National Mission on Drugs: Annual Monitoring Report 2023-2024

8. Outcome 4: People receive high quality treatment and recovery services

8.1 Summary

Outcome 4: People receive high quality treatment and recovery services

• 8,034 people starting specialist treatment who had an initial assessment recorded in 2023/24. Increase of 2% since 2022/23. Lower than at the start of the National Mission.
• 29,817 people prescribed opioid substitution therapy in 2023/24. Stable since before the start of the National Mission.
• 940 approved statutory-funded residential rehabilitation placements in 2023/24. Increase of 13% since 2022/23. Upward trend since the start of the National Mission.
• Access to residential rehabilitation treatment has improved but there is no evidence of any increase in the number of people accessing other forms of specialist treatment. MAT standards reporting indicates evidence of implementation, but more is needed to ensure that all service users are receiving the standards.

8.2 Background

It is vital that treatment is high quality, evidence-based and promotes a recovery-orientated system of care to get more people into the treatment they need. A wide range of community based, and residential services operate to support people with problem substance use in Scotland. This includes access to Medication Assisted Treatment (MAT), often in the form of opioid substitution therapy (OST), as well as access to residential services such as rehabilitation. Targets are in place to increase residential rehabilitation capacity by 50% to 650 beds and increase the number of approved publicly funded residential rehabilitation places to 1,000 by the end of this Parliament.^[53]

The evidence bases for both MAT and residential rehabilitation treatment for problem substance use are well established.^[54],[55] The MAT standards, published in May 2021, are evidence-based standards designed to enable the consistent delivery of safe, accessible, high-quality MAT treatment. The Scottish Government is working with ADPs to fully implement these across all localities.^[56]

8.3 Headline metrics

8.3.1 Headline metric: Number of people who have an initial assessment recorded

In 2023/24, 8,034 people starting specialist drug or co-dependency treatment had a complete initial assessment recorded on DAISy. This is 167 (2%) more people than in 2022/23, but 926 (10%) fewer than in 2021/22, the first year for which these data are available (Figure 9). ^[57]

Source: Drug and alcohol information system (DAISy) overview of initial assessments for specialist drug and alcohol treatment 2023/24, Public Health Scotland, November 2024

The median age of people starting drug treatment in Scotland in 2023/24 was 36 years, the same as in 2022/23 and 2021/22. The sex profile is also stable with 71% recorded as male, similar to in 2022/23 and 2021/22. Cocaine (30%) was the most commonly reported main drug used by people starting specialist drug treatment in Scotland, overtaking heroin (28%) for the first time since drug treatment reporting began.

The median age of those starting treatment for drug and alcohol co-dependency was 33 years, consistent with the previous year. The sex distribution of this group is stable with around 4 in 5 recorded as male. The most commonly reported individual drugs were cocaine (64%), cannabis (38%), and heroin (10%). In comparison to 2022/23, cocaine use increased by four percentage points, while heroin use remained broadly stable.

DAISy is a unique source of data on people accessing treatment for problematic substance use but there are completeness issues that must be considered when interpreting the data. In 2023/24, for drugs, alcohol and co-dependency combined, only 62% of the eligible episodes of care had an initial assessment completed and entered into DAISy. This was a decrease in overall data completeness of four percentage points compared to 2022/23 (66%).

8.3.2 Headline metric: Number of people prescribed Opioid Substitution Therapy

Opioid Substitution Therapy (OST) was prescribed to an estimated minimum of 29,817 people in Scotland in 2023/24. This was a slight decrease (125 people, 0.4%) compared to the 2022/23 estimate (29,942). There has been very little change in the total number of people prescribed OST over the past ten years. ^[58] However, there has been some change in the mix of types of OST prescribed, with an increased proportion of people prescribed long-acting injectable buprenorphine (Buvidal) in recent years.^[59]

8.3.3 Headline metric: Number of approved statutory funded residential rehabilitation placements

There were 940 approved statutory funded placements for residential rehabilitation in 2023/24. This is an increase of 111 approved placements (13%) compared to 2022/23 (829 approved placements) (Figure 10).^[60] The majority of statutory funded placements were approved by ADPs (2023/24: 80%), with the remainder made up of National Mission approved places (e.g. Prison to Rehab placements) and Ward 5 Woodland View placements.

Source: Interim monitoring report on statutory funded residential rehabilitation placements, Public Health Scotland, December 2024

This monitoring metric was developed in 2023 when the PHS approved statutory funded placements data was the only published information available to provide insight into progress. However, this data has limitations - it only captures placements approved and does not capture instances when a person does not start their placement, nor whether a person’s residential treatment programme is completed as planned.

