support to commence and continue MAT. In 2023/24, it was assessed that the standard is fully implemented in 90% of ADP areas (26 out of 29 ADP areas^[49], includes one area with evidence of sustained implementation) and partially implemented in 10% of ADP areas (three ADP areas).

7.4.3 Supporting metric: Percentage of ADP areas supporting referrals within the criminal justice system to specialist treatment services

The percentage of ADP areas reporting that they fund or support referrals to substance use services in 2023/24 varied depending on the stage of engagement with the criminal justice system^[50],[51]:

• Pre-arrest: 53% (up from 38% of ADP areas in 2022/23)
• In police custody: 80% (up from 66% of ADP areas in 2022/23)
• In courts: 43% (data not available for 2022/23)
• In prison: 67% (data not available for 2022/23)
• Upon release: 90% (up from 79% of ADP areas in 2022/23).

Where data is available, it shows an improvement in the number of ADP areas supporting referrals within the criminal justice system to specialist treatment services.^[52]

7.5 Discussion

The metrics present a broadly stable picture of access to treatment and recovery services, with challenges in understanding the extent to which there is unmet need amongst those who are most at risk.

The number of referrals to specialist drug and alcohol treatment has remained broadly stable, but with quarter-on-quarter fluctuations, since the start of the National Mission. While this indicates that there are active referral pathways in place, based on this data alone it is challenging to understand the extent to which people who are most at risk are accessing treatment services to support their recovery. A greater understanding of barriers to accessing services for specific groups such as women, people experiencing homelessness and people using non-opioid drugs would contribute to understanding unmet need.

All ADPs continued to report having referral pathways in place in their area to ensure people who have experienced near-fatal overdose are identified and offered support, most commonly through the Scottish Ambulance Service and specialist substance use treatment services. While these figures are encouraging, they do not provide insight as to the accessibility, use, or outcomes of people who are referred through these pathways.

Nationally, the percentage of referrals resulting in treatment starting within three weeks or less was similar to last year, meeting the waiting time standard that 90% of people should wait no longer than three weeks for community-based specialist treatment to support their recovery. However, there remains regional variation, with only four NHS boards having consistently met the waiting times target for both drugs and co-dependency every quarter since the start of the National Mission. This could indicate that people seeking specialist treatment to support their recovery may have different experiences depending on where they live. The implementation of MAT standard 3, which focuses on proactively identifying and offering support to engage with MAT for people at a high risk of drug-related harm, is ongoing, having been assessed as fully implemented in 90% of ADP areas.

Positive progress was seen in the percentage of ADP areas reporting that they fund or support referrals to substance use services at different stages of engagement with the criminal justice system. There were increases at all stages of engagement where there is comparable data with last year. People engaged with the justice system are often at higher risk of drug-related harms, and therefore this is an encouraging indication of the extent to which referrals to specialist treatment are being embedded within the justice system.

Overall, the metrics present a fairly stable picture of access to treatment and recovery services. There are gaps, however, in our understanding of whether those who are most at risk of drug-related harms are accessing treatment and recovery services, as well as the impacts of treatment and support pathways for those who have experienced near fatal overdose. Evidence from people with lived and living experience would be valuable to identify where and for whom there are unmet needs in terms of treatment and recovery.