Additional published data sources now exist that provide further insight into progress in this area. PHS recently published an analysis of data collected as part of the evaluation of the Scottish Government’s Residential Rehabilitation Programme. In 2022/23 (the most recent data available), there were 1,033 confirmed records of individuals starting a publicly funded residential rehabilitation placement in 2022/23. Based on the data available, the report concludes that the number of individuals publicly funded to go to residential rehabilitation per year in Scotland is likely to have almost doubled between 2019/20 and 2022/23, and that the Scottish Government reached its target of 1,000 individuals publicly funded to go to residential rehabilitation per year in the financial year 2022/23.^[61]

The Scottish Government also has a target to increase residential rehabilitation capacity to 650 beds by 2026. As at September 2024, there was a maximum capacity of 513 residential rehabilitation beds in Scotland across 25 facilities. This was an increase of 88 beds (21%) compared to 2021 (425 beds).^[62]

8.4 Supporting metrics

8.4.1 Supporting metric: Percentage of ADP areas where (a) MAT standard 1, (b) MAT Standard 2, and (c) MAT Standard 5, have been fully implemented

PHS publish annual reporting on the implementation of MAT standards in their National Benchmarking report.^[63] However, the most recent 2023/24 report included changes in the methodologies for how assessments were undertaken since last year’s report. Therefore, it is not possible to make direct comparisons between 2022/23 and 2023/24 - findings should be taken as a snapshot in time as opposed to a comparison progress report.

MAT standard 1 (option to start MAT from the same day of presentation): In 2023/24 this standard was assessed as being fully implemented in 79% of ADP areas (23 out of 29). These areas all met the numerical benchmark that 75% of people receive their MAT assessment ('first date the service offers for MAT assessment and where treatment can be initiated if appropriate') either on the same day of initial presentation or the next day. Where the standard was not met, a combination of resource, geographical and system constraints were noted as possible explanatory factors.

MAT standard 2 (all people are supported to make an informed choice on what medication to use for MAT and the appropriate dose): In 2023/24 this standard was assessed as being fully implemented in 97% of ADP areas (28 out of 29). National data show a decrease in methadone prescribing and an increase in prescribing of long-acting injectable buprenorphine but there are notable geographical differences. In addition to choice, possible explanations for variation include more prescribing options, demographics, organisational culture and patterns of drug use.

MAT standard 5 (support to remain in treatment for as long as requested): In 2023/24 this standard was assessed as being fully implemented in 93% of ADP areas (27 out of 29). Several evidence sources contribute to the assessment of implementation of MAT 5, including a benchmark that 75% of people retained in care for six months – this was achieved by all but one ADP area.

In addition to the PHS benchmarking report, evidence to support these metrics is also available through the Scottish Drugs Forum’s (SDF) Service Evaluation of People’s Experience of Accessing MAT in eight Health Board areas across Scotland report.^[64] Qualitative findings from the research provide additional context to understand the experiences of people accessing MAT:

• Findings showed that participants experienced a number of barriers to access, including experiencing stigma when accessing MAT through GPs and pharmacies, challenges communicating with MAT services and barriers associated with travel, including cost and distance.
• Participants had mixed experiences of being offered initial medication choice, as well as choice in changing medication and dose. This was in terms of explanations that were provided to them by prescribers, ease of making changes and how in control participants felt about their dose. Choice in keyworker, appointment frequency and face-to-face meetings were also highlighted in the research.

8.4.2 Supporting metric: Percentage of ADP areas where MAT standards 6-10 have been fully implemented

PHS publish annual reporting on the implementation of MAT standards in their National Benchmarking report.^{[65], [66]} However, the most recent 2023/24 report included changes in the methodologies for how assessments were undertaken since last year’s 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.

In 2023/24, for MAT standards 6–10, 91% were assessed as partially implemented (evidence that implementation is beginning).

MAT standards 6 (the system that provides MAT is psychologically informed (tier 1); routinely delivers evidence-based low intensity psychosocial interventions (tier 2); and supports individuals to grow social networks) and 10 (all people should receive trauma informed care): MAT standards 6 and 10 were assessed together in the 2023/24 benchmarking report due to the overlap with process documentation and delivery. 97% of ADP areas (28 out of 29 areas) were assessed as partially implemented because they had a service delivery plan in place and evidence of staff completely appropriate tier 1 training over the last two years. However, experiential evidence indicated that though the majority of people felt they were treated with dignity and respect while accessing services, most people felt they were not offered trauma-informed care, and that buildings and spaces were not trauma-informed.

MAT standard 7 (all people have the option to receive medication or support through primary care providers): In 2023/24, 76% of ADP areas (22 of 29 areas) were assessed as this being partially implemented, with agreed pathways and protocols. However, this was not always translated to shared care happening in practice due, for example, to insufficient resources and lack of GP involvement. This was reflected in experiential evidence.

MAT standard 8 (all people should have access to independent advocacy and support for housing welfare and income needs): In 2023/24, all 29 ADP areas were assessed as partially implemented, based on all areas having commissioned or engaged with independent advocacy services and having advocacy training in place for staff. However, this does not assess support provided for accessing housing, welfare or income support.

MAT standard 9 (all people with co-occurring drug use and mental health difficulties can receive mental health care at the point of MAT delivery): In 2023/24 this standard was assessed as being partially implemented in 86% of ADP areas (25 out of 29 ADP areas), where there are documented procedures for joint working to care for people with co-occurring mental health and substance use issues. Of all new referrals to substance use services in the reporting period, 80% were screened for mental health risks and needs. Where data was available, of those screened, 68% had evidence of mental health problems and 38% were already receiving mental health care.

8.5 Discussion

Access to residential rehabilitation treatment has improved but there is no evidence of any increase in the number of people accessing other forms of specialist treatment. MAT standards reporting indicates evidence of implementation, but more is needed to ensure that all service users are receiving the standards.

The number of people starting specialist drug or co-dependency treatment who had a complete initial assessment recorded on DAISy was similar to last year and lower than in 2021/22. However, this may be affected by ongoing DAISy data completeness issues limiting the extent to which conclusions can be drawn from this data in isolation. Research underway at PHS into reasons behind the recent trends in referrals to specialist alcohol and drug treatment services will improve understanding around engagement with treatment services and is expected to be published in Spring 2025. DAISy does provide a useful sample of the overall population of people who use services and analysis of demographic breakdowns from DAISy may also provide further insight into the groups who are more likely to be engaging with specialist treatment services and, conversely, those for whom there may be more barriers.

The total number of people prescribed OST remains stable with an increase in the proportion of people prescribed long-acting injectable buprenorphine (Buvidal) in recent years. The implications of this change in the mix of the type of OST being prescribed for individuals, communities and the wider system remain unclear, with research ongoing into understanding the impact this may have on rates of drug deaths and harms, as well as wider outcomes from treatment.

Available data in relation to residential rehabilitation treatment is indicative of progress in this area. Residential rehabilitation bed capacity has increased. There was an increase in the number of approved statutory funded residential rehabilitation places in 2023/24 and this measure shows consistent improvement over the course of the National Mission. Newly available data on people starting a residential rehabilitation placement shows that the number of individuals who are publicly funded to go to residential rehabilitation per year in Scotland is likely to have almost doubled between 2019/20 and 2022/23, and that the Scottish Government reached its target of 1,000 individuals publicly funded to go to residential rehabilitation per year in the financial year 2022/23. However, these figures do not provide insight into the outcomes from residential rehabilitation in Scotland.

Numerous sources of evidence, including toxicology^[67], DAISy and NESI, have highlighted the rapidly changing patterns of psychoactive drugs and these are likely to have implications for the types of treatment and support that people need. This includes ongoing polydrug use, emergent benzodiazepines, and an overall trend towards cocaine's leading role in drug harms, as seen in post-mortem toxicology, the ASSIST^[68] project and in needle exchange services. This suggests a need for ongoing adaptations to treatment and support service provision. Additionally, this may indicate a need for updated evidence and monitoring metrics to understand progress in treatment and recovery beyond users of opioids. This includes understanding barriers and unmet need for those not accessing services.

The current status of reported MAT standard implementation suggests higher levels implementation of standards 1,2 and 5, which focus on same day access, choice and retention compared to standards 6-10 which focus on psychologically informed, primary care, access to independent advocacy, mental health and trauma informed. Evidence collected by SDF highlights the progress which still needs to be made to ensure that all those accessing services are receiving the standards.

There is a limitation in the current metrics in understanding the quality of treatment and recovery services directly from the perspectives of those who are accessing them, including which groups are currently being best served by available services. There is also a data gap in relation to understanding treatment outcomes. Further work is needed to explore options on how to best capture these aspects.